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Ensuring Skin Cancer Clearance — How to Save Face
Ensuring Skin Cancer Clearance — How to Save Face
3
C H A P T E R
Clinical decisions must be made: What is the diagnosis? What is the extent of the tumor spread? What is the risk of recurrence? How can excision of the tumor and the repair of the defect be most effectively and efficiently timed and coordinated?
Diagnosis Basal cell carcinoma is the most common skin cancer, growing slowly and locally. If untreated, it may lead to severe deformity and, uncommonly, death, due to orbital and CNS extension. Squamous cell carcinoma is less frequent but can be locally aggressive and occasionally spread to local lymph nodes, if neglected or recurrent. Melanoma is the least common. However, lymph node and systemic spread is frequent. Except for small, clinically characteristic and easily repaired tumors, a diagnostic biopsy should be obtained, prior to a formal excision and repair. A shave or excisional biopsy of non-melanotic skin cancers will provide a histologic diagnosis. All suspicious melanotic lesions should be removed by excisional biopsy. Occasionally if a melanoma is large, an incomplete incisional biopsy of the most suspicious area can be done. Definitive excision is then planned to include clinically obvious tumor, with an additional margin of tissue, to ensure complete excision of all cancer.
Curing Skin Cancer Electrodesiccation, curettage and cryotherapy are destructive techniques, frequently employed by dermatologists. They are recommended for small, superficial primary basal and squamous cell carcinomas with well-defined borders. Formal margin evaluation is unavailable. The wound heals secondarily, without formal repair. Radiation therapy can be a safe, noninvasive treatment for selected basal cell carcinoma and squamous cell carcinomas. However, its use is limited to the elderly or to patients who are poor surgical candidates. Postradiation osteitis and chondritis and other late radiation sequela, including carcinogenesis, can occur. The cosmetic effects of radiation therapy can be good, but are variable over time. Late tissue atrophy and irregular pigmentation may occur.
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Surgical excision and reconstruction is the primary treatment for significant cancers. The defect usually consists of external skin and varying amounts of deeper tissues. The amount of tissue loss will depend on the extent of excision required to cure the cancer. Tumors recur because they are incompletely excised. So, the control of skin cancer requires that clear margins be ensured.
Tumor Extent and the Risk of Recurrence Traditionally, the extent of tumor is estimated visually and then an additional margin of normal tissue is excised, based on clinical judgment or published ‘rules of thumb’. The defect is surgically repaired. The specimen is sent for permanent section examination. However, this approach has many limitations. The true extent of tumor spread is unpredictable. Such ‘guesstimated’ surgical margins are arbitrary. The risk of recurrence is high. If the margins are positive, several days later after the final pathologic report is available, a re-excision will be required if recurrence is to be avoided. Intraoperative frozen section can be used to immediately verify the completeness of excision, prior to wound closure. Although satisfactory for small lesions, large tissue excisions, requiring multiple margins for review, place a significant burden on the hospital pathologist. Inconvenience and disinterest may lead to incomplete histologic examination. Intraoperative frozen sections are also time-consuming and disrupt the operating schedule. If the required excision and repair are larger than expected, neither the surgeon nor the patient is prepared for the defect and the needs of its repair. These traditional methods of excision, based on clinical judgment and permanent and frozen section examination, are appropriate for small primary tumors or those with a non-aggressive histology and presentation. They are useful for cancers, located in low risk sites, which will not require a complex repair. However, the responsibility of the surgeon to ensure correct orientation and a competent pathologist remains high. The evaluation of melanoma or melanoma in situ by frozen section is unreliable. When dealing with melanoma in situ, the clinical lesion should be examined preoperatively under a Wood’s light. Previously unseen pigmentation may more clearly delineate the true margin. The lesion is then excised and the wound dressed. A delayed primary repair is performed after the specimen margins are verified by permanent section. If primary repair is performed without known clear margins, the use of large rotation flaps which permit re-excision and re-advancement should be considered. Hopefully, their re-elevation and further advancement will allow a later second repair if the initial excision is found to be inadequate. High risk cancers must be identified. They are characterized by their indistinct clinical margins, their large size and required volume of excised tissue, their discontinuous or nonspherical growth along tissue planes and their proximity to important facial landmarks. All skin cancers, especially difficult cancers, require a three-dimensional evaluation of all lateral and deep margins. In the past, tumors were evaluated pathologically with the ‘breadloaf technique’ (Figure 3–1). This method evaluates, in practice, only the edges of multiple vertical sections. Most of the specimen remains unexamined — less than 0.1% of the true margin. When tumor excision is incomplete, recurrence is common. 54
