Facial Reconstruction for Radiation-Induced Skin Cancer William R. Panje, MD, Thomas J. Dobleman, MD
\s=b\ Radiation-induced skin cancers can be difficult to diagnose and treat. Typically, a patient who has received orthovoltage radiotherapy for disorders such as acne, eczema, tinea capitis, skin tuberculosis, and skin cancer can expect that aggressive skin cancers and chronic radiodermatitis may develop subsequently. Cryptic facial cancers can lead to metastases and death. Prophylactic wide\x=req-\ field excision of previously irradiated facial skin that has been subject to multiple recurrent skin cancers is suggested as a method of deterring future cutaneous malignancy and metastases. The use of tissue expanders and full-thickness skin grafts offers an expedient and successful method of subsequent reconstruction. (Arch Otolaryngol Head Neck Surg.
1990;116:470-474)
Patients usually develops
with facial skin cancer that many years after exposure to superficial ionizing radia¬ tion can often develop multiple recur¬ rences. Unlike isolated basal cell can¬ cers that arise in nonirradiated skin, cutaneous cancer that originates in previously irradiated skin tends to be difficult to detect. Delay in tumor iden¬ tification can lead to métastases and death. Skin cancer can be multifocal and difficult to identify clinically by both the patient and/or the physician. Once regional or distant métastases occur, the cure rate drops from 85% to less than 25%. These facts suggest Accepted for publication September 19, 1989. From the Department of Otolaryngology-Head Neck Surgery, Pritzker School of Medicine, University of Chicago (Ill). Presented in part at the meeting of the American Society of Head and Neck Surgery, San Francisco, Calif, April 5, 1989. Reprint requests to Department of Otolaryngology-Head Neck Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, Box 412, Chicago, IL 60637 (Dr Panje).
that, in select cases, consideration should be given to preventive surgery. Since radiation-induced facial malig¬ nancies arise predominantly in the previously irradiated skin areas, it may be prudent to select high-risk pa¬ tients for early removal of the "con¬
demned skin." We have developed a technique of removing the entire condemned epi¬ dermis and using tissue expanders and a full-thickness skin graft to resurface the nose and middle aspect of the face. We recommend that some patients who develop multiple recurrent skin cancers as a result of prior radiation therapy of the face be considered for total skin excision for prevention of further recurrences, possible mé¬ tastases, and death. PATIENTS AND METHODS We reviewed the charts of seven patients who had received radiation therapy to the face and who were subsequently evaluated by the senior author (W.R.P.) in order to determine which patients might benefit from prophylactic excision of facial skin to prevent subsequent development of integu¬ ment cancers. All seven patients were re¬ ferred to us after having had multiple facial skin cancers that were treated primarily with surgery directed at removal of the bi¬ opsy-proved malignant lesions. Other forms of treatment, including cryotherapy, megavoltage radiation therapy, and topical chemotherapy with agents such as fluorouracil, were also used in an attempt to erad¬ icate the cancers. The clinical courses of the patients are described in the "Report of Cases" section as an illustration of the disastrous conse¬ quences of waiting until the cancer mani¬ fests itself. The technique of total facial re¬ construction with expanded, nonirradiated skin and full-thickness skin grafting uti¬ lized for the seventh patient, is described as
method for replacing facial skin at high risk for developing skin cancer. a
REPORT OF CASES Case 1.—A
74-year-old man who had un¬ dergone facial radium treatments for acne at 18 years of age was referred to W.R.P. for
