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CTA and DSA; however, CTA has the possibility of missed diagnosis. It is an emergency situation that needs emergency treatment, including interventional therapy and surgery. We recommend the surgery as the prior treatment for traumatic pseudoaneurysms of MMA.
REFERENCES 1. Benoit BG, Wortzman G. Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 1973;36:127Y138 2. Lim DH, Kim TS, Joo SP, et al. Intraparenchymal hematoma caused by ruptured traumatic pseudoaneurysm of the middle meningeal artery: a case report. J Korean Neurosurg Soc 2007;42:416Y418 3. Bruneau M, Gustin T, Zekhnini K, et al. Traumatic false aneurysm of the middle meningeal artery causing an intraparenchymal hemorrhage: case report and literature review. Surg Neurol 2002;57:174Y178 4. Kawaguchi T, Kawano T, Kaneko Y, et al. Traumatic lesions of the bilateral middle meningeal arteriesYcase report. Neurol Med Chir (Tokyo) 2002;42:221Y223 5. Srinivasan A, Lesiuk H, Goyal M. Spontaneous resolution of posttraumatic middle meningeal artery pseudoaneurysm. AJNR Am J Neuroradiol 2006;27:882Y883
Nonmelanoma Facial Skin Carcinomas: Methods of Treatment Caner Kili0, MD,* Umit Tuncel, MD,Þ Ela Comert, MD,Þ Ilhan Polat, MDÞ Aim: The objective was to present in this study the administered treatment, reconstruction, and outcomes for lesions excised according to a prediagnosis of facial tumor, whose pathological finding was reported as nonmelanoma skin tumor. Methods: A total of 178 patients with full medical histories who were operated on for skin tumors in the Ear, Nose, and Throat Clinic of Ankara Oncology Education and Research Hospital between February 2010 and March 2012 were evaluated retrospectively. The test group was made up of 125 men (70%) and 53 women (30%), with a median age of 56 years (range, 29Y89 years). Results: Basal cell carcinoma was diagnosed in 112 patients (63%), 45 (40%) of whom underwent flap reconstruction procedures; squamous cell carcinoma (SCC) was diagnosed in 55 patients (31%), 25 (45%) of whom underwent flap reconstruction procedures; 5 patients (3%) were diagnosed with basosquamous carcinoma, 3 (60%) of whom underwent flap reconstruction, and metatypical carcinoma was found in 6 patients (3%), and 5 (80%) underwent flap reconstruction treatment. Recurrence occurred in 10 (18%) of the 55 SCC patients.
Brief Clinical Studies
Invasion depths in the patients with recurrence were between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depths in the other 24 patients (53.3%) were less than 4 mm. Conclusions: Metastatic lymph node involvement localized to the auricular, infra-auricular, and postauricular was present in the pathological specimens of all patients with lesions who had selective neck dissection I to IV included into their treatment. The depth of invasion of SCCs was found to be statistically significant in terms of recurrences. Key Words: Flap, face skin, nonmelanoma, reconstructions
T
he most common cancers of the skin, the largest organ in the body, are basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs), and melanomas. Basal cell carcinoma, SCC, and other rare epithelial tumors are defined as nonmelanoma carcinomas, with BCC being the most common histopathologic type among this group, with an incidence of 75%. Metatypical carcinomas (MTCs) and basosquamous carcinomas (BSCs) are less common, with a frequency of less than 10%, and these are most commonly found in the head and neck.1 Skin tumors most often occur in white males.2,3 Among the many etiologic factors are UV light, arsenic, age, chronic irritation, chromosome abnormalities, and genetics.4 UV is thought to cause mutations in the DNA, whereas gene mutations of glutathione-Stransferase, cytochrome P450, and P53 have also been found to encourage tumor formation. The human papillomavirus has also been known to affect the formation of SCC.5 In surgical treatments of these tumors, total mass excision, in addition to parotidectomy and neck dissection (ND), can be performed when necessary according to the type, size, and location of the tumor. For the reconstruction of the skin following the excision of the tumor, one of the following surgical techniques may be utilized: primary suture, nasolabial flap, bilobar flap, rhomboid flap, forehead flap, glabellar flap, advancement flaps, lateral temporal flap, and temporoparietal flap.6Y10 The decision of which surgical technique to use depends on the location of the tumor and the dimensions of the defect, whereas nonsurgical treatments include cryotherapy, phototherapy, laser treatment, radiotherapy, and chemotherapy.11,12 The rates of local recurrence and metastasis are increased in cases of SCC when the diameter of the tumor is more than 2 cm and the depth is more than 4 mm, with high grade and when the tumor is located in the ear.2 The methods of treatment of facial skin tumors with histopathologic diagnoses of nonmelanoma carcinoma, the achieved results, and the parameters effective in recurrences are discussed in this study.
