Facial Reconstruction after Cancer Resection

Skin cancers of the face are a common problem seen by plastic surgeons. Typically, patients are referred to plastic surgery for excision after more conservative treatment have failed, or the lesion was caught too late and has grown to a size that requires excision. Examples of typical cancers are squamous cell carcinoma, basal cell carcinoma, and malignant melanoma.

When any skin cancer is surgically excised, a small amount of surrounding tissue, a margin, must also be included to insure the cancer is completely resected. Margins typically range from 0.5-2cm. Due to the need of adequate margins, seaming small lesions often result in large skin defects that can be particularly challenging to close, especially in the aesethicially sensitive area of the face. As such, the initial evaluation of a skin lesion is important to determine the type of skin cancer and its physical characteristics, which ultimately dictate treatment.

Management with a one-stage procedure can be undertaken in which the plastic surgeon excises the lesion with appropriate margins and closes the defect in one procedure. This approach is best applied to well circumscribed lesions with clear boarders that are located away from aesthetically valuable tissue in the midface, or that are small enough that adequate margins will not significantly impact facial symmetry. Alternatively, when a lesion is large, located in an aesthetically sensitive area, or with poorly defined boarders, a two-stage approach can be employed. In a two-stage approach, a patient would have the lesion resected by a MOHS surgeon, followed by closure of the wound by plastic surgery typically within a week.

The benefit of a MOHS resection is that the minimal amount of tissue needed to accomplish cancer free margins is excised. This is accomplished by taking thin margins with immediate microscopic evaluation for the presence of cancer. Thin repeat margins are excised until all boarders are free of tumor. Once resection of the tumor is complete, the wound is typically left open and a dressing applied. The patient then follows up with a plastic surgeon for evaluation and planning for reconstruction.

It is important for any patient undergoing skin cancer excision to understand that a scar will be present after the procedure. However, plastic surgeons have multiple techniques at their disposal to best conceal the resulting scar so as to make it as unobtrusive as possible. Such techniques include placing scars in skin wrinkles, along relaxed skin tension lines, or at the junction of facial subunits like the cheek/nasal junction. How a particular defect is closed is individualized to each patient and defect, and depends heavily on the location and size of the defect. Consultation with a USF plastic surgeon is an important first step in skin cancer evaluation.