facial reconstruction. His first facial skin cancer (basal cell carcinoma) had developed at the age of 38 years. Since then, he has had more than 150 operations for facial cancer. He has lost essentially all of his nose, upper lip, palate, and most of one ear. His right eyelids were removed and reconstructed. He suffers from diplopia because of perior¬ bital fibrosis resulting from secondary scarring associated with his multiple oper¬ ations. He has had several operations for reconstruction of his upper lip and alveolus. He still requires special eyeglasses, and he cannot wear a facial prosthesis. He contin¬ ues to have new skin cancers in previously irradiated areas of the face. Case 2.—A 68-year-old man received an unknown dose of orthovoltage radiation therapy to the face and lips for acne vulgaris at the age of 18 years (Fig 1, left). Be¬ cause of his occupation as a farmer, his face also had excessive exposure to actinic dam¬ age. He has had multiple basal cell cancers and actinic kératoses excised from the face, nose, and lips. A 2.5-cm basosquamous cell carcinoma of the lower lip was removed when he was 65 years old. He subsequently developed a large mass on the left side of the neck. A biopsy of the cervical mass showed that it was a metastatic well-dif¬ ferentiated squamous cell carcinoma. De¬ spite aggressive radiation therapy and sur¬ gery, the patient succumbed to this cancer. Case 3.—A 39-year-old woman had re¬ ceived facial irradiation at 16 years of age for pustular acne vulgaris (Fig 1, right). She had 42 excisions of facial basal cell and ba¬ sosquamous cell cancers, mainly involving the lips. Extensive radiation fibrosis, as well as surgical cicatrix formation, pro¬ duced a severe labial deformity. She re¬ cently developed an extensive squamous
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
cell carcinoma of the lips. Although she re¬ ceived radiation therapy and chemother¬ apy, she continues to have recurrent cancer. She refuses any form of surgical treatment. Case 4.—A 59-year-old woman with a history of radiation treatment for acne as a child had severe midfacial mutilation that resulted from multiple local excisions of gross, persistent cancer. She had curative radiation therapy to the face, but it did lit¬ tle to retard the advancement of the malig¬ nant lesions. Her medical history was un¬ remarkable except for her childhood radia¬ tion therapy. Physical examination showed gaping defects in both cheeks and she had only one eye. Pathologic examination re¬ vealed adnexal basosquamous cell carci¬ noma.
Case 5.—A
veloped
76-year-old
a severe
woman
had de¬
contact dermatitis of the
face in the 1940s, and was treated with ra¬ diation in an effort to stop the progression of this disorder. From 1962 to 1985, she had more than 100 local excisions for recurrent basal cell and basosquamous cell carci¬ noma. Her medical history was otherwise unremarkable. On physical examination, chronic radiodermatitis of the face was ev¬ ident, along with multiple facial surgical scars. She had ectropion of her right lower eyelid and notching of her right upper eye¬ lid. Case 6.—A 56-year-old woman had re¬ ceived radium treatments at 24 years of age for removal of excessive facial hair. She subsequently developed radiation dermati¬ tis and facial scarring. She has had five basal cell cancers removed from her face. An insidious right-sided facial paralysis developed over a 3-year period. Because of
increasing pain, a right-sided parotid mass, and the facial paralysis, a radical parotidectomy, temporal-bone excision, and neck dissection were performed. Extensive mu¬ tilation of the face and base of the skull re¬ sulted, without clearance of the margins. Case 7.—A 60-year-old woman who had undergone multiple radiation treatments for facial acne as a child was referred to the senior author (W.R.P.). At the age of ap¬ proximately 30 years, she first noted an ul¬ cerated skin lesion of the left cheek. This lesion was diagnosed as basal cell carci¬ noma and was treated with a local curative excision. Since that time, she has under¬ gone more than 30 excisions of facial carci¬ nomas of both basal and squamous cell types. The last surgical procedure had been carried out 7 months before her referral to the University of Chicago (111). She had also undergone therapy with topical fluorouracil in an effort at chemoprophylaxis. Her facial features were characteristic of a radiation-induced chronic radiodermati¬ tis, with extensive scarring especially over
the cheeks, upper lip, and nose. She had an obvious 0.5-cm lesion of the skin of the na¬ sal tip, which was excised and found to be positive for basal cell carcinoma. The nasal tip was markedly deformed and partially missing because of prior excisions of skin cancers.
