ATLAS OF EXTREME FACIAL CANCER : challenges and solutions

This book shares an expert experience in managing difficult facial skin cancer and presents rare cases from the authors's own practice. The content follows an anatomical approach based on the complex and often staged reconstruction of extreme facial skin cancer. Written in a clear and logical format, it is intended as a guideline atlas and surgical handbook, defining the principles of CLEAR (Complete Local Excision of the cancer + Aesthetic Reconstruction) and DRAPE (Delayed Reconstruction After Pathological Examination) for reconstructing the face. The book incorporates a wealth of multi-disciplinary knowledge from surgeons, anaesthetists, research scientists, speech / swallowing therapists, pathologists, radiologists and prosthetic rehabilitation specialists. The surgical techniques presented here require a high degree of expertise. Accordingly, the book will be of interest to professionals in the fields of Plastic and Oral and Maxillofacial Surgery, as well as Dermatology. Foreword Preface Acknowledgements Contents Contributors Part I: Epidemiology, Science, and Anatomical Concepts The Skin Cancer Epidemic 1 Introduction 2 Why Do Patients Present with Extreme Facial Cancer? 3 Alternative Medical Misadventure: A Salutary Lesson 4 Guiding Principles of Surgical Management 5 Management/Technique 6 Indications 6.1 Loco-Regional Combined Flaps 6.2 Free-Flap Option 7 Contraindications 8 Palliative Surgery as an Option 9 Innovations 10 Management of Complications 11 Controversies 12 Conclusion/Summary References Cancer Stem Cells in the Head and Neck Cancers 1 Models of Cancer 2 Cancer Stem Cells 3 Identification of Cancer Stem Cells 4 Origin of Cancer Stem Cells 5 Cancer Metastasis 6 Circulating Tumour Cells 7 Cancer Stem Cells and Tumour Microenvironment 8 Cancer Stem Cells and Treatment Resistance and Cancer Recurrence and Metastasis 9 Cancer Stem Cells in Cutaneous Malignant Melanoma 10 Cancer Stem Cells in Cutaneous Squamous Cell Carcinoma 11 Cancer Stem Cells in Basal Cell Carcinoma 12 The Renin-Angiotensin System, Its Bypass Loops and Novel Cancer Treatment References Head and Neck Pathology: Practical Points to Ponder 1 Introduction 2 Obtaining a Specimen 3 Fine Needle Aspiration 3.1 Sample Procurement 3.2 Smear Preparation 3.3 Papanicolaou Stain vs Giemsa/Diff-Quik Stain 3.4 Artefacts: What Can Go Wrong in FNA Smears and How to Avoid It 3.4.1 Drying Artefact 3.4.2 Crush Artefact 3.4.3 Too Thick 3.5 Preparing FNA Specimens for Ancillary Studies 4 Frozen Sections 5 Biopsy/Excision or Incision 5.1 Core Needle Biopsy 5.2 The Complex Resection Specimen 5.2.1 Submitting Pathology Specimens 5.2.2 Orientation of Pathology Specimens 6 Transporting a Specimen 7 Ancillary Studies 8 Special Stains 9 Immunohistochemistry 10 Flow Cytometry 11 Molecular Studies 12 Making Sense of the Pathologist’s Report 12.1 Tumour Thickness and Depth of Invasion 12.2 Pattern of Invasion at the Tumour Front 12.3 Perineural Invasion 12.4 Margin Status 12.5 Nodal Status and Pathological Staging 13 A Take-Home Message from Pathologists References Applied Facial Anatomy 1 Introduction 2 Mechanisms of Cancer Spread 2.1 Direct Extension 2.2 Spread from the Ear to the Parotid Gland 2.3 Perineural Invasion 2.4 Lymphovascular and Perineural Invasion 2.5 Metastases with Extranodal Spread 2.6 Periorbital Spread 2.7 Peri-auricular Spread 2.8 Bone Invasion 2.9 CT Appearance of Lymph Node Spread 2.10 Subdermal Spread 2.11 Skull Base Perineural Spread 3 Complication Management 4 Conclusion/Summary References The Team Approach in Cancer Care 1 Introduction 2 Management/Technique 