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Cutaneous malignancies of the head and neck
Cutaneous Malignancies of the Head and Neck Stephen Y. Lai, MD, PhD,1 and Randal S. Weber, MD, FACS2
onmelanoma skin cancer (NMSC), which includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common malignancy to affect humans. In the United States, incidence is at an epidemic level of ⬃1.2 to 1.4 million new cases each year.1 Since the mid-1980s, the incidence has been steadily rising; the causes are uncertain. Eighty percent of these lesions occur in the cervicofacial region.2 For Caucasians, the lifetime risk for NMSC is 8 to 11% for SCC and 28 to 33% for BCC. Although mortality from NMSC is relatively low (0.1-0.3% of incidence), the morbidity and treatmentrelated costs of this disease represent a significant burden to the health care system. Of particular concern is a subset of this disease termed “aggressive nonmelanoma skin cancer.” These lesions are identified by the following features: rapid growth, diam-
N
From the 1Department of Otolaryngology, Head and Neck Surgery, The Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA; and 2 Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX. Address reprint requests to Randal S. Weber, MD, FACS, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Unit 441, 1515 Holcombe Blvd, Houston, TX 77030-4009. © 2004 Elsevier Inc. All rights reserved. 1524-153X/04/0602-0009$30.00/0 doi:10.1053/j.optechgensurg.2004.05.002
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eter greater than 2 cm, and recurrence. These lesions frequently occur in the midface “H-zone,” which includes the medial canthus, glabella, posterolateral nares, alar rims, nasolabial sulcus, columella-labial junction, and auricular regions including the tragus and antitragus.3 Additionally, poorly differentiated SCC, spindle-cell-type SCC, and morpheaform- or basosquamous-type BCC tend to exhibit more aggressive behavior. Aggressive NMSC places the patient at higher risk for disease recurrence, perineural invasion, regional metastasis, and increased mortality.4 Management of aggressive NMSC is further complicated by the potential sequelae of radical tumor resection. The surgeon’s first priority should be definitive local control accomplished by wide local excision. However, the functional and cosmetic results of surgical resection and underestimation of the depth of invasion may lead to incomplete excision of these tumors.5 We describe the technique of surgical excision, geometric orientation of the resected specimen, and frozen section analysis to insure complete tumor removal. We also review NMSC lesions located in cosmetically and functionally sensitive areas of the face, and discuss various techniques for reconstruction after removal of these lesions.
Operative Techniques in General Surgery, Vol 6, No 2 (June), 2004: pp 132-142
SURGICAL TECHNIQUE
1
Wide local excision, specimen orientation for frozen section analysis and V-Y advancement flap. Although cosmetic and functional issues are important, local disease control is the primary goal of surgical resection of NMSC. The extent of peripheral and deep margins of normal surrounding tissues removed for en bloc resection of skin cancer lesions depends on tumor histology, location, size, and whether the tumor is being treated for the first time or is a recurrence.6 BCC lesions tend to require less of a margin than SCC lessions. However, morpheaform BCC lesions tend to be more invasive than nodular or nodulo-ulcertive BCC lesions. Lesions that recur after surgical excision or radiotherapy may be more invasive and require larger excision margins. Deep margins of skin lesions depend on the extent of tumor invasion. Excision of superficial lesions not extending beyond the dermis should include a portion of the subcutaneous fat. Lesions that involve the entire thickness of the scalp and adhere to the calvarium may require a full thickness craniectomy because of possible bone invasion or extension along preformed vascular channels. Verification of adequate resection margins requires microscopic analysis by frozen section. The head and neck surgeon and pathologist must clearly understand the original location and orientation of the specimen. A specimen map is created to depict the orientation and location of the resection margins. Peripheral margins should be obtained en face around the entire circumference of the lesion and be indicated clearly on the specimen map. Once the peripheral margins are obtained, the deep margin should be sampled and similarly mapped. Thus, if any of the margins demonstrate residual disease, the pathologist can clearly communicate the proper anatomical site to the surgeon to perform additional resection(s). Careful attention and communication at this critical step can ensure adequate tumor excision and avoid the potential need to disrupt surgical reconstruction efforts to obtain additional margins. When the adequacy of excision is in doubt, definitive reconstruction should be delayed until the final pathologic assessment is complete. After excision of a lesion near the nasal ala, a triangular advancement flap may be mobilized to close the defect. The flap is incised to the level of the subcutaneous fat and advanced on the subcutaneous pedicle to close the skin defect. The peripheral edges of the wound are undermined to allow tension-free advancement. The edges of the flap are trimmed to match the defect site, and the donor site is closed in a V-Y fashion. This flap is extremely versatile and may be used in many different areas of the face, including the cheek and nasolabial region. Incision lines are planned along relaxed skin tension lines to improve the cosmetic outcome. Although a split thickness skin graft may provide adequate coverage in this area, the thickness and color of potential donor tissue do not provide an adequate match to this facial area.