All malignant and premalignant local le¬ sions were excised from the patient's face. Reconstruction was attempted only after a
permanent-section pathologic diagnosis
with evidence of clear surgical margins was obtained. Only those areas of the face that had been exposed to radiation and that demonstrated scarring, radiodermatitis, and/or prior skin cancer were removed. In order to use cervical cutaneous tissues for facial reconstruction, we inserted four tissue expanders (250- and 400-mL size) under the midclavicular and supraclavicular skin of the neck. Prophylactic intrave¬ nous antibiotics were administered preoperatively. We injected 0.5% lidocaine with 1:100000 solution of epinephrine into the skin and subdermal regions of the posterior neck hairline and of the supraclavicular ar¬ eas. Subcutaneous pockets superficial to the platysma muscle were sharply developed for tissue expander insertion. The 250-mL oval expanders were used in the upper mid¬ dle aspect of the neck, and the 400-mL oval expanders were used in the supraclavicular areas. Before placement of the expanders, hemostasis was achieved, and the pockets were copiously irrigated with sterile phys¬ iologic saline containing a cephalosporin antibiotic (1 g/100 mL). At the time of the insertion, the tissue expanders were par¬ tially (10% of maximum volume) filled with saline. The filler ports were positioned pos¬ teriorly in the scalp and upper aspect of the back. Postoperatively the patient was given a 7-day course of antibiotics (erythromycin, 250 mg orally three times a day). Approxi¬ mately 2 weeks later, the tissue expanders were injected weekly with 20 to 40 mL of saline. This procedure was carried out by the patient's local physician, who was ad¬ monished to monitor for infection, extru¬ sion of the expanders, and tissue ischemia. Two months after implantation of the tissue expanders, the patient was admitted for excision of her irradiated facial skin, removal of the tissue expanders, and facial resurfacing with bilateral cervical rotation advancement flaps consisting of the ex¬ panded tissue (Fig 2). The previously scarred, irradiated cheek, lip, and lower fa¬ cial skin was excised and the cervical ad¬ vancement flaps were rotated into the tis¬ sue defect. Advancement of the cervical ro¬ tation flaps produced tissue redundancy in the melolabial area (Fig 3). This tissue was used subsequently for nasal reconstruction.
Three weeks later, a tubed, bipedicled flap was developed from the anterior redundant skin of the cervical advancement flap skin. The middle part of this flap was attached to the philtrum following full-thickness exci¬ sion of the lip skin (Fig 4). After another 3 weeks, the proximal pedicles were cut and the tubes were unrolled and used for resur¬ facing of the nose. Three weeks after this procedure the lip-based pedicle was cut and used for reconstruction of the nasal ala. The columella was formed by advancement of the bony cartilaginous septum caudally and forward (Fig 5). A full-thickness skin graft was harvested from the medial upper as¬ pect of the forearm and used for resurfac¬ ing of the entire upper lip (Fig 6). Thus, the cheeks, upper lip, and nose were recon¬ structed entirely with nonirradiated skin
(Fig 7). RESULTS
Patient 7 had tissue expanders in¬ serted in October 1985. The final stage of her facial reconstruction, which in¬ cluded nasal resurfacing and place¬ ment of an upper lip full-thickness skin graft, was completed in March 1986. Since that time, the patient has had dermabrasion of her advance¬ ment-flap facial scars (Fig 8). She has been free of local disease, with no recurrence of skin cancer since the procedure was carried out. Before the resurfacing procedure, she had aver¬ aged two new or recurrent skin cancers a year for 5 years. Over a 25-year period, she had had 30 new or recur¬ rent basal cell or squamous cell can¬ cers in the previously irradiated field. COMMENT
Modern radiotherapy with the use of supervoltage has eliminated, in large part, the once-common skin sequela of orthovoltage radiation, ie, chronic radiodermatitis. Orthovoltage radiation, which was used successfully in the past
for treatment of acne, eczema, hirsutism, and other benign dermatoses, as well as tuberculosis and skin cancer, unfortunately has left a population of middle-aged and elderly patients suf¬ fering from its long-term, unremitting sequelae. Chronic radiodermatitis, fa¬ cial scarring, and cancer are the major delayed effects of irradiating benign lesions and simple skin cancers. Although the cosmetic consequences of chronic radiodermatitis of the face can have a significant emotional im-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
the patient, it is the fear of of the face, with the possibility of spread, that causes the greatest anxiety. The fear of facial disfigure¬ ment is shared by the patient and the
pact
on
cancer
surgeon.