3 Indications 4 Pathologist’s Role 5 Psychological Issues/Body Image 6 Anaesthetist’s Role 7 Nursing Care Issues 8 Speech Pathologist/Nutrition Issues 9 Innovations 9.1 Consult Other Specialists 10 Conclusion/Summary References Part II: Avoiding Complications The Burden of Facial Deformity 1 Introduction 2 Further Clinical Cases Illustrating the Principles of Aesthetic Reconstruction to Reduce the Deformity 3 Aesthetic and Functional Reconstruction 4 Planning in Reverse Principles 5 Planning for Multiple Local Flaps 6 Large Composite Facial Defects Requiring Free Flap Solutions 7 Contraindications 8 Innovations 9 Conclusion/Summary References Pedicled Versus Free Flaps 1 Introduction 2 Defect Analysis 3 Patient Analysis 4 Reconstructive Options 4.1 Primary Closure 4.2 Skin Grafts 4.3 Biological Wound Agents 4.4 Flap Reconstruction 4.5 Regional and Free Flap Reconstruction 4.6 Pedicle Flaps 4.6.1 The Submental Island Pedicled Flap 4.6.2 The Supraclavicular Artery Island Flap 4.6.3 The Pectoralis Major Flap 4.7 Pedicle Flap Limitations 5 Free Flaps 5.1 Free Flap Limitations 6 Comparison of Pedicle and Free Flap Reconstruction in Facial Reconstructive Surgery 7 Conclusion References The Novel Expanded Forehead Flap 1 Introduction 2 Basic Surgical Anatomy 3 Indications and Technique Selection 4 Techniques and Management 4.1 Advancement Forehead Flap 4.1.1 Serial Excision of a Congenital Forehead Naevus (Fig. 2) 4.1.2 Bilateral Advancement Flap for a Case of Carcinoma (Fig. 3) 4.2 Transposition Forehead Flap 4.2.1 Midline Forehead Flap with an Inter-eyebrow Pedicle (Fig. 4) 4.2.2 Staged Interpolated Transverse Forehead Flap (Fig. 5) 4.3 Axial Forehead Flap 4.3.1 Island Forehead Flap to Repair an Upper Eyelid Defect (Fig. 6) 4.3.2 Over-extended Forehead Flap for Nasal and Hemi-mid-facial Reconstruction (Fig. 7) 4.4 Expanded Forehead Flap 5 Contraindications 6 Innovations 6.1 New Concept of Expanded Forehead Flap 7 Complication Management 8 Controversies 9 Conclusion/Summary References Keystone Flap Concepts 1 Introduction 2 The Science Behind the Keystone Flap 3 Clinical Signs and Observational Facts for the Keystone Flap 4 Dermal Precincts 5 Surgical Principles for Raising a Keystone Island Flap 6 Case Presentations 6.1 Case 1 6.2 Case 2 6.3 Case 3 6.4 Case 4 6.5 Case 5 6.6 Case 6 6.7 Case 7 6.8 Case 8 6.9 Case 9 6.10 Case 10 6.11 Case 11 6.12 Case 12 6.13 Case 13 6.14 Case 14 7 Contraindications 7.1 Cases 15 and 16 8 Conclusion/Summary References Basal Cell Carcinoma: A Surgical Enigma 1 Introduction 2 Fitzpatrick Skin Types [1] 3 Classification of Basal Cell Carcinoma 4 Papulo-Nodular BCC 5 Superficial BCC 6 Infiltrating BCC 7 Multifocal BCC 8 Morphoeic or Sclerosing BCC 9 Incompletely Excised BCC 10 Recurrent BCC 11 High- and Low-Risk BCCs 12 Case Records of Complex Advanced Cases 13 The Neglected BCC 13.1 Case A 13.2 Case B 13.3 Case C 14 Post Radiotherapy Tumours 14.1 Case D 15 Sclerosing BCC 15.1 Case E 16 Infiltrating BCC 16.1 Case F 17 Tumours Following Immunosuppression 18 Local Recurrence of BCC 19 Histopathology 19.1 Orientation of Excised Lesion 19.2 Punch Biopsy 19.3 Elliptical Excisions 19.4 Wedge Excision 19.5 Slow Mohs Procedure 19.6 Frozen Sections 19.7 Tissue Stains 20 Management/Technique 20.1 Primary Treatment Goals 20.2 Observation Is the Basis of Surgical Diagnosis 21 Guidelines 22 Excision Margins 23 Management of the Incompletely Excised BCC 24 Surgical Repairs: Graft Vs Flap 25 Conclusions and Summary References Part III: Anatomical Focus Scalp and Forehead Cancer 1 Introduction 2 Management/Technique 3 Squamous Cell Cancer 4 Recurrent SCC Post-surgery and Radiation 5 Melanoma 