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Abbe–Estlander flap. Skin cancer lesions involving the lip and oral commisure are challenging to reconstruct in an aesthetically and functionally satisfying manner. Oral competence must be ensured by careful reestablishment of the oral commisure and re-approximation of the orbicularis oris muscle. Typically, a quarter to a third of the upper lip can be excised and closed primarily without difficulty. A variety of local flaps have been devised to address larger full thickness defects in different locations along the lip. An Abbe flap may use up to a quarter of the upper lip to reconstruct full thickness defects of the lower lip. Typically, the donor flap width is half the width of the base of the surgical defect. The upper lip flap is pedicled on the vermilion border, with a small cuff of muscle preserved around the labial artery. The flap is rotated into position and the vermilion border is carefully reestablished. The muscular, skin, and mucosal layers are repaired with particular attention paid near the pedicle to avoid injury to the labial artery. The donor site area is closed primarily. After ⬃3 weeks, sufficient neovascularization of the flap has occurred to permit division of the bridged pedicle. When the skin cancer excision involved the oral commissure, the Abbe–Estlander flap is employed with the vascular pedicle located within the medial border of the flap. The resulting commissure will be rounded and may require a secondary commisureplasty.
Cutaneous Malignancies of the Head and Neck
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Glabellar flap near the medial canthus. The glabellar flap is an axial flap that derives its blood supply primarily from the supratrochlear artery and secondarily from the dorsal nasal branches. The flap can be easily designed to reconstruct defects involving the bridge or upper half of the nose. This patient has a defect near the medial canthus of the eye that does not involve the periosteum or underlying bone. The resected lesion produces a triangle while preserving the medial canthal tendon. The flap is designed and raised above the periosteum of the frontal and nasal bones. The flap is transposed into the defect site, and trimmed and closed with as little tension as possible to prevent distortion of the medial end of the upper eyelid. Care must be taken in selecting the donor area to prevent placement of hair-bearing skin into the medial canthus area.
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Nasolabial flap. The nasolabial flap is a versatile axial flap that receives its blood supply from the nasolabial artery. The flap is extremely reliable and is employed in reconstructing defects on the lateral aspect of the nose or ala. Additionally, this flap may also be used to reconstruct the philtrum and columella. The nasolabial flap may be designed with an inferior or superior base. The flap is raised along the nasolabial crease, with a sufficient amount of subcutaneous fat. For a through-and-through nasal alar defect, the distal portion of the flap can be turned in to provide an inner lining and a portion of the flap is de-epithelialized before closure. The donor site can be closed primarily.
Cutaneous Malignancies of the Head and Neck
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Total rhinectomy. The nose has enormous aesthetic and functional significance as the dominant midface structure. Nevertheless, extensive skin cancers that invade the cartilaginous and bony skeleton of the nose may necessitate total rhinectomy. Depending on the extent of resection, the surgeon should attempt to preserve lateral nasal wall structures such as the turbinates. A split thickness skin graft is used to cover the superficial areas of the surgical resection site to reduce wound contracture and distortion of the midface. A skin graft serves as an excellent base for the prosthetic appliance. Formal nasal reconstruction is an elaborate multistage procedure and should be deferred until the final histologic clearance of tumor is assured. Many surgeons prefer to delay the reconstruction until adjuvant radiotherapy is completed and a period of observation has passed to ensure that the disease is controlled. A nasal prosthesis can quickly restore appearance, in contrast to multistage nasal reconstructive techniques that require prolonged periods of time and a great deal of patient cooperation. Patients need to be adequately counseled about the dramatic cosmetic and psychological effects of a total rhinectomy. The interval from surgical resection of the skin cancer to placement of the final nasal prosthesis can be lengthy, since these patients often require adjuvant radiation therapy.