MATERIALS AND METHOD From the *University of Ordu, Training and Research Hospital, Ordu; and †Department of Otorhinolaryngology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey. Received July 22, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Caner Kili0, MD, University of Ordu, Training and Research Hospital, Bucak District Nefsibucak st. 52000 Ordu, Turkey; E-mail: [email protected] The authors did not receive financial support for this article. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000390
A total of 178 patients with full medical histories who were operated on for skin tumors in the Ear, Nose, and Throat Clinic of the Ankara Oncology Education and Research Hospital between February 2010 and March 2012 were analyzed retrospectively. The test group was made up of 125 men (70%) and 53 women (30%), with a median age of 56 years (range, 29Y89 years). Patients with facial skin lesions diagnosed as BCC, SCC, MTC, and BSC were included in the study. The locations of lesions were classified by location under the headings nasal dorsum, nasal tip, alar, nasolabial, preauricular, postauricular, infra-auricular, auricular, frontal, zygomatic, cheek, infraorbital, and glabellar regions. A total excision of the lesion
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Histopathologic Diagnosis of Lesions Located in the Nasal Region and the Reconstructions
Lesion Location
No. Histopathology Patients (%)
Nasal dorsum
Nasal- type
Nasal alar region
Nasolabial region
BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
Primary Suture, n (%)
40 (76) 12 (23) 1 (0.02)
17 (42) 2 (16)
Advancement Nasolabial Flap, n (%) Flap, n (%) 6 (15) 3 (25)
4 (10) 3 (25)
Glabellar Flap, n (%)
Auricular Bilobed Flap, Forehead Flap, Composite Rotation n (%) n (%) Graft, n (%) Flap, n (%)
13 (32.5) 4 (33) 1 (100)
10 (83) 2 (16)
10 (100) 2 (100)
10 (63) 2 (13) 2 (13) 2 (13) 16 (89) 2 (11)
4 (40)
6 (60) 2 (100)
2 (100) 1 (50) 10 (62.5)
1 (50)
6 (37.5) 2 (100)
according to the reported diagnosis after an incisional biopsy was performed in all cases, and lesions diagnosed as BCC were excised together with 0.5 cm of healthy tissue, whereas SCC, MTC, and BSC lesions were excised with 1.5 cm of healthy tissue. The size of the resulting defect led the decision of whether to make a primary suture or carry out a reconstruction with a flap. The patients were classified according to tumor type, location, type of flap reconstruction, and additional treatment methods, such as ND and parotidectomy. The depth of invasion in cases of SCC and the positivity of the surgical margin in cases of BCC were analyzed in cases of recurrence, and the results are presented herein. The effect of the depth of invasion on recurrence was analyzed using a W2 test in SPSS 15 (SPSS Inc., Chicago, IL).
RESULTS Of the 178 test subjects, 112 (63%) were diagnosed with BCC, and a flap reconstruction procedure was applied to 45 (40%); SCC was the diagnosis in 55 patients (31%), and flap reconstruction was applied to
25 (45%); 5 patients (3%) were diagnosed with BSCs, and 3 of them (60%) underwent flap reconstruction, and finally, MTCs were found present in 6 patients (3%), and 5 of them (80%) underwent flap reconstruction treatment. Recurrence developed in 10 (18%) of the 55 SCC patients. Invasion depths in these patients with recurrence was between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depth in the other 24 patients (53.3%) were less than 4 mm. The postoperative surgical contours of the SCC-diagnosed lesions were negative. Of the 112 patients diagnosed with BCC, 10 patients (9%) had positive surgical contours in their postoperative specimens; reexcision was performed for these patients. One patient with BCC (20%) suffered 2 recurrences due to surgical margin positivity. No recurrences were observed in cases with MTC or BSC, and no significant association was found between the rate of recurrence and the location of lesions. A primary excision with local flap reconstruction was performed in cases in which the lesions presented in the nasal region, with no additional treatment (Table 1).