6 Basal Cell Cancer 7 Complication Management 8 Controversies 9 Conclusion and Summary References Extreme Cancer of the Periorbital Region 1 Introduction 2 Management/Technique 2.1 Multidisciplinary Care 2.2 Staging 3 Treatment 3.1 Margin Control in Tumour Excision 3.2 Surgical Treatment 3.2.1 Vision 3.2.2 Structural Considerations 3.2.3 Tears 3.2.4 Blinking 3.2.5 Eyelid Posture 3.2.6 The Periorbital Tissues’ Mechanical Protective Function 3.2.7 Tear Drainage 3.2.8 Orbital Invasion by Facial Tumours 3.2.9 Perineural Invasion 3.2.10 Lymphovascular Invasion and Tumour Staging 4 Indications 4.1 Medial Canthal Lesions 4.1.1 Basal Cell Carcinoma of the Medial Canthus 4.1.2 The Rhomboid Flap in Medial Canthal Reconstruction 4.1.3 Full-Thickness Skin Grafts for Medial Canthal Reconstruction (Fig. 5) 4.1.4 The Pericranial Flap in Medial Canthal Reconstruction (Fig. 6) 4.1.5 Squamous Cell Carcinoma of the Medial Canthus with Orbital Invasion 4.1.6 Lower Eyelid Reconstruction 4.1.7 The Lacrimal Outflow System 4.1.8 The Hughes Tarsoconjunctival Flap in Lower Eyelid Reconstruction 4.1.9 Periosteal Flaps in Eyelid Reconstruction 4.1.10 The Lateral Periosteal Flap (Fig. 18) 4.1.11 The Medial Periosteal Flap (Fig. 19) 4.1.12 The Mustardé Cheek Rotation Flap in Lower Eyelid Reconstruction (Fig. 20) 4.1.13 Laissez-Faire in Eyelid Reconstruction Laissez-Faire for Full-Thickness Eyelid Margin Defects (Fig. 23) Laissez-Faire for Medial Canthal Defects (Fig. 24) Laissez-Faire for Large Lower Eyelid Defects (Fig. 25) 5 Large Upper Eyelid Defects 5.1 Upper Eyelid Reconstruction with the Mustardé Lower Lid Flap 5.2 Subtotal Upper Eyelid Reconstruction with a Mustardé Staged Lower Eyelid Flap 5.3 The Cutler Beard Procedure for Upper Eyelid Reconstruction 5.4 The Upper Eyelid Composite Graft in Upper Eyelid Reconstruction 6 Lateral Canthal Lesions (Fig. 31) 6.1 Basal Cell Carcinoma of the Lateral Canthus 6.2 Squamous Cell Carcinoma of the Lateral Canthus 6.3 Uncommon Orbital Invasion at the Lateral Canthus by a Desmoplastic SCC 7 Loss of the Entire Upper and Lower Lids (Figs. 36 and 37) 7.1 Orbital Invasion by Facial Cancer 8 Prosthetic Rehabilitation/Reconstruction 9 Complication Management 9.1 Lower Eyelid Ectropion (Figs. 42, 43, and 44) 9.2 Recurrent Tumour at the Site of Previous Tumour Causing Lower Eyelid Cicatricial Ectropion (Fig. 45) 9.3 Lagophthalmos (Fig. 46) 9.4 Severe Postoperative Lagophthalmos and Blindness (Fig. 47) 9.5 Postoperative Diplopia (Fig. 49) 10 Innovations 11 Conclusion/Summary References Nose and Ear Cancer 1 Introduction 2 Management/Technique 3 Indications 4 Forehead Flap Options 5 Forehead Flap and Skin Graft 6 Recurrent Multifocal Nasal BCCs Despite Mohs Surgery 7 Double Forehead Flaps—When a Second Nasal Reconstruction Is Required 8 Penetrating Nasal Skin Cancers Involving the Lining 9 Cancers of the Nasal Vestibule 10 The Art of Planning in Reverse 11 The Nasolabial Flap Option 11.1 Multiple Staged Nasolabial Flap 11.2 Single-Stage Nasolabial Flap 11.3 Longer Nasolabial Flaps in Women for Nasal Tip Repair 12 Other Traditional Local Flaps for the Elderly 13 Ear Cancers 13.1 Clinical Presentation 13.2 Other Variations of the Postauricular Local Flap 13.3 The Preauricular Flap for Ear Reconstruction 14 Contraindications 15 Innovations 16 Complication Management 16.1 How Robust Is a Forehead Flap? 16.2 The Notched Alar Rim Deformity 17 Conclusion/Summary References Cheek and Perioral Cancer 1 Introduction 2 Modern Concepts 3 Management/Technique 3.1 Direct Closure After Undermining 3.2 Local Cheek Flap 3.3 The Facelift Flap 3.4 Anteriorly Based Cervicofacial Rotation Advancement Local Flaps