Tumor Extent and the Risk of Recurrence
Breadloaf technique 0.1% margin evaluation
Missed projections of tumor Figure 3–1
To better evaluate peripheral and deep margins, the surgeon can use the Margin Check Technique. First, the surgical margins are outlined clinically, based on physical examination, clinical history, histology and clinical judgment. An en bloc excision is performed. Then, additional 1 to 2 mm slivers of the entire lateral and deep margins are excised, carefully orienting the specimen with colored inks or sutures. The primary excision and the additional margins are sent for permanent section to a willing pathologist. The wound is dressed. The patient is discharged. This complete re-excision of the peripheral and deep margins allows the pathologist to focus on ‘what is left’ after the primary excision, rather than ‘what has been removed’. Careful orientation by the surgeon improves the likelihood that the margins will be evaluated accurately, in their entirety. A delayed primary repair is scheduled 24 to 72 hours later, pending verification of clear margins and complete tumor excision. If any margin shows residual tumor, it is re-excised and the repair postponed until complete clearance is verified. This is not Mohs Micrographic Surgery, but it can be an effective and efficient method. 55
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
In Figure 3–2, a large recurrent basal cell carcinoma is present within the tip and dorsum. The clinical tumor was marked with ink. Three millimeters of normal skin was included as an additional margin. The specimen was excised. A sliver of additional skin along the entire outer border of the wound was excised and carefully oriented with sutures. The specimens and a drawing of the excision were hand carried to the pathology department by the surgeon. The pathologist was asked to direct his attention to the additional marginal excisions and the entire horizontal deep surface of the excised specimen. In this case, an additional excision of the deep margin was not undertaken to avoid excision of the underlying tip cartilages. If the frozen sections are clear, the wound can be reconstructed. Or, preferentially, the wound can be dressed and the repair delayed. After permanent sections reveal clear margins, the patient is returned to the operating room. A delay between excision and repair is desirable. The pathologist has time to leisurely examine the specimen. The surgeon and patient have the opportunity to plan their options. The OR schedule is not disrupted. In this case, adjacent normal skin, within the tip subunit, was excised and the nose resurfaced with a subunit forehead flap.
A Figure 3–2
56
B
Tumor Extent and the Risk of Recurrence
C
D
Figure 3–2, Continued
The margin check technique is especially helpful in the treatment of melanoma in situ. It is impossible to evaluate melanocytic lesions by frozen sections. So margins are outlined, based on visual observation and Wood’s light examination. The lesion is excised with a margin of peripheral tissue. Then the entire defect margin is re-excised and carefully oriented for permanent histologic section. The wound is left open and a dressing applied. The defect is only repaired with a skin graft or flap after permanent sections reveal a complete excision. If positive, the margin is re-excised and further permanent sections are obtained. Mohs Micrographic Surgery originally used the escharotic, zinc chloride, to chemically ‘fix’ the lesion in vivo. Twenty-four hours later, the coagulated, anesthetic area was excised and stained histologically. Today, Mohs surgery employs traditional frozen section techniques. The fresh wound, which follows modern technique, allows immediate excision and pathologic examination. Clinically visible tumor is excised, in saucer-like layers. Serial horizontal sections are removed and oriented with detailed mapping techniques. One hundred per cent of all lateral and deep margins are examined. This permits microscopically controlled identification of the exact size, shape and extension of the tumor. Further excision of any histologically positive area is performed until all tumor margins are clear. This microscopically controlled excision is performed under local anesthesia in an office setting. 57
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs histographic surgery (Figure 3–3) is especially useful for difficult tumors — basal and squamous cell skin cancers which are large (greater than 2 cm in size), recurrent, have poorly defined visible borders, are morphea or sclerotic basal cell cancers
Moh’s Technique
Curretage
Local Anesthesia
Moh’s Technique
Horizontal excision
Inverted deep margin
Fresh wound
Mapping and color coding
Moh’s Technique
Frozen Section Figure 3–3 (Courtesy of Michael Huether MD, Tucson, Arizona.)