TABLE 2. Histopathologic Diagnosis of Lesions Located in the Auricular Region and the Reconstructions
Lesion Location Preauricular region
Postauricular region
Infra-auricular region
Auricular region
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Histopathology
No. Patients (%)
Primary Suture, n (%)
BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
10 (63) 6 (37)
6 (60) 4 (66)
3 (50) 1 (16) 1 (16) 1 (16) 4 (80) 1 (20)
3 (100)
10 (31) 20 (63) 1 (3) 1 (3)
10 (100) 11 (55)
Advancement Flap, n (%)
Rotation Flap, n (%)
Rhomboid Flap, n (%)
Lateral Temporal flap, n (%)
4 (40) 2 (33)
1 (100) 1 (100) 1 (100) 3 (75)
1 (25) 1 (100)
4 (20) 1 (100) 1 (100)
5 (25)
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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& Volume 25, Number 2, March 2014
All 6 cases (100%) with SCC located at the preauricular region had superficial parotidectomies added to their treatments. Selective ND (SND) II-IV was added to the treatment of one (16%) of the patients. No metastasis was identified in the pathological specimen. A level II-Va posterolateral ND was performed on 3 patients (100%) with tumors located in the postauricular region with the diagnoses of SCC, BSC, and MTC. These 3 patients had more than 1 pathological lymph node invasion in the ND specimens, located in the lateral neck. Radiotherapy was planned as an additional treatment in these patients. One patient with an SCC located in the infra-auricular region (100%) had a superficial parotidectomy and SND II-IV added to its treatment, and a pathological lymph node invasion was made in the ND specimens. An SND II-IV was added to the treatment of 5 cases (25%) with SCC, 1 case (100%) with MTC, and 1 case (100%) with BSC for patients with lesions located on the auricular skin who had undergone total auricular excisions. All patients with ND had metastatic lymph node involvement proven by histopathologic examinations, and radiotherapy was planned in these patients because of the large size of the primary tumors. Patients with tumors located in the auricular skin region, on the other hand, most frequently underwent primary sutures, whereas cases with total auricular excisions underwent reconstruction with wide musculocutaneous flaps (Table 2). A superficial parotidectomy was added to the treatment of 2 cases (100%) with SCC and in 1 case (100%) with MTC located in the frontal region of the head with no pathological lymph node involvement. An SND I-IV was performed on 4 patients (100%) with SCC located on the cheeks with no pathological lymph node involvement. Reconstructions following the removal of tumors located in areas other than the nasal and auricular regions were carried out with rhomboid flaps because of large surface areas involved (Table 3).
TABLE 3. Histopathologic Diagnosis of Lesions Other Than Nasal and Auricular Region and the Reconstructions
Lesion Location Frontal region
Zygomatic region
Cheek
Glabellar region
Infraorbital region
No. Patients Histopathology (%) BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
Primary Suture, n (%)
4 (57) 2 (28) 1 (14)
4 (100)
1 (33) 2 (66)
1 (100) 2 (100)
1 (20) 4 (80)
1 (100) 4 (100)
2 (100)
2 (100)
1 (50) 1 (50)
1 (100)
Advancement Rhomboid Flap, n (%) Flap, n (%)
2 (100) 1 (100)
1 (100)
Brief Clinical Studies
DISCUSSION Nonmelanoma skin tumors are the most common in the human body and are most frequently found in the head and neck region. Of these, BCCs are the most common,13 with MTCs and BSCs seen in less than 5% of cases. In a study of head and neck tumors, the number of patients with SCC exceeds all others.1 Basal cell carcinomas, SCCs, MTCs, and BSCs were identified in 112 (63%), 55 (31%), 5 (3%), and 6 (3%) patients, respectively, among the 178 cases studied. This distribution of incidences was in concordance with previously reported data in literature. The numbers of males (n = 125, 70%) and females (n = 53, 30%) of this study were also consistent with previous studies.2,3,6 Skin tumors in the head and neck region can be seen in different anatomic localizations according to their histopathologic types. Basal cell carcinoma lesions are more commonly located in the nasal region, whereas SCCs are most often found in the auricular region.6 In this series, the lesions of 76 cases (67%) with BCC were located in the nasal region, whereas the lesions of 20 cases (36%) were located in the auricular, which is in accordance with previous literature. The establishment of a balance between functional and aesthetic concerns in the surgical approach to these tumoral lesions, whenever needed, is imperative, and thus the excision of the mass and the reconstruction should be planned accordingly.14 Surgeons perform different reconstruction techniques