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

Abstract

Squamous cell carcinoma (SCC) is a non-melanoma skin cancer, with a rising worldwide incidence. Wide excision with an intraoperative frozen section decreases its recurrence rate and metastases. Case: We reported an SCC case in a 50-year-old woman with clinical manifestations of a 4 × 6 × 0.3 cm solitary ulcer that easily bled. Dermoscopy and histopathological examination support the diagnosis of SCC. Due to its size, a wide excision was initiated, followed by a frozen section being carried out to determine the cancer cell-free margin. We performed an additional 1 cm margin excision as residual tumor still remained in the margin on the first excision. The forehead interpolation flap reconstruction was performed right after the excision to cover the extensive defects on the cheek, followed by a full-thickness skin graft (FTSG) for the forehead. The patient recovered well without complication within eight weeks post-procedure. Discussion: SCC with a diameter larger than 2 cm is considered as high-risk, and a wide excision is the standard treatment in this condition. However, this may risk incomplete excision, leaving residual tumor and increased recurrence rate. Intraoperative frozen section aids the surgeon to determine tumor margin, thus improving the success rate of therapy by up to 95%. A skin graft on the cheek was avoided due to concerns of wound contraction, which may lead to lower tissue survival rates with poor color and texture matching. Therefore, we preferred a skin flap to increase tissue survival and preserve facial contour as well as skin color. Forehead interpolation flap was carried out as it could cover the large size of the skin defect. The forehead skin as donor was later closed by a FTSG. Conclusion: Wide excision surgery with frozen sections is the best option for managing large SCC while a skin flap is preferred to close defects on the cheek.

Squamous cell carcinoma in the malar region. Case report

“…Once the bone defect is evaluated, we address the soft-tissue defects, including the skin, muscles, palate, and mucosal lining of the cheek. Finally, important structures such as the palate, oral commissure, nasal airways, and eyelids are addressed in an attempt to restore function and form, which is a real challenge, especially knowing that most of these patients will require post-operative radiotherapy 6,7,10 .…”

“…One of the most modern classifications is that of James Brown from the year 2000, where class I involves maxillectomy without an oro-antral fistula, class 2 is a low maxillectomy, which does not include the floor of the orbit or its content, class 3 is a high maxillectomy involving the orbital content, and class 4 additionally includes orbital exenteration 6,7 .…”

“…The reconstruction of significant facial defects, especially in the mid-face, requires a thorough understanding of the area's complex anatomy and involves various techniques such as primary closure, skin grafting, and local tissue flaps 5 . The anterolateral thigh (ALT) flap is frequently used in head and neck reconstructions, chosen for its versatility and ability to minimize surgical and anesthesia time 6,7 .…”

Application of a Modified Perforator Flap of the Transverse Facial Artery for Zygomaticofacial Skin Defect Repair After Tumor Resection

“…Because of the proliferation of malignant skin tumors, different degrees of extended resection are often required in the treatment of these tumors. The zygomatic face is an prominent part of the face, and patients are particularly concerned about postoperative function and aesthetics 2,3 . In recent years, some well-known arteries have been used to reconstruct facial defects, such as the facial artery and the superficial temporal artery.…”

“…The zygomatic face is an prominent part of the face, and patients are particularly concerned about postoperative function and aesthetics. 2,3 In recent years, some well-known arteries have been used to reconstruct facial defects, such as the facial artery and the superficial temporal artery. The perforator flap of the transverse facial artery is rarely reported because its branches are relatively constant at the position of the zygomatic arch , whereas their variability is high at other positions.…”