58
Tumor Extent and the Risk of Recurrence
45%
Lateral margin clear
1.
Cancer 1 2 3 4 5 2.
Horizontal sections until “clear”
5.
3.
4.
Deep and lateral clear
Figure 3–3, Continued
(histologic types with imperceptible margins difficult to evaluate clinically), and those in difficult locations (such as the nose, ear or eye where maximum tissue preservation may ease repair). The cure rate for Mohs excision of a primary basal cell carcinoma is 99% and, for a squamous cell carcinoma, 95%. Recurrent basal cell carcinoma and squamous cell carcinoma have cure rates of 95% and 90%, respectively. Because the risk of recurrence after Mohs excision is very low, early repair is appropriate. The Mohs defect can be closed immediately or in a delayed primary fashion. Traditionally, melanomas are excised with a 1, 2 or 3-cm margin depending on the depth (less than 1 mm, 1 to 4 mm, or greater than 4 mm, respectively). More recently, Mohs surgeons have applied their technique to the excision of melanoma, using special stains. Survival rates, published in the dermatologic literature, are comparable to traditional surgical margin excision. However, the use of Mohs surgery for melanoma or melanoma in situ may not be accepted by all oncologists. 59
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs and the Plastic Surgeon The pre-Mohs consult Ideally, the patient is seen prior to tumor excision (Figure 3–4). The patient may be your own whom you will refer for Mohs or the patient may be referred to you by a Mohs dermatologist, prior to cancer excision. During the initial consultation, the tumor diagnosis is verified, the likely extent of excision and reconstruction discussed, and the treatment options outlined with the patient. After a complete history and physical examination of the head and neck area, the patient’s health status is clarified. A preoperative medical clearance can be obtained by referral to appropriate specialties. The Mohs excision and the subsequent plastic repair are coordinated between physicians. The Mohs surgery is scheduled, a follow-up appointment is made to allow a post excisional evaluation of the defect and operating time is set aside for repair. Occasionally, the true tumor extent is not obvious to the dermatologist prior to excision. The Mohs surgeon may refer a patient, unexpectedly, with a large defect which requires plastic repair.
Figure 3–4
60
Mohs and the Plastic Surgeon
The post-Mohs consult After tumor clearance, the patient is re-examined (Figure 3–5). The true extent of the defect is confirmed. The anatomic and aesthetic loss is defined and the repair planned, after discussion with the patient. Reconstruction usually follows within 48 to 72 hours after Mohs excision, although it can be delayed to a future date. This repair is illustrated in Chapter 7. Combining Mohs excision and delayed primary repair is highly effective — a high cure rate permits early repair with minimal risk of recurrence. It is also efficient — the repair becomes a planned elective operation. Because tumor clearance has been confirmed prior to coming to the operating room, evaluation of a specimen does not delay the procedure. The length of anesthesia and operating times are shortened. Occasionally, the Mohs surgeon finds the tumor to be more extensive than suspected prior to starting the excision. Or patient anxiety, bleeding, or unexpected bone or deep intranasal tumor extension prevents complete tumor clearance. In such circumstances,
A
C
B
Figure 3–5
61
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs surgery and standard intraoperative excisions are combined. After completion of the first stage Mohs, further surgical excision is completed in the operating room by the plastic surgeon. Clearance of the deep and lateral margins or tumor extension into hard tissue is performed. In other circumstances, the patient may present with a complex wound for repair after routine surgical excision. Too often, the accompanying pathology reports raise concern about tumor clearance. This patient (Figure 3–6) presented with an open wound and ‘clear’ pathologic margins. He had undergone multiple surgical excisions, over several days, by a team of ENT and plastic surgeons until the tumor was ‘completely excised’. A history of multiple specimens, staged procedures, and large-volume tissue excisions should raise concern. Was each specimen properly oriented? Are the margins truly clear? Is the final pathologic report reliable? Multiple reports from the surgeon and pathologist are confusing at best and dangerous at worst. In such cases, reconstruction is best postponed. The entire wound margin should be re-excised by the Mohs technique to rule out residual tumor. The repair begins only when tumor clearance is assured. In this case, multiple foci of residual basal cell carcinoma were identified by the Mohs technique. This ‘missed’ tumor was cleared. The defect was considerably enlarged but the likelihood of recurrence was considerably decreased (Figure 3–7). Reconstruction with intranasal lining flaps, primary cartilage grafts, and a three-stage forehead flap was then undertaken with confidence as illustrated in Chapter 7.