Premalignant and malignant skin changes following irradiation may not appear for more than 25 years.1 Early detection is crucial for prevention of both local and distant spread of the cancer. Therefore, the patient and the physician must constantly be vigilant. Early detection may be hampered by (1) the patient's fear of discovering fa¬ cial cancer, that of possible facial dis¬ figurement, and delay in seeking med¬ ical attention for early lesions; and (2)
Fig 1.—Different patients who had received prior orthovoltage irradiation for benign dermatoses subsequently developed multifocal and multiple recurrences for skin carcinoma.
who
the likelihood that the entire irradi¬ ated skin will form multicentric le¬ sions that can have the appearance of chronic radiodermatitis but may be
malignant.2 The patient's and physician's
con¬
about radiation-induced skin can¬ cer is justified. Not only is there a pro¬ pensity for multicentric lesions, but aggressive local growth can invade through embryonic fusion planes.3 The incidence of cervical node métastases may be as high as 20% with squamous cell cancer of the integument.4 Skin cancer and premalignant cern
Fig 2.—Tissue expanders (250 mL and 400 mL) were placed in the middle aspect of the neck and supraclavicular areas 8 weeks prior to reconstruction. The stippled area indicates the area of skin
to be excised.
Fig 3.—Following advancement of the cervical rotation flaps. Note the anterior redundant skin be¬ neath the chin.
Fig 4.—The submental redundant skin was formed into a bipedicle flap with the central portion attached to the philtrum.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Fig 5.—Three weeks later, the nasal tip
was
reconstructed by advancing the septum. The
pedicles
were
then
transplanted
center, The septum was advanced caudally to form the columella and support for the nasal transferred to the nose.
to the upper dorsum. Left and
tip. Right,
The
pedicles
were
Fig 6.—Three weeks later the flap's philtrum base was detached from the lip to resurface the na¬ sal tip. A full-thickness skin graft taken from the forearm was used to resurface the upper lip.
Fig 7.—Cutaneous area replaced with cervical rotation advancement flaps and full-thickness skin graft.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Fig 8.—Appearance
1 year later. Note
changes can be treated successfully with topical chemotherapy, cryotherapy, or radiation therapy, or by local excision with
or
without the
use
of
chemosurgical techniques. Skin grafts and regional flaps have been used successfully for replacement
of entire facial aesthetic units that have been damaged by radiation
therapy.5
Full-thickness skin grafts have been used in resurfacing smaller facial units, ie, the nose, with good results. However, covering a larger surface area such as the middle aspect of the face with full-thickness skin grafts produces a significant donor site de¬ formity. Skin grafts are not good for reconstructing composite tissue defi¬ ciencies such as the nasal ala or col¬ umella. Prior to the development of tissue expanders most reconstructive techniques for resurfacing large facial areas were difficult to complete with¬ out prolonged hospitalization and do¬ nor site deformity. The cervical rota-
flap's
excellent color and texture matching the remaining facial skin.
tion advancement flap has been found to produce excellent cosmesis when resurfacing cheek defects. This neck flap has excellent color match and tex¬ ture comparable with facial skin. How¬ ever, if this flap is used without expan¬ sion a large incision and extensive un¬ dermining onto the chest is necessary. Even with these maneuvers the flap will only resurface the cheek area. In our report the middle aspect of the face and the nose are reconstructed. This is the first report of nasal reconstruction with the cervical rotation advance¬ ment
tire irradiated facial skin, regardless of whether or not cancer is present at the time, be performed for patients who have shown a propensity for mul¬ ticentric, recurrent skin cancers. The face should then be reconstructed with nonirradiated skin grafts or flaps. Ex¬ panded neck skin provides sufficient tissue for rotation and advancement flap reconstruction of the middle as¬ pect of the face and the nose. Excellent cosmesis, including a match of color and texture, is achieved with a local cutaneous flap.
flap.
Our review of seven patients who had undergone radiation therapy some years previously for a benign skin con¬ dition demonstrated multiple recur¬ rences of cancerous lesions within the previously irradiated fields, as well as métastases and death. We regard this as being secondary to late detection and undertreatment of recurrent skin cancers in the "condemned skin." We propose that excision of the en-
References 1. Martin H, Strong E, Spiro RH. Radiation induced skin cancer of the head and neck. Cancer.
