Reconstrução de grandes defeitos de couro cabeludo e fronte em oncologia: tática pessoal e experiência - análise de 25 casos

Abstract

Background: The anatomical peculiarities of extensive malignant neoplasms of the scalp and forehead remain a challenge for plastic surgeons. Although several procedures for re pair of these defects have been described, the ideal reconstruction relies on careful assessment of each clinical case and aims to achieve the best functional and aesthetic outcome with minimal morbidity of the donor area. The aim of this study is to evaluate a series of patients who underwent immediate reconstruction following scalp and forehead tumor resection, in order to demonstrate the personal technique and experience of the author. Methods: This is a retrospective analysis of 25 patients who underwent scalp and forehead reconstruction between June 2009 and June 2011 following treatment for advanced skin cancer. The following parameters were studied: gender, age, diagnosis, clinical staging, location and size of the defect, repair strategy, complications, and current clinical status. Results: Of the 25 patients, 60% were men; the average age was 64.8 years.Patients most frequently presented in clinical stage III (88%). Squamous cell carcinoma was the most common tumor (84%) and the biparietal region was the most commonly affected area (20%). The size of the defects varied from 3.8 cm × 3.5 cm to 22.9 cm × 15 cm. The reconstructive procedure used most often (80%) relies on the production of a local flap. Two (8%) cases of partial flap necrosis and 1 case (4%) of partial graft loss were noted. All patients are still alive and only one shows signs of proliferative malignant neoplasm (tumor recurrence without treatment options). With regard to functional and aesthetic aspects, both the author and the patients considered the results obtained to be satisfactory. Conclusions: In the literature, a variety of procedures for scalp reconstruction have already been described. In patients with extensive loss of soft tissues, microsurgical flaps are the most commonly used option. Reconstruction with a local advancement flap is a safe technique, provides satisfactory results, and is performed with a simple technical procedure. It therefore may be ideal for borderline-operable patients.Keywords: Surgical flaps. Plastic surgery. Scalp/surgery. Head and neck neoplasms. Reconstructive surgical procedures. RESUMOIntrodução: Neoplasias malignas extensas em couro cabeludo e fronte tornam-se um desafio para o cirurgião plástico, em decorrência das particularidades anatômicas da região. Apesar da existência de muitas técnicas para o reparo dos defeitos, a reconstrução ideal depende da This study was performed at the Fundação Pio XII do

Análise e descrição de dois casos de carcinoma espinocelular avançado em cabeça e pescoço

“…Na cirurgia de cabeça e pescoço, em geral, escolhe-se o retalho miocutâneo do músculo peitoral maior, como nos casos 1 e 2, quando há a necessidade de ressecções amplas, em decorrência de sua espessura e por permitir ilha de pele de grande diâmetro (14) (Figura 5). Nesse contexto, é interessante acrescentar que as possibilidades de retalhos que podem ser usados para cirurgias de reconstrução são: a) o retalho microcirúrgico, primeira opção para a maioria dos casos por oferecer tecido bem vascularizado para preenchimento, suporte e isolamen-to de estruturas ósseas, evitando complicações de alta morbimortalidade, sendo sua maior desvantagem o seu alto custo, gerado pela necessidade de equipe médica completa e treinada, análises patológicas repetidas e tempo cirúrgico prolongado (7,14) ; b) retalho local, utilizado para defeitos menores e sem estruturas nobres expostas (15) ; c) retalho miocutâneo, com aspectos técnicos simples e de alta versatilidade, pode ser utilizado quando há ressecções extensas, podendo-se aproveitar tecido dos músculos peitoral maior e grande dorsal (14,16) ; d) retalhos fasciocutâneos, como o supraclavicular e o Bakamjian, que apresentam bom arco de rotação, promovendo cobertura satisfatória, além de terem cor e textura semelhantes à região receptora (17) .…”

A Large Squamous Cell Carcinoma on the Face Treated with Wide Excision and Defect Closure Using Forehead Flap Reconstruction

“…Reconstruction after facial tumor surgery is essential as tumors might cause facial asymmetry. 19 As the lesion is on the cheek, the surgeon may face a reconstructive challenge due to the extremely visible site, as well as limited local tissue supply. In addition, the cheek may perform several important functions such as face expression because it harbors several facial muscles underneath.…”

“…12 Skin flaps also have a 96% success rate for closing skin cancer defects such as SCC and BCC, without complications such as hematoma or infection. 19 Some authors recommend rhomboid, circular, bilobed, or cheek advancement flaps for wound closure on zone 1. 20,23,24 However, as for this case, we considered a different approach as those aforementioned techniques might only work on a smaller defect.…”

“…Flap donors taken from the forehead skin are suitable for reconstructing defects in the cheek, oral cavity, maxillary antrum, and mouth corners due to their similarity in texture and color, along with appropriate vascularization on the recipient tissue. 11,19 As for the donor site on the forehead, the wound was extensive so that primary closure would not be appropriate. Therefore, FTSG for wound closure on the forehead was performed.…”