Figure 3–6
62
A Team Effort
Figure 3–7
A Team Effort Although the old zinc chloride technique precluded primary closure, modern Mohs micrographic surgery, which verifies all lateral and deep margins by frozen section, creates a fresh wound for immediate repair. Many smaller defects will be closed, appropriately, without referral by the Mohs surgeon. However, Mohs excision and reconstruction by a plastic surgeon are ideally combined. Mohs is often used for extensive or recurrent tumors. The subsequent defects may be large and of unpredictable size and shape. Frequently, they are associated with previous cancer excision, radiation and prior repair. The resultant repair is complicated by old and new deformities. Donor sites may be depleted. Often, the patient is anxious. These more extensive and complicated reconstructions will require the training and hospital facilities that a plastic surgeon can provide. Combining Mohs excision and plastic repair allows the surgeon to discuss the goals and options with the patient in a leisurely manner — often prior to tumor excision. This permits a truly informed consent. The patient’s anxiety is lessened and his or her commitment and cooperation are magnified. The donor sites, stages, the need for general anesthesia, operative time and hospital stay can be predetermined, prior to scheduling surgery. An elective operation is planned and a complex repair outlined, preoperatively. Intraoperatively, stressful decision-making is minimized. On the day of surgery, neither the patient nor the surgeon is ‘surprised’ by the defect and the complexity of the repair. The surgery schedule is not disrupted by unforeseen re-excisions and pathology delay. Operative and anesthesia time are minimized. Mohs micrographic surgery and delayed primary repair by a plastic surgeon are effective and efficient. The Mohs surgeon and the plastic surgeon make an attractive team. 63
3
C H A P T E R
Clinical decisions must be made: What is the diagnosis? What is the extent of the tumor spread? What is the risk of recurrence? How can excision of the tumor and the repair of the defect be most effectively and efficiently timed and coordinated?
Diagnosis Basal cell carcinoma is the most common skin cancer, growing slowly and locally. If untreated, it may lead to severe deformity and, uncommonly, death, due to orbital and CNS extension. Squamous cell carcinoma is less frequent but can be locally aggressive and occasionally spread to local lymph nodes, if neglected or recurrent. Melanoma is the least common. However, lymph node and systemic spread is frequent. Except for small, clinically characteristic and easily repaired tumors, a diagnostic biopsy should be obtained, prior to a formal excision and repair. A shave or excisional biopsy of non-melanotic skin cancers will provide a histologic diagnosis. All suspicious melanotic lesions should be removed by excisional biopsy. Occasionally if a melanoma is large, an incomplete incisional biopsy of the most suspicious area can be done. Definitive excision is then planned to include clinically obvious tumor, with an additional margin of tissue, to ensure complete excision of all cancer.
Curing Skin Cancer Electrodesiccation, curettage and cryotherapy are destructive techniques, frequently employed by dermatologists. They are recommended for small, superficial primary basal and squamous cell carcinomas with well-defined borders. Formal margin evaluation is unavailable. The wound heals secondarily, without formal repair. Radiation therapy can be a safe, noninvasive treatment for selected basal cell carcinoma and squamous cell carcinomas. However, its use is limited to the elderly or to patients who are poor surgical candidates. Postradiation osteitis and chondritis and other late radiation sequela, including carcinogenesis, can occur. The cosmetic effects of radiation therapy can be good, but are variable over time. Late tissue atrophy and irregular pigmentation may occur.
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Surgical excision and reconstruction is the primary treatment for significant cancers. The defect usually consists of external skin and varying amounts of deeper tissues. The amount of tissue loss will depend on the extent of excision required to cure the cancer. Tumors recur because they are incompletely excised. So, the control of skin cancer requires that clear margins be ensured.