1970;25:61-71. 2. Conley J. Cancer of the skin of the nose. Ann Otol. 1974;83:2-8. 3. Panje WR. Influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope. 1979;12:1914-1920. 4. Pack GT, Davis J. Radiation cancer of the skin. Radiology. 1965;84:436-441. 5. Goepfert H, Ballantyne AJ, Luna MA. Cancer of the skin of the nose. Arch Otolaryngol Head Neck Surg. 1976;102:90-93.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
\s=b\ Radiation-induced skin cancers can be difficult to diagnose and treat. Typically, a patient who has received orthovoltage radiotherapy for disorders such as acne, eczema, tinea capitis, skin tuberculosis, and skin cancer can expect that aggressive skin cancers and chronic radiodermatitis may develop subsequently. Cryptic facial cancers can lead to metastases and death. Prophylactic wide\x=req-\ field excision of previously irradiated facial skin that has been subject to multiple recurrent skin cancers is suggested as a method of deterring future cutaneous malignancy and metastases. The use of tissue expanders and full-thickness skin grafts offers an expedient and successful method of subsequent reconstruction. (Arch Otolaryngol Head Neck Surg.
1990;116:470-474)
Patients usually develops
with facial skin cancer that many years after exposure to superficial ionizing radia¬ tion can often develop multiple recur¬ rences. Unlike isolated basal cell can¬ cers that arise in nonirradiated skin, cutaneous cancer that originates in previously irradiated skin tends to be difficult to detect. Delay in tumor iden¬ tification can lead to métastases and death. Skin cancer can be multifocal and difficult to identify clinically by both the patient and/or the physician. Once regional or distant métastases occur, the cure rate drops from 85% to less than 25%. These facts suggest Accepted for publication September 19, 1989. From the Department of Otolaryngology-Head Neck Surgery, Pritzker School of Medicine, University of Chicago (Ill). Presented in part at the meeting of the American Society of Head and Neck Surgery, San Francisco, Calif, April 5, 1989. Reprint requests to Department of Otolaryngology-Head Neck Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, Box 412, Chicago, IL 60637 (Dr Panje).
that, in select cases, consideration should be given to preventive surgery. Since radiation-induced facial malig¬ nancies arise predominantly in the previously irradiated skin areas, it may be prudent to select high-risk pa¬ tients for early removal of the "con¬
demned skin." We have developed a technique of removing the entire condemned epi¬ dermis and using tissue expanders and a full-thickness skin graft to resurface the nose and middle aspect of the face. We recommend that some patients who develop multiple recurrent skin cancers as a result of prior radiation therapy of the face be considered for total skin excision for prevention of further recurrences, possible mé¬ tastases, and death. PATIENTS AND METHODS We reviewed the charts of seven patients who had received radiation therapy to the face and who were subsequently evaluated by the senior author (W.R.P.) in order to determine which patients might benefit from prophylactic excision of facial skin to prevent subsequent development of integu¬ ment cancers. All seven patients were re¬ ferred to us after having had multiple facial skin cancers that were treated primarily with surgery directed at removal of the bi¬ opsy-proved malignant lesions. Other forms of treatment, including cryotherapy, megavoltage radiation therapy, and topical chemotherapy with agents such as fluorouracil, were also used in an attempt to erad¬ icate the cancers. The clinical courses of the patients are described in the "Report of Cases" section as an illustration of the disastrous conse¬ quences of waiting until the cancer mani¬ fests itself. The technique of total facial re¬ construction with expanded, nonirradiated skin and full-thickness skin grafting uti¬ lized for the seventh patient, is described as
method for replacing facial skin at high risk for developing skin cancer. a
REPORT OF CASES Case 1.—A
74-year-old man who had un¬ dergone facial radium treatments for acne at 18 years of age was referred to W.R.P. for