depending on the location and dimensions of the tumors and, more importantly, according to their own experience.15,16 An attempt has been made to standardize the reconstructions performed according to the location of the lesions, and surgical interventions have been carried out accordingly with satisfying results in both function and aesthetics, both for the clinic and the patients. Bilobar flap reconstructions following the removal of nasal skin lesions have been reported with very low complication rates and satisfying aesthetic results.6,16 In a study of nasal skin tumors and their reconstructions, bilobar flaps were used in nasal skin reconstructions with adequate aesthetic results and no reported alar retractions.17 In the study, bilobar flaps were applied in some reconstructions of the skin lesions located at the nasal tip and in the alar region that were not advance-stage tumors, with no complications and satisfactory aesthetic results. In a study of 70 patients with alar defects, alar reconstructions were carried out using auricular composite grafts, with satisfactory results.7 Composite auricular flaps were applied to 3 patients (1%) in the study who had developed necrosis of the skin on the cartilage. In all cases, which were subsequently debrided, the wounds healed with secondary epithelialization. Rhomboid flaps were used in the reconstruction of nasal, forehead, and lip lesions with lesser rates of complication, such as dog ear formation, and achieved better aesthetic results.8 No complications were encountered in cases of rhomboid flap reconstruction in this study. Advancement flaps, used for different regions of the facial skin,9,18 and nasolabial flaps, used for nasal region defects,11,19 both recorded low complication rates and yielded satisfying results in terms of both function and aesthetic appearance. Minor dog ear deformities were seen in only the nasolabial flap reconstructions, which were treated with minor surgical interventions. Parotidectomies and ND are added to the treatment of advancestage auricular BCC, MTC, and SCC, because the risk of regional metastases is high. Metastases in the fifth region were identified in a study analyzing auricular lesions, and thus it was reported that this region had to be added to the ND.20 Among the patients who underwent ND, 1 patient (1%) had an infra-auricular SCC, 5 (2%) had an SCC with advanced stages, 1 BSC (1%) and 1 MTC patient (1%) with auricular localization, 4 patients (2%) had SCC on the cheeks, and 1 patient (1%) each had an SCC, BSC, or MTC in a postauricular location. All of the patients
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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who had ND added to their treatments for lesions on their auricular, infra-auricular, and postauricular skin had metastatic lymph node involvement in their pathological specimens. For this reason, it is suggested that ND should be included in the treatment of lesions in this region. No pathologic lymph nodes were encountered in the follow-up of cases with lesions in other areas. On rare occasions, regional metastases were reported in cases with BCC13; however, no further metastasis was encountered in the patients during follow-up consultations. Depths of invasion greater than 4 mm in cases with SCC and auricular localization are reported as significant factors in increased rates of local recurrence and regional metastasis.1 Recurrence developed in 10 (18%) of the 55 SCC patients. Invasion depths in these patients with recurrence were between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depths in the other 24 patients (53.3%) were below 4 mm. The effect of the depth of invasion on the potential for recurrence was statistically significant in this study (P = 0.004). These results concord with previous literature.
CONCLUSIONS We suggest the principal use of bilobar flaps for tumors in the nasal region, composite auricular flaps in patients with alar cartilage resections, and advancement flaps and rhomboid flaps in tumors of the preauricular region, on the other hand, in terms of functionality and aesthetic appearance. Metastatic lymph node involvement was found during histopathologic examinations of the ND materials in patients with lesions localized on the skin of the auricular, preauricular, postauricular, and infra-auricular skin, who had SND I-IV added to their treatments. On the other hand, no metastatic involvement was present in their parotidectomy specimens. Thus, we recommend an additional parotidectomy and ND to mass excisions in these localizations, depending on the size of the lesions. Statistics show that depths of invasion greater than 4 mm in cases with SCC lead significantly to recurrences in this study.
