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Cutaneous Malignancies
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of Head and Neck
PrajwalSDange, KarthikNRao, andRupaMehta
1 Introduction
The skin is the largest organ in the body and can
be prone to various malignancies due to its size
and diverse appendages. Basal cell carcinoma
and squamous cell carcinoma (SCC) are the most
common types of skin cancer, and malignant skin
lesions can vary from locally destructive basal
cell carcinoma (BCC) to rapidly metastatic melanoma. It is difcult to determine the exact incidence of these types of cancer.
1.1 Principles ofEvaluation
andTreatment
• Majority of the cutaneous malignancies pres-
ent as surface lesions. Certain adnexal tumours
may present as cutaneous bulges and subepithelial lesions.
• A thorough clinical examination by gentle
palpation of the lesion and surrounding tissue
P. S. Dange · K. N. Rao
All India Institute of Medical Sciences,
Raipur, Chhattisgarh, India
R. Mehta (*)
Department of ENT, All India Institute of Medical
Sciences, Raipur, Chhattisgarh, India
to determine the extent of the tumour and
draining of the lymph node basin.
• Bilateral parotid glands and submental and
submandibular regions must be thoroughly
examined for lymph nodal metastasis.
• Radiologic evaluation is directed towards assessing the local extension of disease in the dermis,
subcutaneous plane and satellite nodules, along
with bone erosion, which can be dened by contrast-enhanced computerized tomography
(CECT) or magnetic resonance imaging (MRI).
• Several cutaneous malignancies can be neurotropic and manifest perineural extensions.
• Depth of invasion (DOI) assessment is also
critical in the evaluation and treatment.
1.2 Operative Techniques
• After following all standard protocols and
under strict aseptic precautions, all patients
were taken under general anaesthesia.
– A wide local excision (WLE) of the cutane-
ous lesion was performed in a well-planned
manner. The aim was to achieve R0 resection
with the least morbidity, and the best possi-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
N. M. Nagarkar et al. (eds.), Atlas of Head Neck and Skull-base Surgery,
https://doi.org/10.1007/978-981-99-6132-0_3
29
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P. S. Dange et al.
ble reconstruction was done to provide good
form and possibly function (as necessary).
– Adjuvant therapy was planned after postop-
erative staging and case-by-case scenarios.
2 Surgical Tips
The face is divided into complex aesthetic units,
including the central face units of the lips, nose,
eyebrows and eyelids and the lateral complex
unit of the external ear. Reconstructing these
units involves specic techniques to maintain
function and appearance. Lip reconstruction aims
to preserve oral competence, labial sensation and
aperture size by properly aligning the orbicularis
oris muscle and suturing the layers. Eyelid reconstruction involves rebuilding the trilaminar structure of the eyelid, with larger defects able to be
closed directly in elderly patients due to laxity in
the lower lid skin and tarsus. Nasal reconstruction involves restoring the skin, skeletal support
and nose lining, with aps taken from the forehead, nasolabial region or glabella often used for
the skin only, and full thickness or total defects
requiring the reconstruction of all three layers.
In reconstructive surgery, the main principles
are to place scars in natural lines of facial expression, reconstruct aesthetic subunits, replace like
with like, consider colour differences in the head
and neck skin and mimic the natural contours of
the head and neck, avoiding excess bulk or thinness. The facial nerve branches exit the skull at the
stylomastoid foramen, with landmarks such as the
posterior belly of the digastric muscle, tragal
pointer and tympanomastoid suture line aiding in
identication. Proper wound closure without tension is important for optimal and early healing.
3 Concepts ofCutaneous
Malignancies
Skin cancer rates have increased among higher
socio-economic groups, possibly due to sunbathing and indoor tanning facilities. Tanning beds are
a modiable risk factor for all types of skin cancer
and should be a focus for public education and
awareness. Studies have shown that indoor tanning
can increase the risk of squamous cell carcinoma
by 15–67% and basal cell carcinoma by 15–29%.
Using indoor tanning more than four times per
year can also increase the risk of melanoma by
11%. Other risk factors for skin cancer include
prolonged sun exposure, sunburns, having a
Fitzpatrick skin type I or II, genetics, exposure to
ionising radiation and immune system suppression. Increased ultraviolet radiation makes skin
cancers more common at high altitudes and
inlocations closer to the equator. UVB radiation
can cause DNA damage and is linked to non-melanoma skin cancers. Intermittent and intense sun
exposure in early life increases the risk of basal
cell carcinoma, while cumulative UV radiation
exposure is a risk factor for SCC.Multiple sunburns may also increase the risk of melanoma.
3.1 Basal Cell Carcinoma
The basal layer of the epidermis and its appendages
give birth to BCC, a slow-growing epithelial cancer.
Even though BCC seldom metastasises (1:35,000),
its invasive and locally destructive behaviour can
nonetheless be exceedingly morbid. BCC is the
most prevalent form of human cancer worldwide,
accounting for about 80% of newly diagnosed cases
in the west. Nearly 25% of these occur on the nose,
and around 80% occur in the head and neck [1].