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Wedge excision and primary closure of a helical lesion. Skin cancer lesions of the helix of the ear frequently involve the skin and cartilage. Adequate resection requires full thickness removal of the skin and cartilage that also facilitates reconstruction. The resection should also include the ante-helical fold to permit rotation of the superior and inferior segments of the remaining auricle and to avoid buckling of the ante-helical fold and skin dehiscence. A wedge excision involving one third of the vertical height of the pinna may be closed primarily in an aesthetically acceptable fashion. The incision lines are drawn on both surfaces of the auricle, with the apex located at the same point on both the anterior and posterior surface. After the wedge excision, Burrow’s triangles of skin and cartilage are excised from the apex of the anterior aspect of the wound to facilitate skin approximation. The anterior and posterior perichondrium are approximated with fine absorbable suture. A single suture is placed at the lateral border to approximate the edges of the helix, and the anterior and posterior skin surfaces are closed in two separate layers. The resultant ear is smaller but maintains the appropriate contour. Larger excisions generally require multistage reconstructions and, similar to total nasal defects, can be managed with an auricular prosthesis.
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Cervicofacial advancement flap for a preauricular lesion. Periauricular skin cancers may require extensive resection of the skin, subcutaneous tissue, and the lateral lobe of the parotid gland. A large preauricular defect can be closed with a cervicofacial advancement flap. (A) This patient required wide local excision of the preauricular lesion, superficial parotidectomy, and a selective neck dissection. The neck incision is designed to allow for sufficient rotation of the cervicofacial flap into the preauricular defect. In patients not requiring a neck dissection, the margins of the excised lesion are examined by frozen section analysis before raising the cervicofacial flap. The flap is raised in the subplatysmal plane to the midline.
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(continued) (B) The flap is then rotated to cover the defect and sutured.
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(continued) (C) The cervicofacial flap will reach to the level of the zygoma, but defects extending above this region may also require skin grafting to complement the rotational flap. The anterior portion of the auricle was excised in this patient because of tumor involvement, but the patency of the external auditory canal was maintained by securing the edges of the skin graft around the canal. Preservation of the anterior helix will facilitate placement of an auricular prosthesis and the wearing of eyeglasses.
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Lai and Weber
CONCLUSION
REFERENCES
The treatment of cutaneous malignancies of the head and neck remains difficult because of the potentially catastrophic nature of disease progression and the potential morbidity of definitive tumor management. High-risk lesions need to be recognized early and completely resected. Radical tumor excision can result in significant patient morbidity caused by severe functional and cosmetic consequences. Definitive locoregional control may require parotidectomy and/or cervical lymphadenectomy to address direct invasion of the parotid gland or regional metastases. Adjuvant radiation therapy may be valuable when there is disease recurrence, perineural invasion, close tumor margins, or unfavorable tumor histopathology.7,8 As with other head and neck cancers, a comprehensive, multidisciplinary treatment approach involving the head and neck surgeon, Mohs’ micrographic surgeon, surgical pathologist, reconstructive surgeon, and radiation oncologist is necessary to eradicate this disease.
1. Padgett JK, Hendrix JD Jr: Cutaneous malignancies and their management. Otol Clin North Am 34:523-553, 2001 2. Kaldor J, Shugg D, Young B, et al: Non-melanoma skin cancer: Ten years of cancer-registry-based surveillance. Int J Cancer 53:886891, 1993 3. Rowe DE, Carroll RJ, Day CL , Jr, et al: Prognostic factors for local recurrence, metastasis and survival rates in squamous cell carcinoma of the skin, ear and lip: Implications for treatment modality selection. J Am Acad Dermatol 26:976-990, 1992 4. Goepfert H, Dichtel WJ, Medina JE, et al: Perineural invasion of squamous cell skin carcinoma of the head and neck. Am J Surg 148:542-547, 1984 5. Wentzell JM, Robinson JK: Embryologic fusion planes and the spread of cutaneous carcinoma: A review and reassessment. J Dermatol Surg Oncol 16:1000-1006, 1990 6. Sewell DA, Lai SY, Weber RS: Nonmelanoma skin cancer of the head and neck, in Myers EN, Suen JY, Myers JN, Hanna EYN (eds): Cancer of the Head and Neck, 4. Philadelphia, PA, Saunders, 2003, pp 117-132 7. Taylor BW Jr, Brant TA, Mendenhall NP, et al: Carcinoma of the skin metastatic to the parotid area lymph nodes. Head Neck 13:427-433, 1991 8. Morrison WH, Garden AS, Ang KK: Radiation therapy for nonmelanoma skin carcinomas. Clin Plast Surg 24:719-729, 1997