Tumor Extent and the Risk of Recurrence Traditionally, the extent of tumor is estimated visually and then an additional margin of normal tissue is excised, based on clinical judgment or published ‘rules of thumb’. The defect is surgically repaired. The specimen is sent for permanent section examination. However, this approach has many limitations. The true extent of tumor spread is unpredictable. Such ‘guesstimated’ surgical margins are arbitrary. The risk of recurrence is high. If the margins are positive, several days later after the final pathologic report is available, a re-excision will be required if recurrence is to be avoided. Intraoperative frozen section can be used to immediately verify the completeness of excision, prior to wound closure. Although satisfactory for small lesions, large tissue excisions, requiring multiple margins for review, place a significant burden on the hospital pathologist. Inconvenience and disinterest may lead to incomplete histologic examination. Intraoperative frozen sections are also time-consuming and disrupt the operating schedule. If the required excision and repair are larger than expected, neither the surgeon nor the patient is prepared for the defect and the needs of its repair. These traditional methods of excision, based on clinical judgment and permanent and frozen section examination, are appropriate for small primary tumors or those with a non-aggressive histology and presentation. They are useful for cancers, located in low risk sites, which will not require a complex repair. However, the responsibility of the surgeon to ensure correct orientation and a competent pathologist remains high. The evaluation of melanoma or melanoma in situ by frozen section is unreliable. When dealing with melanoma in situ, the clinical lesion should be examined preoperatively under a Wood’s light. Previously unseen pigmentation may more clearly delineate the true margin. The lesion is then excised and the wound dressed. A delayed primary repair is performed after the specimen margins are verified by permanent section. If primary repair is performed without known clear margins, the use of large rotation flaps which permit re-excision and re-advancement should be considered. Hopefully, their re-elevation and further advancement will allow a later second repair if the initial excision is found to be inadequate. High risk cancers must be identified. They are characterized by their indistinct clinical margins, their large size and required volume of excised tissue, their discontinuous or nonspherical growth along tissue planes and their proximity to important facial landmarks. All skin cancers, especially difficult cancers, require a three-dimensional evaluation of all lateral and deep margins. In the past, tumors were evaluated pathologically with the ‘breadloaf technique’ (Figure 3–1). This method evaluates, in practice, only the edges of multiple vertical sections. Most of the specimen remains unexamined — less than 0.1% of the true margin. When tumor excision is incomplete, recurrence is common. 54
Tumor Extent and the Risk of Recurrence
Breadloaf technique 0.1% margin evaluation
Missed projections of tumor Figure 3–1
To better evaluate peripheral and deep margins, the surgeon can use the Margin Check Technique. First, the surgical margins are outlined clinically, based on physical examination, clinical history, histology and clinical judgment. An en bloc excision is performed. Then, additional 1 to 2 mm slivers of the entire lateral and deep margins are excised, carefully orienting the specimen with colored inks or sutures. The primary excision and the additional margins are sent for permanent section to a willing pathologist. The wound is dressed. The patient is discharged. This complete re-excision of the peripheral and deep margins allows the pathologist to focus on ‘what is left’ after the primary excision, rather than ‘what has been removed’. Careful orientation by the surgeon improves the likelihood that the margins will be evaluated accurately, in their entirety. A delayed primary repair is scheduled 24 to 72 hours later, pending verification of clear margins and complete tumor excision. If any margin shows residual tumor, it is re-excised and the repair postponed until complete clearance is verified. This is not Mohs Micrographic Surgery, but it can be an effective and efficient method. 55
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
In Figure 3–2, a large recurrent basal cell carcinoma is present within the tip and dorsum. The clinical tumor was marked with ink. Three millimeters of normal skin was included as an additional margin. The specimen was excised. A sliver of additional skin along the entire outer border of the wound was excised and carefully oriented with sutures. The specimens and a drawing of the excision were hand carried to the pathology department by the surgeon. The pathologist was asked to direct his attention to the additional marginal excisions and the entire horizontal deep surface of the excised specimen. In this case, an additional excision of the deep margin was not undertaken to avoid excision of the underlying tip cartilages. If the frozen sections are clear, the wound can be reconstructed. Or, preferentially, the wound can be dressed and the repair delayed. After permanent sections reveal clear margins, the patient is returned to the operating room. A delay between excision and repair is desirable. The pathologist has time to leisurely examine the specimen. The surgeon and patient have the opportunity to plan their options. The OR schedule is not disrupted. In this case, adjacent normal skin, within the tip subunit, was excised and the nose resurfaced with a subunit forehead flap.