REFERENCES 1. Tarallo M, Cigna E, Sorvillo V, et al. Metatypical carcinoma. A review of 327 cases. Ann Ital Chir 2011;82:131Y135 2. Adinarayan M, Krishnamurthy SP. Clinicopathological evaluation of nonmelanoma skin cancer. Indian J Dermatol 2011;56:670Y672 3. Butler ST, Fosko SW. Increased prevalence of left-sided skin cancers [published online ahead of print March 11, 2010]. J Am Acad Dermatol 2010;63:1006Y1010 4. Berger E, Hunt R, Tzu J, et al. Squamous-cell carcinoma in situ in a patient with oculocutaneous albinism. Dermatol Online J 2011;17:22 5. Samarasinghe V, Madan V. Nonmelanoma skin cancer. J Cutan Aesthet Surg 2012;5:3Y10 6. Salgarelli AC, Cangiano A, Sartorelli F, et al. The bilobed flap in skin cancer of the face: our experience on 285 cases. J Craniomaxillofac Surg 2010;38:460Y464 7. Teltzrow T, Arens A, Schwipper V. One-stage reconstruction of nasal defects: evaluation of the use of modified auricular composite grafts. Facial Plast Surg 2011;27:243Y248 8. Wu HL, Le SJ, Zheng SS. Double opposing-rhomboid flaps for closure of a circular facial defect in a special position. Aesthetic Plast Surg 2009;33:523Y526 9. Rapstine ED, Knaus WJ 2nd, Thornton JF. Simplifying cheek reconstruction: a review of over 400 cases. Plast Reconstr Surg 2012;129:1291Y1299
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10. Sclafani AP, Sclafani JA, Sclafani AM. Successes, revisions, and postoperative complications in 446 Mohs defect repairs. Facial Plast Surg 2012;28:358Y366 11. Ceylan C, Ozdemir F, Erboz S, et al. Topical photodynamic therapy of basal cell carcinoma. Turkderm 1999;33:153Y157 12. Ermertcan AT, Hellings PW, Cingi C. Nonmelanoma skin cancer of the head and neck: nonsurgical treatment. Facial Plast Surg Clin North Am 2012;20:445Y454 13. Tirelioglu S, Ozgenel GY, Filiz G. Retrospective analysis of 576 cases with basal cell cancer. Turk J Plast Surg 2004;12 14. Bogle M, Kelly P, Shenaq J, et al. The role of soft tissue reconstruction after melanoma resection in the head and neck. Head Neck 2001;23:8 15. Eskiizmir G, Hircin HZ, Celik O, et al. Our experience in nasal reconstruction with local nasal and regional flaps. Turk J Ear Nose Throat 2011;21:1Y9 16. Steiger JD. Bilobed flaps in nasal reconstruction. Facial Plast Surg Clin North Am 2011;19:107Y111 17. Xue CY, Li L, Guo LL, et al. The bilobed flap for reconstruction of distal nasal defect in Asians. Aesthetic Plast Surg 2009;33:600Y604 18. Eker E, Tellioglu AT, Menevse GT, et al. Repair of soft tissue defects of the nose. Turk J Ear Nose Throat 2010;20:64Y70 19. Masic T, Lincender I, Dizdarevic D. Reconstruction of total and subtotal nose defects. Med Arh 2010;64:110Y112 20. Peiffer N, Kutz JW Jr, Myers LL, et al. Patterns of regional metastasis in advanced stage cutaneous squamous cell carcinoma of the auricle. Otolaryngol Head Neck Surg 2011;144:36Y42
Self-Mutilation of the Tongue in a Patient With Schizophrenia Jin-Myung Hong, MD, Seok-Chan Eun, MD Abstract: Attempts at tongue replantation are rare, possibly because of the friable nature of the tongue vasculature. We describe the successful replantation of the tongue in a patient with schizophrenia who attempted self-mutilation. Anastomosis of the right deep lingual artery and vein was performed under microscopy. To ensure that the patient did not make another mutilation attempt, he was kept under sedation in the intensive care unit, and a Denhardt mouth gag was placed for 5 days. Currently, his pronunciation is close to normal, and he has recovered some degree of somatic and gustatory sensation. It may be argued that the amputated tongue should be discarded; however, successful replantation can be achieved with high satisfaction for the patient and family, especially in a psychiatric patient. Key Words: Tongue, replantation, schizophrenia, self-mutilation
A
ttempts at replantation of the tongue are rare, possibly because the friable nature of the tongue vasculature makes replantation difficult. Some individuals are believed to practice self-mutilation From the Department of Plastic & Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. Received July 22, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Seok-Chan Eun, MD, Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000447
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 25, Number 2, March 2014
CTA and DSA; however, CTA has the possibility of missed diagnosis. It is an emergency situation that needs emergency treatment, including interventional therapy and surgery. We recommend the surgery as the prior treatment for traumatic pseudoaneurysms of MMA.