onmelanoma skin cancer (NMSC), which includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common malignancy to affect humans. In the United States, incidence is at an epidemic level of ⬃1.2 to 1.4 million new cases each year.1 Since the mid-1980s, the incidence has been steadily rising; the causes are uncertain. Eighty percent of these lesions occur in the cervicofacial region.2 For Caucasians, the lifetime risk for NMSC is 8 to 11% for SCC and 28 to 33% for BCC. Although mortality from NMSC is relatively low (0.1-0.3% of incidence), the morbidity and treatmentrelated costs of this disease represent a significant burden to the health care system. Of particular concern is a subset of this disease termed “aggressive nonmelanoma skin cancer.” These lesions are identified by the following features: rapid growth, diam-
N
From the 1Department of Otolaryngology, Head and Neck Surgery, The Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA; and 2 Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, TX. Address reprint requests to Randal S. Weber, MD, FACS, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Unit 441, 1515 Holcombe Blvd, Houston, TX 77030-4009. © 2004 Elsevier Inc. All rights reserved. 1524-153X/04/0602-0009$30.00/0 doi:10.1053/j.optechgensurg.2004.05.002
132
eter greater than 2 cm, and recurrence. These lesions frequently occur in the midface “H-zone,” which includes the medial canthus, glabella, posterolateral nares, alar rims, nasolabial sulcus, columella-labial junction, and auricular regions including the tragus and antitragus.3 Additionally, poorly differentiated SCC, spindle-cell-type SCC, and morpheaform- or basosquamous-type BCC tend to exhibit more aggressive behavior. Aggressive NMSC places the patient at higher risk for disease recurrence, perineural invasion, regional metastasis, and increased mortality.4 Management of aggressive NMSC is further complicated by the potential sequelae of radical tumor resection. The surgeon’s first priority should be definitive local control accomplished by wide local excision. However, the functional and cosmetic results of surgical resection and underestimation of the depth of invasion may lead to incomplete excision of these tumors.5 We describe the technique of surgical excision, geometric orientation of the resected specimen, and frozen section analysis to insure complete tumor removal. We also review NMSC lesions located in cosmetically and functionally sensitive areas of the face, and discuss various techniques for reconstruction after removal of these lesions.
Operative Techniques in General Surgery, Vol 6, No 2 (June), 2004: pp 132-142
SURGICAL TECHNIQUE
1
Wide local excision, specimen orientation for frozen section analysis and V-Y advancement flap. Although cosmetic and functional issues are important, local disease control is the primary goal of surgical resection of NMSC. The extent of peripheral and deep margins of normal surrounding tissues removed for en bloc resection of skin cancer lesions depends on tumor histology, location, size, and whether the tumor is being treated for the first time or is a recurrence.6 BCC lesions tend to require less of a margin than SCC lessions. However, morpheaform BCC lesions tend to be more invasive than nodular or nodulo-ulcertive BCC lesions. Lesions that recur after surgical excision or radiotherapy may be more invasive and require larger excision margins. Deep margins of skin lesions depend on the extent of tumor invasion. Excision of superficial lesions not extending beyond the dermis should include a portion of the subcutaneous fat. Lesions that involve the entire thickness of the scalp and adhere to the calvarium may require a full thickness craniectomy because of possible bone invasion or extension along preformed vascular channels. Verification of adequate resection margins requires microscopic analysis by frozen section. The head and neck surgeon and pathologist must clearly understand the original location and orientation of the specimen. A specimen map is created to depict the orientation and location of the resection margins. Peripheral margins should be obtained en face around the entire circumference of the lesion and be indicated clearly on the specimen map. Once the peripheral margins are obtained, the deep margin should be sampled and similarly mapped. Thus, if any of the margins demonstrate residual disease, the pathologist can clearly communicate the proper anatomical site to the surgeon to perform additional resection(s). Careful attention and communication at this critical step can ensure adequate tumor excision and avoid the potential need to disrupt surgical reconstruction efforts to obtain additional margins. When the adequacy of excision is in doubt, definitive reconstruction should be delayed until the final pathologic assessment is complete. After excision of a lesion near the nasal ala, a triangular advancement flap may be mobilized to close the defect. The flap is incised to the level of the subcutaneous fat and advanced on the subcutaneous pedicle to close the skin defect. The peripheral edges of the wound are undermined to allow tension-free advancement. The edges of the flap are trimmed to match the defect site, and the donor site is closed in a V-Y fashion. This flap is extremely versatile and may be used in many different areas of the face, including the cheek and nasolabial region. Incision lines are planned along relaxed skin tension lines to improve the cosmetic outcome. Although a split thickness skin graft may provide adequate coverage in this area, the thickness and color of potential donor tissue do not provide an adequate match to this facial area.