A Figure 3–2
56
B
Tumor Extent and the Risk of Recurrence
C
D
Figure 3–2, Continued
The margin check technique is especially helpful in the treatment of melanoma in situ. It is impossible to evaluate melanocytic lesions by frozen sections. So margins are outlined, based on visual observation and Wood’s light examination. The lesion is excised with a margin of peripheral tissue. Then the entire defect margin is re-excised and carefully oriented for permanent histologic section. The wound is left open and a dressing applied. The defect is only repaired with a skin graft or flap after permanent sections reveal a complete excision. If positive, the margin is re-excised and further permanent sections are obtained. Mohs Micrographic Surgery originally used the escharotic, zinc chloride, to chemically ‘fix’ the lesion in vivo. Twenty-four hours later, the coagulated, anesthetic area was excised and stained histologically. Today, Mohs surgery employs traditional frozen section techniques. The fresh wound, which follows modern technique, allows immediate excision and pathologic examination. Clinically visible tumor is excised, in saucer-like layers. Serial horizontal sections are removed and oriented with detailed mapping techniques. One hundred per cent of all lateral and deep margins are examined. This permits microscopically controlled identification of the exact size, shape and extension of the tumor. Further excision of any histologically positive area is performed until all tumor margins are clear. This microscopically controlled excision is performed under local anesthesia in an office setting. 57
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs histographic surgery (Figure 3–3) is especially useful for difficult tumors — basal and squamous cell skin cancers which are large (greater than 2 cm in size), recurrent, have poorly defined visible borders, are morphea or sclerotic basal cell cancers
Moh’s Technique
Curretage
Local Anesthesia
Moh’s Technique
Horizontal excision
Inverted deep margin
Fresh wound
Mapping and color coding
Moh’s Technique
Frozen Section Figure 3–3 (Courtesy of Michael Huether MD, Tucson, Arizona.)
58
Tumor Extent and the Risk of Recurrence
45%
Lateral margin clear
1.
Cancer 1 2 3 4 5 2.
Horizontal sections until “clear”
5.
3.
4.
Deep and lateral clear
Figure 3–3, Continued
(histologic types with imperceptible margins difficult to evaluate clinically), and those in difficult locations (such as the nose, ear or eye where maximum tissue preservation may ease repair). The cure rate for Mohs excision of a primary basal cell carcinoma is 99% and, for a squamous cell carcinoma, 95%. Recurrent basal cell carcinoma and squamous cell carcinoma have cure rates of 95% and 90%, respectively. Because the risk of recurrence after Mohs excision is very low, early repair is appropriate. The Mohs defect can be closed immediately or in a delayed primary fashion. Traditionally, melanomas are excised with a 1, 2 or 3-cm margin depending on the depth (less than 1 mm, 1 to 4 mm, or greater than 4 mm, respectively). More recently, Mohs surgeons have applied their technique to the excision of melanoma, using special stains. Survival rates, published in the dermatologic literature, are comparable to traditional surgical margin excision. However, the use of Mohs surgery for melanoma or melanoma in situ may not be accepted by all oncologists. 59
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs and the Plastic Surgeon The pre-Mohs consult Ideally, the patient is seen prior to tumor excision (Figure 3–4). The patient may be your own whom you will refer for Mohs or the patient may be referred to you by a Mohs dermatologist, prior to cancer excision. During the initial consultation, the tumor diagnosis is verified, the likely extent of excision and reconstruction discussed, and the treatment options outlined with the patient. After a complete history and physical examination of the head and neck area, the patient’s health status is clarified. A preoperative medical clearance can be obtained by referral to appropriate specialties. The Mohs excision and the subsequent plastic repair are coordinated between physicians. The Mohs surgery is scheduled, a follow-up appointment is made to allow a post excisional evaluation of the defect and operating time is set aside for repair. Occasionally, the true tumor extent is not obvious to the dermatologist prior to excision. The Mohs surgeon may refer a patient, unexpectedly, with a large defect which requires plastic repair.