REFERENCES 1. Benoit BG, Wortzman G. Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 1973;36:127Y138 2. Lim DH, Kim TS, Joo SP, et al. Intraparenchymal hematoma caused by ruptured traumatic pseudoaneurysm of the middle meningeal artery: a case report. J Korean Neurosurg Soc 2007;42:416Y418 3. Bruneau M, Gustin T, Zekhnini K, et al. Traumatic false aneurysm of the middle meningeal artery causing an intraparenchymal hemorrhage: case report and literature review. Surg Neurol 2002;57:174Y178 4. Kawaguchi T, Kawano T, Kaneko Y, et al. Traumatic lesions of the bilateral middle meningeal arteriesYcase report. Neurol Med Chir (Tokyo) 2002;42:221Y223 5. Srinivasan A, Lesiuk H, Goyal M. Spontaneous resolution of posttraumatic middle meningeal artery pseudoaneurysm. AJNR Am J Neuroradiol 2006;27:882Y883
Nonmelanoma Facial Skin Carcinomas: Methods of Treatment Caner Kili0, MD,* Umit Tuncel, MD,Þ Ela Comert, MD,Þ Ilhan Polat, MDÞ Aim: The objective was to present in this study the administered treatment, reconstruction, and outcomes for lesions excised according to a prediagnosis of facial tumor, whose pathological finding was reported as nonmelanoma skin tumor. Methods: A total of 178 patients with full medical histories who were operated on for skin tumors in the Ear, Nose, and Throat Clinic of Ankara Oncology Education and Research Hospital between February 2010 and March 2012 were evaluated retrospectively. The test group was made up of 125 men (70%) and 53 women (30%), with a median age of 56 years (range, 29Y89 years). Results: Basal cell carcinoma was diagnosed in 112 patients (63%), 45 (40%) of whom underwent flap reconstruction procedures; squamous cell carcinoma (SCC) was diagnosed in 55 patients (31%), 25 (45%) of whom underwent flap reconstruction procedures; 5 patients (3%) were diagnosed with basosquamous carcinoma, 3 (60%) of whom underwent flap reconstruction, and metatypical carcinoma was found in 6 patients (3%), and 5 (80%) underwent flap reconstruction treatment. Recurrence occurred in 10 (18%) of the 55 SCC patients.
Brief Clinical Studies
Invasion depths in the patients with recurrence were between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depths in the other 24 patients (53.3%) were less than 4 mm. Conclusions: Metastatic lymph node involvement localized to the auricular, infra-auricular, and postauricular was present in the pathological specimens of all patients with lesions who had selective neck dissection I to IV included into their treatment. The depth of invasion of SCCs was found to be statistically significant in terms of recurrences. Key Words: Flap, face skin, nonmelanoma, reconstructions
T
he most common cancers of the skin, the largest organ in the body, are basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs), and melanomas. Basal cell carcinoma, SCC, and other rare epithelial tumors are defined as nonmelanoma carcinomas, with BCC being the most common histopathologic type among this group, with an incidence of 75%. Metatypical carcinomas (MTCs) and basosquamous carcinomas (BSCs) are less common, with a frequency of less than 10%, and these are most commonly found in the head and neck.1 Skin tumors most often occur in white males.2,3 Among the many etiologic factors are UV light, arsenic, age, chronic irritation, chromosome abnormalities, and genetics.4 UV is thought to cause mutations in the DNA, whereas gene mutations of glutathione-Stransferase, cytochrome P450, and P53 have also been found to encourage tumor formation. The human papillomavirus has also been known to affect the formation of SCC.5 In surgical treatments of these tumors, total mass excision, in addition to parotidectomy and neck dissection (ND), can be performed when necessary according to the type, size, and location of the tumor. For the reconstruction of the skin following the excision of the tumor, one of the following surgical techniques may be utilized: primary suture, nasolabial flap, bilobar flap, rhomboid flap, forehead flap, glabellar flap, advancement flaps, lateral temporal flap, and temporoparietal flap.6Y10 The decision of which surgical technique to use depends on the location of the tumor and the dimensions of the defect, whereas nonsurgical treatments include cryotherapy, phototherapy, laser treatment, radiotherapy, and chemotherapy.11,12 The rates of local recurrence and metastasis are increased in cases of SCC when the diameter of the tumor is more than 2 cm and the depth is more than 4 mm, with high grade and when the tumor is located in the ear.2 The methods of treatment of facial skin tumors with histopathologic diagnoses of nonmelanoma carcinoma, the achieved results, and the parameters effective in recurrences are discussed in this study.