facial reconstruction. His first facial skin cancer (basal cell carcinoma) had developed at the age of 38 years. Since then, he has had more than 150 operations for facial cancer. He has lost essentially all of his nose, upper lip, palate, and most of one ear. His right eyelids were removed and reconstructed. He suffers from diplopia because of perior¬ bital fibrosis resulting from secondary scarring associated with his multiple oper¬ ations. He has had several operations for reconstruction of his upper lip and alveolus. He still requires special eyeglasses, and he cannot wear a facial prosthesis. He contin¬ ues to have new skin cancers in previously irradiated areas of the face. Case 2.—A 68-year-old man received an unknown dose of orthovoltage radiation therapy to the face and lips for acne vulgaris at the age of 18 years (Fig 1, left). Be¬ cause of his occupation as a farmer, his face also had excessive exposure to actinic dam¬ age. He has had multiple basal cell cancers and actinic kératoses excised from the face, nose, and lips. A 2.5-cm basosquamous cell carcinoma of the lower lip was removed when he was 65 years old. He subsequently developed a large mass on the left side of the neck. A biopsy of the cervical mass showed that it was a metastatic well-dif¬ ferentiated squamous cell carcinoma. De¬ spite aggressive radiation therapy and sur¬ gery, the patient succumbed to this cancer. Case 3.—A 39-year-old woman had re¬ ceived facial irradiation at 16 years of age for pustular acne vulgaris (Fig 1, right). She had 42 excisions of facial basal cell and ba¬ sosquamous cell cancers, mainly involving the lips. Extensive radiation fibrosis, as well as surgical cicatrix formation, pro¬ duced a severe labial deformity. She re¬ cently developed an extensive squamous
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
cell carcinoma of the lips. Although she re¬ ceived radiation therapy and chemother¬ apy, she continues to have recurrent cancer. She refuses any form of surgical treatment. Case 4.—A 59-year-old woman with a history of radiation treatment for acne as a child had severe midfacial mutilation that resulted from multiple local excisions of gross, persistent cancer. She had curative radiation therapy to the face, but it did lit¬ tle to retard the advancement of the malig¬ nant lesions. Her medical history was un¬ remarkable except for her childhood radia¬ tion therapy. Physical examination showed gaping defects in both cheeks and she had only one eye. Pathologic examination re¬ vealed adnexal basosquamous cell carci¬ noma.
Case 5.—A
veloped
76-year-old
a severe
woman
had de¬
contact dermatitis of the
face in the 1940s, and was treated with ra¬ diation in an effort to stop the progression of this disorder. From 1962 to 1985, she had more than 100 local excisions for recurrent basal cell and basosquamous cell carci¬ noma. Her medical history was otherwise unremarkable. On physical examination, chronic radiodermatitis of the face was ev¬ ident, along with multiple facial surgical scars. She had ectropion of her right lower eyelid and notching of her right upper eye¬ lid. Case 6.—A 56-year-old woman had re¬ ceived radium treatments at 24 years of age for removal of excessive facial hair. She subsequently developed radiation dermati¬ tis and facial scarring. She has had five basal cell cancers removed from her face. An insidious right-sided facial paralysis developed over a 3-year period. Because of
increasing pain, a right-sided parotid mass, and the facial paralysis, a radical parotidectomy, temporal-bone excision, and neck dissection were performed. Extensive mu¬ tilation of the face and base of the skull re¬ sulted, without clearance of the margins. Case 7.—A 60-year-old woman who had undergone multiple radiation treatments for facial acne as a child was referred to the senior author (W.R.P.). At the age of ap¬ proximately 30 years, she first noted an ul¬ cerated skin lesion of the left cheek. This lesion was diagnosed as basal cell carci¬ noma and was treated with a local curative excision. Since that time, she has under¬ gone more than 30 excisions of facial carci¬ nomas of both basal and squamous cell types. The last surgical procedure had been carried out 7 months before her referral to the University of Chicago (111). She had also undergone therapy with topical fluorouracil in an effort at chemoprophylaxis. Her facial features were characteristic of a radiation-induced chronic radiodermati¬ tis, with extensive scarring especially over
the cheeks, upper lip, and nose. She had an obvious 0.5-cm lesion of the skin of the na¬ sal tip, which was excised and found to be positive for basal cell carcinoma. The nasal tip was markedly deformed and partially missing because of prior excisions of skin cancers.