Figure 3–4
60
Mohs and the Plastic Surgeon
The post-Mohs consult After tumor clearance, the patient is re-examined (Figure 3–5). The true extent of the defect is confirmed. The anatomic and aesthetic loss is defined and the repair planned, after discussion with the patient. Reconstruction usually follows within 48 to 72 hours after Mohs excision, although it can be delayed to a future date. This repair is illustrated in Chapter 7. Combining Mohs excision and delayed primary repair is highly effective — a high cure rate permits early repair with minimal risk of recurrence. It is also efficient — the repair becomes a planned elective operation. Because tumor clearance has been confirmed prior to coming to the operating room, evaluation of a specimen does not delay the procedure. The length of anesthesia and operating times are shortened. Occasionally, the Mohs surgeon finds the tumor to be more extensive than suspected prior to starting the excision. Or patient anxiety, bleeding, or unexpected bone or deep intranasal tumor extension prevents complete tumor clearance. In such circumstances,
A
C
B
Figure 3–5
61
Chapter • 3 • Ensuring Skin Cancer Clearance — How to Save Face
Mohs surgery and standard intraoperative excisions are combined. After completion of the first stage Mohs, further surgical excision is completed in the operating room by the plastic surgeon. Clearance of the deep and lateral margins or tumor extension into hard tissue is performed. In other circumstances, the patient may present with a complex wound for repair after routine surgical excision. Too often, the accompanying pathology reports raise concern about tumor clearance. This patient (Figure 3–6) presented with an open wound and ‘clear’ pathologic margins. He had undergone multiple surgical excisions, over several days, by a team of ENT and plastic surgeons until the tumor was ‘completely excised’. A history of multiple specimens, staged procedures, and large-volume tissue excisions should raise concern. Was each specimen properly oriented? Are the margins truly clear? Is the final pathologic report reliable? Multiple reports from the surgeon and pathologist are confusing at best and dangerous at worst. In such cases, reconstruction is best postponed. The entire wound margin should be re-excised by the Mohs technique to rule out residual tumor. The repair begins only when tumor clearance is assured. In this case, multiple foci of residual basal cell carcinoma were identified by the Mohs technique. This ‘missed’ tumor was cleared. The defect was considerably enlarged but the likelihood of recurrence was considerably decreased (Figure 3–7). Reconstruction with intranasal lining flaps, primary cartilage grafts, and a three-stage forehead flap was then undertaken with confidence as illustrated in Chapter 7.
Figure 3–6
62
A Team Effort
Figure 3–7
A Team Effort Although the old zinc chloride technique precluded primary closure, modern Mohs micrographic surgery, which verifies all lateral and deep margins by frozen section, creates a fresh wound for immediate repair. Many smaller defects will be closed, appropriately, without referral by the Mohs surgeon. However, Mohs excision and reconstruction by a plastic surgeon are ideally combined. Mohs is often used for extensive or recurrent tumors. The subsequent defects may be large and of unpredictable size and shape. Frequently, they are associated with previous cancer excision, radiation and prior repair. The resultant repair is complicated by old and new deformities. Donor sites may be depleted. Often, the patient is anxious. These more extensive and complicated reconstructions will require the training and hospital facilities that a plastic surgeon can provide. Combining Mohs excision and plastic repair allows the surgeon to discuss the goals and options with the patient in a leisurely manner — often prior to tumor excision. This permits a truly informed consent. The patient’s anxiety is lessened and his or her commitment and cooperation are magnified. The donor sites, stages, the need for general anesthesia, operative time and hospital stay can be predetermined, prior to scheduling surgery. An elective operation is planned and a complex repair outlined, preoperatively. Intraoperatively, stressful decision-making is minimized. On the day of surgery, neither the patient nor the surgeon is ‘surprised’ by the defect and the complexity of the repair. The surgery schedule is not disrupted by unforeseen re-excisions and pathology delay. Operative and anesthesia time are minimized. Mohs micrographic surgery and delayed primary repair by a plastic surgeon are effective and efficient. The Mohs surgeon and the plastic surgeon make an attractive team. 63