Introduction: Nonmelanoma skin cancer is the most common malignancy of the scalp. Of these, squamous cell carcinoma (SCC) is the most troublesome. It poses a challenge to the surgeons caring for these patients as the anatomy of the scalp makes excision and reconstruction difficult. Although more superficial lesions are amenable to Mohs micrographic surgery, more invasive lesions require a different approach. This manuscript is a retrospective review of outer table resection for SCC of the scalp invading to the depth of the pericranium. We include a discussion of full thickness craniectomy for invasive SCC, regardless of depth of invasion, for completeness. Methods: IRB approval was obtained from St. Joseph’s Hospital and Medical Center in Phoenix, Arizona. One hundred four potential cases identified based on ICD codes. Ultimately, 23 cases met study criteria and were included in this analysis. Seventeen cases of outer table resection and 6 cases of full craniectomy were discussed. Additionally, the authors’ approach for resection and reconstruction is articulated. Results: Seventeen patients underwent outer table resection at an average age of 79.3 years. All had invasion of the pericranium with a mean surface area of 42.6 cm2. Eight patients had prior radiation treatment for SCC of the scalp and 12 patients had at least 1 prior surgery to attempt excision of their lesions. Two patients had local recurrence for a local control rate of 88.2% (15/17). One patient with metastasis prior to presentation, died 6 months after his initial surgery for disease-free survival rate of 94.1% (16/17) at a mean of 15.4months. Thirteen patients were able to achieve immediate reconstruction with local flaps with or without additional skin grafting (76.5%). Discussion: The data in this study supports that in instances of locally invasive primary SCC of the scalp that extends to the pericranium, excision down to the calvarium with complete circumferential and deep peripheral margin assessment, followed by resection of the outer table, is an excellent option. The low rate of local recurrence and high disease-free survival in this study support that this method allows for optimal oncologic outcome while mitigating the significant morbidity associated with the alternative option of a full thickness craniectomy.
Invasive atypical fibroxanthomas and undifferentiated pleomorphic sarcomas of the scalp are relatively rare spindle cell tumors that recur at high rates. Wide local excision and Mohs surgery alone are not feasible for the definitive management of lesions adhering to the underlying pericranium and/or calvarium. This brief clinical study presents 2 patient cases and includes a systematic review of the literature. In our literature review, 2 of 4 patients treated with outer table resection had no disease recurrence, 1 died due to an unrelated cause, and 1 died due to disease progression. Three of 9 patients treated with full-thickness craniectomy had no disease recurrence, 5 patient outcomes were not specified, and 1 died from disease progression. There are currently no recommendations for the management of these invasive scalp lesions. We believe invasive atypical fibroxanthomas/undifferentiated pleomorphic sarcomas of the scalp without frank calvarial involvement can be effectively treated with outer table resection.
Amputation of facial soft tissue, particularly avulsion due to human bite, is an uncommon injury that has severe cosmetic and functional implications. Microsurgical replantation has the potential for superior aesthetic outcomes and restoration of function. We report a case of a 46-year-old male who sustained avulsion injuries from human bites, which included portions of his eyebrow, nose, and upper lip. Artery and vein microvascular replantation was performed on the upper lip. The amputated eyebrow and nasal segments were replanted in a similar fashion to a skin graft. On post-operation day 1, our patient suffered an ischemic stroke followed by a myocardial infarction requiring systemic tissue plasminogen activator (tPA) treatment. Following administration of tPA, there was continuous bloody discharge from the replant sites and the eyebrow, nose, and upper lip began to appear increasingly dusky. Our patient was determined to be a high-risk candidate for immediate revision surgery and he subsequently underwent a six-stage secondary reconstruction. At his most recent four-month follow-up, our patient is satisfied with his cosmetic and functional outcomes. This was a case of failed microvascular upper lip replantation and eyebrow and nasal replacement complicated by stroke and myocardial infarction. The authors review the common complications in replantation, particularly pertaining to upper lip reanastamosis, and discuss a potential novel complication encountered in this case relevant to both free graft and microvascular replantation.
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