of the Cheek 3.5 Posteriorly Based Cervicofacial Rotation Advancement Local Flaps of the Cheek 4 Lip Reconstruction 5 Chin Reconstruction 6 Very Extreme Cases 7 Fundamental Surgical Techniques/Surgical Anatomy 8 Parotidectomy 9 Neck Dissection 10 Tracheostomy 11 Gaining Access to the Oral Cavity 12 FAMM Flap 13 Deep Facial Spaces 14 Innovations 14.1 Changes to the Classification and Staging of Lip SCC 14.2 Tissue-Expanded Local Flaps 14.3 Keystone Interposition Flap 15 Complication Management 16 Conclusion/Summary References Palliative Surgery 1 Introduction 2 Reconstruction 3 Clinical Examples 3.1 Advanced Squamous Cell Cancer of the Midface 3.2 Advanced Basal Cell Cancer of the Naso-Orbital Region 3.3 Recurrent Squamous Cell Carcinoma of the Neck Post-surgery and Adjuvant Radiotherapy 3.4 Recurrent Left Orbital Sarcoma Invading the Hard and Soft Palate 4 Conclusions and Summary Reference Part IV: Form and Function Metastatic Cancer to the Parotid Region 1 Introduction 2 Staging 3 Extent of Parotidectomy/Neck Dissection 4 Management of the External Auditory Canal, Temporal Bone and Temporomandibular Joint 5 Management of Nerves 6 Facial Nerve 7 Trigeminal and Cervical Plexus Nerves 8 Reconstruction 9 Conclusion References Modern Maxillofacial Rehabilitation 1 Introduction 2 Indications 3 Important Surgical Principles for Prosthetics 4 Taking the Impression 5 Wax-Up Evaluation 6 Orbital Prostheses 7 Silicones and Intrinsic Colour Matching 8 Osseointegrated Implant Retention 9 Selection Criteria of Patients for Implant Therapy 10 The Vistafix Implant System 11 Planning for Implant Surgery 12 A Key Osseointegration Principle Is that the Peri-abutment Skin or Mucosa Should Be Immobile to Reduce the Risk of Infection and Implant Failure 13 Digital Imaging for Facial Prosthetics 13.1 Software 13.2 Indications for Digital Imaging 13.2.1 Case Example 1 13.2.2 Case Example 2 13.2.3 Case Example 3 14 Surgical Considerations for Oral and Facial Rehabilitation Post-cancer Resection 14.1 Timing of Surgery and Prosthetic Rehabilitation 14.2 3D Model-Assisted Surgery 14.3 Indications 14.4 3D-Guided Placement of Osseointegrated Implants 15 Virtual Surgical Planning (VSP) 16 Immediate Implant Placement 17 Soft Tissue Adjustments 18 The Cheesecake Flap for Total Glossectomy 19 Maintaining Alveolar Ridge Height in the Dentate Patient 20 Controversies 21 Conclusion/Summary References Perioperative and Anaesthetic Care in Head and Neck Cancer Surgery 1 Introduction 2 A Brief History and Development of Anaesthesia in the Western World [1, 2] 3 Modern Anaesthesia 4 Perioperative Care and Communication 5 Preoperative Assessment 5.1 Risk Assessment and Stratification 5.2 Types of Risk Assessment Tools 6 Airway Assessment and Plan 6.1 Basics of Airway Assessment 6.1.1 History 6.1.2 Physical Examination 7 Intraoperative Care 7.1 Preoperative Considerations 8 Airway Management and Airway Equipment 9 Intraoperative Monitoring 10 Commonly Used Drugs in General Anaesthesia 10.1 Intravenous Vs Inhalational Anaesthetics (Table 2) 10.2 Analgesia and Co-analgesia 11 Local Anaesthetics (Tables 4, 5, and 6) 12 Postoperative Management 13 Crisis Management 14 New Technologies/Innovations 15 Conclusion/Summary References Assessment of Function Post-cancer 1 Introduction 2 Breathing/Speaking 3 Speaking/Swallowing/Nutrition 4 Assessment of Swallowing Function 5 Chemoradiation Effects 6 Conclusion/Summary References Modern Morphing Technology in Facial Reconstruction 1 Introduction 2 Technique 3 Innovation 4 Complication Management 5 Limitations and Controversies 6 Informed Consent 7 Future Perspectives 8 Conclusions References Index