A BCC can be recognised clinically by its
nodular, pearly opalescence and noticeable telangiectasia. It frequently has a rolling, elevated border with ulceration in the centre and may itch.
Some subtypes manifest as a scar-like lesion in a
region that has never been damaged or as a patch
of the skin that regularly ulcerates and heals in a
normal-appearing area. The benign melanocytes
in pigmented BCC may give it a dark colour [2].
BCC appears as nests of symmetrical, incredibly dark basaloid cells with scant cytoplasm and
oval nuclei under a microscope. The cells can be
seen penetrating the papillary dermis and frequently going deeper into the epidermis. These
cells consist of separate islands and cords, many
of which have palisading borders. Cells frequently form a ‘picket fence’ pattern comparable
to the skin’s basal layer [3]. Some tumours
secrete keratin, which congeals into pearl-like
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forms surrounding the tumour. This is different
from SCC pearls, which originate inside the
tumour.
BCC nearly always develops in the skin with
hair, and its growth relies on the area’s dermal
stroma. This reliance on cutaneous broblastproduced loose connective tissue that may account
for the BCC has a limited metastatic potential.
Similar to healthy, cycling adult hair follicles, BCC
cells communicate with the mesenchymal cells of
the stroma. Proteolytic enzymes that the tumour
produces break down pre-existing dermal tissue and
promote the development of tumour cells.
BCC is a type of skin cancer that can take various forms, including nodular, supercial multifocal, sclerosing, inltrative and morpheaform. The
nodular form is the most common, appearing as a
pearly, dome-shaped nodule with central ulceration. Supercial multifocal BCC appears as a
scaly red-brown patch with a subtle pearly border, often found on the trunk of patients. This
subtype is often seen in people exposed to arsenic
or radiation but can also occur without such
exposure. Sclerosing BCC appears as an atrophic
plaque with telangiectasias and ulceration and is
typically found around the ears and nose. It can
be difcult to diagnose and identify the margins
of this type due to its desmoplastic reaction.
Inltrative BCC, which occurs in 20% of cases,
is characterised by only a small portion of the
tumour being visible, while the rest extends widely
beneath the skin. These tumours have a high recurrence rate and a widespread invasion pattern.
Morpheaform BCC appears as a yellow, scar-like
plaque with telangiectasias and indistinct margins.
It can spread widely within the skin and often
requires radical surgery for complete removal.
Ulcus terebrans is an aggressive form of BCC that
can invade large vessels, bones and even the meninges and can be fatal due to bleeding or infection.
Unlike other types of cancer, BCC does not
tend to become more aggressive over time despite
continued exposure to UV radiation. It is not
fully understood why BCC cells do not acquire
additional mutations that lead to more aggressive
behaviour. However, certain characteristics are
associated with more aggressive BCC, including
a size greater than 6mm on the face or greater
than 10 mm on the forehead, scalp and neck,
perineural invasion, a subtype other than nodular
or supercial, previous radiation exposure and
poorly dened clinical borders.
In 2012, the US Food and Drug Administration
approved the use of vismodegib to treat metastatic
and locally advanced BCC.This is the rst systemic
medication to be approved for this use. Vismodegib
is taken as a 150mg capsule daily until the disease
progresses and is an option for patients who are not
candidates for surgery or radiation.
4 Complications
Wound breakdown, also known as dehiscence, is
the splitting or separation of a wound along a surgical incision. It can be caused by excessive wound
tension or an infection. If a wound breakdown
occurs within 24h after surgery, it may be possible
to try closing the wound again. However, attempting to close the wound after this time increases the
risk of infection. Dehisced wounds are usually
allowed to heal on their own, with revision surgery
considered after the wound has fully healed.
Flap necrosis occurs when the blood ow to the
distal end of a ap is impaired, resulting in ischemia. This can happen if the pedicle, or the blood
vessels that supply the ap, is too small to support
the ap, if it is too thin and disrupts the dermal
plexus, or if excessive undermining of the surrounding tissue disrupts the perforating vessels feeding
the pedicle. Flap necrosis may present as sloughing
of the epidermis, and it is important not to debride
the affected area until the wound has fully healed. In
some cases, only the epidermal portion of the ap
may have necrosed and debriding the ap could disturb the viable tissue. Even when the entire ap has
necrosed, the eschar (dead tissue) over the wound
can act as a natural dressing and allow the wound to
heal on its own.
Scarring can occur when a wound heals by secondary intention, resulting in a disgured appearance. Facial weakness may be temporary if the
injury is a neuropraxia or permanent if the main
trunk or a terminal branch of the facial nerve is
transected or injured by cautery. The exact cause
of neuropraxia is not well understood. Still, it is
thought to be caused by a combination of factors
such as trauma to the nerve during surgery, trac-
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tion injury, heat injury from cautery and prolonged
surgery time. The lower division branches of the
facial nerve, particularly the marginal mandibular
branch, are more thin and fragile and may be more
prone to neuropraxia.
