Being diagnosed with skin cancer is usually worrying enough, but the situation is further compounded when a patient’s face is involved. Excising the cancer may be lifesaving, but patients are often left with real concerns about their post-procedure appearance. Dr Mark Phipson explains all you need to know about the most common forms of skin cancer, how they are treated, and what reconstructive procedures are available to save both patients’ lives and restore their appearances.
In the South African context, skin cancers are particularly common among the Caucasian population. These cancers are classified into two broad groups, namely melanoma and non-melanoma skin cancer (NMSC).
Melanomas are generally more serious because they have the potential to enter lymphatic vessels, spreading to lymph nodes and other organs. If not contained, they may be fatal.
Common skin cancers
NMSC is more prevalent than melanomas. The two most common types are:
- Basal cell carcinoma: Basal cell carcinomas tend to be more locally aggressive and can cause significant tissue destruction, especially on the face. It is extremely rare for them to spread to other organs.
- Squamous cell carcinoma: Squamous cell carcinomas can be relatively small and slow-growing, but can also be very locally aggressive, destroying local tissues. Although they do have the potential to spread to other organs, this happens far less commonly than with melanomas.
There are several other, rarer types of NMSC, some of which are particularly aggressive and present a high risk of spreading to other organs.
If detected early, most skin cancers are easily treatable. If you have pale skin that burns easily, or have a family history of skin cancers, it is advisable to see a dermatologist with a special interest in skin cancer diagnosis and treatment at least once a year. Your dermatologist should have up-to-date screening equipment.
There are robust, evidence-based, internationally available guidelines for the diagnosis and treatment of skin cancers. It is highly recommended that you see practitioners who recognise and follow these guidelines. The National Comprehensive Cancer Network provides free, publicly available guidelines.
Defects resulting from the excision of skin cancers range from small ones that can be easily repaired to very large, complex defects that require intricate reconstruction. Many defects require reconstruction of moderate complexity.
Non-melanoma skin cancer
In selected cases, a diagnosis can be made based on the appearance alone; however, it is preferable to confirm the diagnosis with a biopsy. Small lesions can often be excised with an excision biopsy, which entails the removal of the entire lesion. Larger lesions are best treated with an incision biopsy, in which only a piece of the lesion is removed to confirm the diagnosis.
Larger skin cancers in sensitive areas, especially the face and hands, usually require confirmation that the cancer has been completely excised before reconstruction is performed. The best way of doing this is by having the entire margin of the cancer assessed microscopically in theatre. This is called PDEMA. It includes Moh’s surgery along with other techniques. Once the pathologist has confirmed that the cancer has been excised, the surgeon can safely proceed with reconstruction.
In complicated cases, the decision may be made to put a dressing on the wound, assess the specimen in the laboratory and then reconstruct once clear margins have been confirmed. This is called a “Slow Moh’s” approach.
Melanomas
Melanomas must be excised with wider and deeper margins than NMSCs. The extent of excision is related to the depth of the melanoma, with deeper ones requiring wider peripheral margins up to 2 cm. Melanomas must be excised to the next fascial layer.
It is preferable to perform an excision biopsy of the entire suspected melanoma to determine an accurate depth, but if the suspected melanoma is too large to practically do so, it may be reasonable to simply biopsy a piece of the melanoma.
Further, the assessment of melanoma margins by a pathologist during the operation is not as accurate as for NMSC and is seldom done.
In sensitive areas where we are unsure of the margins, a “Slow Moh’s” approach is employed. The lesion is excised, a dressing is applied, and reconstruction is performed once adequate, clear margins have been established.
Repair and reconstruction of defects after skin cancer excision
Techniques for repairing the defect range from very simple to highly complex.
Simple closure involves converting the defect into an ellipse, which is then closed as a straight line.
More complex closures involve rearranging the tissues around the defect to fit into it. These are used when it is not practical to close the defect in a straight line. The advantage of this technique is that the defect can be repaired with tissue similar to that which was lost, and the contour of the tissues can be optimally preserved. This technique, known as closure with a local flap, is used for defects that are too large to close as a straight line and in cosmetically sensitive areas (nose, ears, eyelids, and forehead).
Commonly used local flaps are:
- Advancement flaps
- Bilobed flaps
- Limberg flaps
- V-Y flaps
Sometimes one is not able to close the defect with a flap. In these cases, a full thickness skin graft may be used. This involves removing a piece of skin from another part of the body and applying it to the defect. The skin graft does not have its own blood supply and relies on the growth of new blood vessels from the base and edges of the defect. This process usually takes a week or two and the graft needs to be held firmly in place while this is happening.
The advantage of skin grafts is that large defects can be closed with minimal to no distortion of the surrounding tissues. The disadvantage of skin grafts is that they are a different colour to the skin around the defect and leave varying degrees of indentation. For this reason, they are rarely the first choice for reconstruction.
In some areas, however, they deliver exceptional results. These areas include the part of the nose near the eye, the ears, and the eyelids. Skin grafts are also useful in other areas where they may be more visible with defects too large to close using a local flap.
Nose reconstruction
Nose reconstruction after skin cancer removal is an area of special interest because the nose is a central feature of the face.
Very small defects of the nose can be closed as a straight line. The preferred technique for closing skin defects of the nose is the use of local skin flaps, typically the bilobed flap. Other options include nasolabial flaps, originating from the fold between the cheek and the lip, and glabellar flaps, which come from higher up along the nose and the skin between the eyebrows. Full-thickness skin grafts can be done in more concave areas, especially the side of the nose close to the inner eye and sometimes on other parts of the nose, especially when the defect is shallow.
More complex defects of the nose require staged reconstructions, which may take place over several weeks or even months.
This may involve replacing the cartilage with cartilage from the ear or ribs. As seen above, a forehead flap is commonly used to replace the soft tissue defect. This is a staged procedure performed in two or three (sometimes more) operations over a three-to-six-week period. The patient may appear very strange during this process, but the result is usually well worth the inconvenience and discomfort.
In summary
In conclusion, reconstructive procedures after the excision of skin cancers play a crucial role in not only saving lives but also preserving patients’ appearances. This is doubly important when it comes to the face, which is almost always on display for others to see and interpret as we go about our daily lives.
Dr Mark’s Top Insights for Patients
- Being diagnosed with skin cancer can be somewhat alarming and sometimes frightening.
- If properly treated, most skin cancers can be cured.
- Patients with skin cancers should be treated by a team of professionals with an interest in the diagnosis and management of skin cancers – preferably a multidisciplinary team of dermatologists, surgeons, pathologists, and oncologists who work according to evidence-based guidelines and discuss complex cases among themselves.
- The main objective is to remove the cancer. Once this has been done, the reconstructive surgeon will repair the defect to the best of their ability.
- There will always be a scar after a cut has been made.
- Depending on the extent of excision required and reconstructive techniques available, there may be varying degrees of distortion of the areas repaired. Experienced reconstructive surgeons will endeavour to minimise any distortion and achieve the best cosmetic outcomes.
MBBCh (Wits) FCS(SA)(Plast)
Dr Mark Phipson is a Plastic and Reconstructive Surgeon currently practising at Mediclinic Sandton in Johannesburg. He received his MBBCh from the University of the Witwatersrand in 1995 and went on to qualify as a Plastic Surgeon through the College of Plastic Surgeons of South Africa, in 2003.
He has developed special interests in the treatment of skin cancers and facial reconstruction post cancer excision in particular. He also does some trauma and burn treatment and reconstruction. Dr Phipson is a full member of the Association of Plastic Reconstructive and Aesthetic Surgeons of Southern Africa (APRASSA) where he has served on the executive board since 2019.