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Abbe–Estlander flap. Skin cancer lesions involving the lip and oral commisure are challenging to reconstruct in an aesthetically and functionally satisfying manner. Oral competence must be ensured by careful reestablishment of the oral commisure and re-approximation of the orbicularis oris muscle. Typically, a quarter to a third of the upper lip can be excised and closed primarily without difficulty. A variety of local flaps have been devised to address larger full thickness defects in different locations along the lip. An Abbe flap may use up to a quarter of the upper lip to reconstruct full thickness defects of the lower lip. Typically, the donor flap width is half the width of the base of the surgical defect. The upper lip flap is pedicled on the vermilion border, with a small cuff of muscle preserved around the labial artery. The flap is rotated into position and the vermilion border is carefully reestablished. The muscular, skin, and mucosal layers are repaired with particular attention paid near the pedicle to avoid injury to the labial artery. The donor site area is closed primarily. After ⬃3 weeks, sufficient neovascularization of the flap has occurred to permit division of the bridged pedicle. When the skin cancer excision involved the oral commissure, the Abbe–Estlander flap is employed with the vascular pedicle located within the medial border of the flap. The resulting commissure will be rounded and may require a secondary commisureplasty.
Cutaneous Malignancies of the Head and Neck
3
135
Glabellar flap near the medial canthus. The glabellar flap is an axial flap that derives its blood supply primarily from the supratrochlear artery and secondarily from the dorsal nasal branches. The flap can be easily designed to reconstruct defects involving the bridge or upper half of the nose. This patient has a defect near the medial canthus of the eye that does not involve the periosteum or underlying bone. The resected lesion produces a triangle while preserving the medial canthal tendon. The flap is designed and raised above the periosteum of the frontal and nasal bones. The flap is transposed into the defect site, and trimmed and closed with as little tension as possible to prevent distortion of the medial end of the upper eyelid. Care must be taken in selecting the donor area to prevent placement of hair-bearing skin into the medial canthus area.
136
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Nasolabial flap. The nasolabial flap is a versatile axial flap that receives its blood supply from the nasolabial artery. The flap is extremely reliable and is employed in reconstructing defects on the lateral aspect of the nose or ala. Additionally, this flap may also be used to reconstruct the philtrum and columella. The nasolabial flap may be designed with an inferior or superior base. The flap is raised along the nasolabial crease, with a sufficient amount of subcutaneous fat. For a through-and-through nasal alar defect, the distal portion of the flap can be turned in to provide an inner lining and a portion of the flap is de-epithelialized before closure. The donor site can be closed primarily.
Cutaneous Malignancies of the Head and Neck
5
137
Total rhinectomy. The nose has enormous aesthetic and functional significance as the dominant midface structure. Nevertheless, extensive skin cancers that invade the cartilaginous and bony skeleton of the nose may necessitate total rhinectomy. Depending on the extent of resection, the surgeon should attempt to preserve lateral nasal wall structures such as the turbinates. A split thickness skin graft is used to cover the superficial areas of the surgical resection site to reduce wound contracture and distortion of the midface. A skin graft serves as an excellent base for the prosthetic appliance. Formal nasal reconstruction is an elaborate multistage procedure and should be deferred until the final histologic clearance of tumor is assured. Many surgeons prefer to delay the reconstruction until adjuvant radiotherapy is completed and a period of observation has passed to ensure that the disease is controlled. A nasal prosthesis can quickly restore appearance, in contrast to multistage nasal reconstructive techniques that require prolonged periods of time and a great deal of patient cooperation. Patients need to be adequately counseled about the dramatic cosmetic and psychological effects of a total rhinectomy. The interval from surgical resection of the skin cancer to placement of the final nasal prosthesis can be lengthy, since these patients often require adjuvant radiation therapy.