5 Excision ofTumour
oftheNasoethmoidal
Region
P. S. Dange et al.
5.1 Case 1
A 5-year-old girl presented with a 2-month history of growth in the right nasoethmoidal region,
gradually progressive. Contrast-enhanced computerized tomography (CECT) was suggestive of
epithelial lesion without bony involvement. A
preoperative biopsy was suggestive of BCC, and
the nal HPE report was BCC.
5.2 Operative Technique
The surgical steps are depicted in Figs.1, 2, 3, 4,
5, 6 and 7. The postoperative follow-up of the
patient in the ninth month is shown in Fig.8.
Fig. 2 Incision deepened up to the bone, preserving the
medial canthus. The angular vessels may need to be
ligated
Fig. 3 The specimen is gently elevated off the bone, preserving the medial canthal ligament and lacrimal apparatus (whenever oncologically safe)
Fig. 1 Incision marking with 0.5cm margin
Fig. 4 The arrow depicts the preserved lacrimal appara-
tus and medial canthal ligament; this ensures the stability
of the upper and lower eyelids
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Fig. 5 Resected specimen must be oriented and marked
for accurate histopathological diagnosis
Fig. 6 A paramedian forehead ap based on supratrochlear and supraorbital artery was performed to close the
defect
Fig. 8 Postoperative 9-month follow-up showing excellent healing with good locoregional control
6 Excision ofTumour oftheNasal
Tip withtheForehead Flap
6.1 Case 2
A 56-year-old male presented with a 3-month
history of gradually progressive growth on the
nasal tip. CECT suggested an epithelial lesion
without underlying cartilage involvement. A preoperative biopsy was suggestive of poorly differentiated carcinoma, but the nal HPE report was
suggestive of well-differentiated squamous cell
carcinoma (WDSCC).
Fig. 7 The paramedian ap second-stage division and reinsetting procedure done in the third postoperative week
6.2 Operative Technique
The surgical steps are depicted in Figs.9, 10, 11,
12, 13 and 14. The postoperative follow-up of the
patient in the third week after ap division and
sixth month is shown in Figs.15 and 16.
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Fig. 9 A 0.5×0.8 cm ulceroproliferative growth on he
nasal tip, more on the left side
P. S. Dange et al.
Fig. 12 A Paramedian forehead ap was planned
Fig. 10 A complete three-dimensional R0 resection was
done
Fig. 11 Excision of the nasal septum
Fig. 13 The ap was bipaddled to create the nasal alar
portion
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Fig. 14 Well-maintained contour of the ala of the nose
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Fig. 16 A 6-month postoperative follow-up photograph
showing excellent healing
Fig. 15 Flap division was done at the third week
7 Excision ofNasal Bridge
Tumour withtheGlabellarFlap
7.1 Case 3
A 48-year-old male presented with a 9-month
history of growth on the nasal dorsum, gradually
progressive. CECT was suggestive of the epithelial lesion without bony involvement. A preoperative biopsy was suggestive of BCC, and the nal
HPE report was also suggestive of BCC.
7.2 Operative Technique
The surgical steps are depicted in Figs.17, 18,
19, 20 and 21.
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P. S. Dange et al.
Fig. 17 A 2×3cm pigmented ulceroproliferative growth
with rolled edges on the nasal dorsum
Fig. 18 WLE was done with a 0.5cm margin. The base
of excision was up to the periosteum of the nasal bone
Fig. 19 A glabellar rotation ap was planned to close the
defect, and one should note that the length of the ap
reduces by 40% when it is rotated by 180 degrees
Fig. 20 Glabellar ap is raised and rotated to inset into
the defect
Cutaneous Malignancies of Head and Neck
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Fig. 21 The forehead defect is closed primarily, and the
inset is done without tension
8 Excision ofLeft Cheek Tumour
withtheMustardeFlap
8.1 Case 4
A 65-year-old male presented with a 6-month
history of gradually progressive growth on the
left cheek. CECT was suggestive of the epithelial
lesion without bony involvement. A preoperative
biopsy was suggestive of BCC, and the nal HPE
was also suggestive of BCC.
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Fig. 22 A 2×3 cm dark pigmented ulceroproliferative
growth with rolled-up edges
8.2 Operative Technique
The surgical steps are depicted in Figs.22, 23,
24, 25, 26 and 27. The postoperative follow-up of
the patient in the sixth month is shown in Fig.28.
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P. S. Dange et al.
Fig. 23 The tumour was excised circumferentially, and
the muscle was taken as the base. Indiscriminate cautery
must be avoided as it may lead to inadvertent injury to the
facial nerve branches
Fig. 24 The specimen shrinkage can be clearly seen.
More shrinkage (up to 30%) is expected following formalin xation
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