All malignant and premalignant local le¬ sions were excised from the patient's face. Reconstruction was attempted only after a
permanent-section pathologic diagnosis
with evidence of clear surgical margins was obtained. Only those areas of the face that had been exposed to radiation and that demonstrated scarring, radiodermatitis, and/or prior skin cancer were removed. In order to use cervical cutaneous tissues for facial reconstruction, we inserted four tissue expanders (250- and 400-mL size) under the midclavicular and supraclavicular skin of the neck. Prophylactic intrave¬ nous antibiotics were administered preoperatively. We injected 0.5% lidocaine with 1:100000 solution of epinephrine into the skin and subdermal regions of the posterior neck hairline and of the supraclavicular ar¬ eas. Subcutaneous pockets superficial to the platysma muscle were sharply developed for tissue expander insertion. The 250-mL oval expanders were used in the upper mid¬ dle aspect of the neck, and the 400-mL oval expanders were used in the supraclavicular areas. Before placement of the expanders, hemostasis was achieved, and the pockets were copiously irrigated with sterile phys¬ iologic saline containing a cephalosporin antibiotic (1 g/100 mL). At the time of the insertion, the tissue expanders were par¬ tially (10% of maximum volume) filled with saline. The filler ports were positioned pos¬ teriorly in the scalp and upper aspect of the back. Postoperatively the patient was given a 7-day course of antibiotics (erythromycin, 250 mg orally three times a day). Approxi¬ mately 2 weeks later, the tissue expanders were injected weekly with 20 to 40 mL of saline. This procedure was carried out by the patient's local physician, who was ad¬ monished to monitor for infection, extru¬ sion of the expanders, and tissue ischemia. Two months after implantation of the tissue expanders, the patient was admitted for excision of her irradiated facial skin, removal of the tissue expanders, and facial resurfacing with bilateral cervical rotation advancement flaps consisting of the ex¬ panded tissue (Fig 2). The previously scarred, irradiated cheek, lip, and lower fa¬ cial skin was excised and the cervical ad¬ vancement flaps were rotated into the tis¬ sue defect. Advancement of the cervical ro¬ tation flaps produced tissue redundancy in the melolabial area (Fig 3). This tissue was used subsequently for nasal reconstruction.
Three weeks later, a tubed, bipedicled flap was developed from the anterior redundant skin of the cervical advancement flap skin. The middle part of this flap was attached to the philtrum following full-thickness exci¬ sion of the lip skin (Fig 4). After another 3 weeks, the proximal pedicles were cut and the tubes were unrolled and used for resur¬ facing of the nose. Three weeks after this procedure the lip-based pedicle was cut and used for reconstruction of the nasal ala. The columella was formed by advancement of the bony cartilaginous septum caudally and forward (Fig 5). A full-thickness skin graft was harvested from the medial upper as¬ pect of the forearm and used for resurfac¬ ing of the entire upper lip (Fig 6). Thus, the cheeks, upper lip, and nose were recon¬ structed entirely with nonirradiated skin
(Fig 7). RESULTS
Patient 7 had tissue expanders in¬ serted in October 1985. The final stage of her facial reconstruction, which in¬ cluded nasal resurfacing and place¬ ment of an upper lip full-thickness skin graft, was completed in March 1986. Since that time, the patient has had dermabrasion of her advance¬ ment-flap facial scars (Fig 8). She has been free of local disease, with no recurrence of skin cancer since the procedure was carried out. Before the resurfacing procedure, she had aver¬ aged two new or recurrent skin cancers a year for 5 years. Over a 25-year period, she had had 30 new or recur¬ rent basal cell or squamous cell can¬ cers in the previously irradiated field. COMMENT
Modern radiotherapy with the use of supervoltage has eliminated, in large part, the once-common skin sequela of orthovoltage radiation, ie, chronic radiodermatitis. Orthovoltage radiation, which was used successfully in the past
for treatment of acne, eczema, hirsutism, and other benign dermatoses, as well as tuberculosis and skin cancer, unfortunately has left a population of middle-aged and elderly patients suf¬ fering from its long-term, unremitting sequelae. Chronic radiodermatitis, fa¬ cial scarring, and cancer are the major delayed effects of irradiating benign lesions and simple skin cancers. Although the cosmetic consequences of chronic radiodermatitis of the face can have a significant emotional im-
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
the patient, it is the fear of of the face, with the possibility of spread, that causes the greatest anxiety. The fear of facial disfigure¬ ment is shared by the patient and the
pact
on
cancer
surgeon.