138
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Lai and Weber
Wedge excision and primary closure of a helical lesion. Skin cancer lesions of the helix of the ear frequently involve the skin and cartilage. Adequate resection requires full thickness removal of the skin and cartilage that also facilitates reconstruction. The resection should also include the ante-helical fold to permit rotation of the superior and inferior segments of the remaining auricle and to avoid buckling of the ante-helical fold and skin dehiscence. A wedge excision involving one third of the vertical height of the pinna may be closed primarily in an aesthetically acceptable fashion. The incision lines are drawn on both surfaces of the auricle, with the apex located at the same point on both the anterior and posterior surface. After the wedge excision, Burrow’s triangles of skin and cartilage are excised from the apex of the anterior aspect of the wound to facilitate skin approximation. The anterior and posterior perichondrium are approximated with fine absorbable suture. A single suture is placed at the lateral border to approximate the edges of the helix, and the anterior and posterior skin surfaces are closed in two separate layers. The resultant ear is smaller but maintains the appropriate contour. Larger excisions generally require multistage reconstructions and, similar to total nasal defects, can be managed with an auricular prosthesis.
Cutaneous Malignancies of the Head and Neck
7
139
Cervicofacial advancement flap for a preauricular lesion. Periauricular skin cancers may require extensive resection of the skin, subcutaneous tissue, and the lateral lobe of the parotid gland. A large preauricular defect can be closed with a cervicofacial advancement flap. (A) This patient required wide local excision of the preauricular lesion, superficial parotidectomy, and a selective neck dissection. The neck incision is designed to allow for sufficient rotation of the cervicofacial flap into the preauricular defect. In patients not requiring a neck dissection, the margins of the excised lesion are examined by frozen section analysis before raising the cervicofacial flap. The flap is raised in the subplatysmal plane to the midline.
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(continued) (B) The flap is then rotated to cover the defect and sutured.
Cutaneous Malignancies of the Head and Neck
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(continued) (C) The cervicofacial flap will reach to the level of the zygoma, but defects extending above this region may also require skin grafting to complement the rotational flap. The anterior portion of the auricle was excised in this patient because of tumor involvement, but the patency of the external auditory canal was maintained by securing the edges of the skin graft around the canal. Preservation of the anterior helix will facilitate placement of an auricular prosthesis and the wearing of eyeglasses.
142
Lai and Weber
CONCLUSION
REFERENCES
The treatment of cutaneous malignancies of the head and neck remains difficult because of the potentially catastrophic nature of disease progression and the potential morbidity of definitive tumor management. High-risk lesions need to be recognized early and completely resected. Radical tumor excision can result in significant patient morbidity caused by severe functional and cosmetic consequences. Definitive locoregional control may require parotidectomy and/or cervical lymphadenectomy to address direct invasion of the parotid gland or regional metastases. Adjuvant radiation therapy may be valuable when there is disease recurrence, perineural invasion, close tumor margins, or unfavorable tumor histopathology.7,8 As with other head and neck cancers, a comprehensive, multidisciplinary treatment approach involving the head and neck surgeon, Mohs’ micrographic surgeon, surgical pathologist, reconstructive surgeon, and radiation oncologist is necessary to eradicate this disease.
1. Padgett JK, Hendrix JD Jr: Cutaneous malignancies and their management. Otol Clin North Am 34:523-553, 2001 2. Kaldor J, Shugg D, Young B, et al: Non-melanoma skin cancer: Ten years of cancer-registry-based surveillance. Int J Cancer 53:886891, 1993 3. Rowe DE, Carroll RJ, Day CL , Jr, et al: Prognostic factors for local recurrence, metastasis and survival rates in squamous cell carcinoma of the skin, ear and lip: Implications for treatment modality selection. J Am Acad Dermatol 26:976-990, 1992 4. Goepfert H, Dichtel WJ, Medina JE, et al: Perineural invasion of squamous cell skin carcinoma of the head and neck. Am J Surg 148:542-547, 1984 5. Wentzell JM, Robinson JK: Embryologic fusion planes and the spread of cutaneous carcinoma: A review and reassessment. J Dermatol Surg Oncol 16:1000-1006, 1990 6. Sewell DA, Lai SY, Weber RS: Nonmelanoma skin cancer of the head and neck, in Myers EN, Suen JY, Myers JN, Hanna EYN (eds): Cancer of the Head and Neck, 4. Philadelphia, PA, Saunders, 2003, pp 117-132 7. Taylor BW Jr, Brant TA, Mendenhall NP, et al: Carcinoma of the skin metastatic to the parotid area lymph nodes. Head Neck 13:427-433, 1991 8. Morrison WH, Garden AS, Ang KK: Radiation therapy for nonmelanoma skin carcinomas. Clin Plast Surg 24:719-729, 1997