Premalignant and malignant skin changes following irradiation may not appear for more than 25 years.1 Early detection is crucial for prevention of both local and distant spread of the cancer. Therefore, the patient and the physician must constantly be vigilant. Early detection may be hampered by (1) the patient's fear of discovering fa¬ cial cancer, that of possible facial dis¬ figurement, and delay in seeking med¬ ical attention for early lesions; and (2)
Fig 1.—Different patients who had received prior orthovoltage irradiation for benign dermatoses subsequently developed multifocal and multiple recurrences for skin carcinoma.
who
the likelihood that the entire irradi¬ ated skin will form multicentric le¬ sions that can have the appearance of chronic radiodermatitis but may be
malignant.2 The patient's and physician's
con¬
about radiation-induced skin can¬ cer is justified. Not only is there a pro¬ pensity for multicentric lesions, but aggressive local growth can invade through embryonic fusion planes.3 The incidence of cervical node métastases may be as high as 20% with squamous cell cancer of the integument.4 Skin cancer and premalignant cern
Fig 2.—Tissue expanders (250 mL and 400 mL) were placed in the middle aspect of the neck and supraclavicular areas 8 weeks prior to reconstruction. The stippled area indicates the area of skin
to be excised.
Fig 3.—Following advancement of the cervical rotation flaps. Note the anterior redundant skin be¬ neath the chin.
Fig 4.—The submental redundant skin was formed into a bipedicle flap with the central portion attached to the philtrum.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Fig 5.—Three weeks later, the nasal tip
was
reconstructed by advancing the septum. The
pedicles
were
then
transplanted
center, The septum was advanced caudally to form the columella and support for the nasal transferred to the nose.
to the upper dorsum. Left and
tip. Right,
The
pedicles
were
Fig 6.—Three weeks later the flap's philtrum base was detached from the lip to resurface the na¬ sal tip. A full-thickness skin graft taken from the forearm was used to resurface the upper lip.
Fig 7.—Cutaneous area replaced with cervical rotation advancement flaps and full-thickness skin graft.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Fig 8.—Appearance
1 year later. Note
changes can be treated successfully with topical chemotherapy, cryotherapy, or radiation therapy, or by local excision with
or
without the
use
of
chemosurgical techniques. Skin grafts and regional flaps have been used successfully for replacement
of entire facial aesthetic units that have been damaged by radiation
therapy.5
Full-thickness skin grafts have been used in resurfacing smaller facial units, ie, the nose, with good results. However, covering a larger surface area such as the middle aspect of the face with full-thickness skin grafts produces a significant donor site de¬ formity. Skin grafts are not good for reconstructing composite tissue defi¬ ciencies such as the nasal ala or col¬ umella. Prior to the development of tissue expanders most reconstructive techniques for resurfacing large facial areas were difficult to complete with¬ out prolonged hospitalization and do¬ nor site deformity. The cervical rota-
flap's
excellent color and texture matching the remaining facial skin.
tion advancement flap has been found to produce excellent cosmesis when resurfacing cheek defects. This neck flap has excellent color match and tex¬ ture comparable with facial skin. How¬ ever, if this flap is used without expan¬ sion a large incision and extensive un¬ dermining onto the chest is necessary. Even with these maneuvers the flap will only resurface the cheek area. In our report the middle aspect of the face and the nose are reconstructed. This is the first report of nasal reconstruction with the cervical rotation advance¬ ment
tire irradiated facial skin, regardless of whether or not cancer is present at the time, be performed for patients who have shown a propensity for mul¬ ticentric, recurrent skin cancers. The face should then be reconstructed with nonirradiated skin grafts or flaps. Ex¬ panded neck skin provides sufficient tissue for rotation and advancement flap reconstruction of the middle as¬ pect of the face and the nose. Excellent cosmesis, including a match of color and texture, is achieved with a local cutaneous flap.
flap.
Our review of seven patients who had undergone radiation therapy some years previously for a benign skin con¬ dition demonstrated multiple recur¬ rences of cancerous lesions within the previously irradiated fields, as well as métastases and death. We regard this as being secondary to late detection and undertreatment of recurrent skin cancers in the "condemned skin." We propose that excision of the en-
References 1. Martin H, Strong E, Spiro RH. Radiation induced skin cancer of the head and neck. Cancer.
1970;25:61-71. 2. Conley J. Cancer of the skin of the nose. Ann Otol. 1974;83:2-8. 3. Panje WR. Influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope. 1979;12:1914-1920. 4. Pack GT, Davis J. Radiation cancer of the skin. Radiology. 1965;84:436-441. 5. Goepfert H, Ballantyne AJ, Luna MA. Cancer of the skin of the nose. Arch Otolaryngol Head Neck Surg. 1976;102:90-93.
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