MATERIALS AND METHOD From the *University of Ordu, Training and Research Hospital, Ordu; and †Department of Otorhinolaryngology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey. Received July 22, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Caner Kili0, MD, University of Ordu, Training and Research Hospital, Bucak District Nefsibucak st. 52000 Ordu, Turkey; E-mail: [email protected] The authors did not receive financial support for this article. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000390
A total of 178 patients with full medical histories who were operated on for skin tumors in the Ear, Nose, and Throat Clinic of the Ankara Oncology Education and Research Hospital between February 2010 and March 2012 were analyzed retrospectively. The test group was made up of 125 men (70%) and 53 women (30%), with a median age of 56 years (range, 29Y89 years). Patients with facial skin lesions diagnosed as BCC, SCC, MTC, and BSC were included in the study. The locations of lesions were classified by location under the headings nasal dorsum, nasal tip, alar, nasolabial, preauricular, postauricular, infra-auricular, auricular, frontal, zygomatic, cheek, infraorbital, and glabellar regions. A total excision of the lesion
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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& Volume 25, Number 2, March 2014
TABLE 1. Histopathologic Diagnosis of Lesions Located in the Nasal Region and the Reconstructions
Lesion Location
No. Histopathology Patients (%)
Nasal dorsum
Nasal- type
Nasal alar region
Nasolabial region
BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
Primary Suture, n (%)
40 (76) 12 (23) 1 (0.02)
17 (42) 2 (16)
Advancement Nasolabial Flap, n (%) Flap, n (%) 6 (15) 3 (25)
4 (10) 3 (25)
Glabellar Flap, n (%)
Auricular Bilobed Flap, Forehead Flap, Composite Rotation n (%) n (%) Graft, n (%) Flap, n (%)
13 (32.5) 4 (33) 1 (100)
10 (83) 2 (16)
10 (100) 2 (100)
10 (63) 2 (13) 2 (13) 2 (13) 16 (89) 2 (11)
4 (40)
6 (60) 2 (100)
2 (100) 1 (50) 10 (62.5)
1 (50)
6 (37.5) 2 (100)
according to the reported diagnosis after an incisional biopsy was performed in all cases, and lesions diagnosed as BCC were excised together with 0.5 cm of healthy tissue, whereas SCC, MTC, and BSC lesions were excised with 1.5 cm of healthy tissue. The size of the resulting defect led the decision of whether to make a primary suture or carry out a reconstruction with a flap. The patients were classified according to tumor type, location, type of flap reconstruction, and additional treatment methods, such as ND and parotidectomy. The depth of invasion in cases of SCC and the positivity of the surgical margin in cases of BCC were analyzed in cases of recurrence, and the results are presented herein. The effect of the depth of invasion on recurrence was analyzed using a W2 test in SPSS 15 (SPSS Inc., Chicago, IL).
RESULTS Of the 178 test subjects, 112 (63%) were diagnosed with BCC, and a flap reconstruction procedure was applied to 45 (40%); SCC was the diagnosis in 55 patients (31%), and flap reconstruction was applied to
25 (45%); 5 patients (3%) were diagnosed with BSCs, and 3 of them (60%) underwent flap reconstruction, and finally, MTCs were found present in 6 patients (3%), and 5 of them (80%) underwent flap reconstruction treatment. Recurrence developed in 10 (18%) of the 55 SCC patients. Invasion depths in these patients with recurrence was between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depth in the other 24 patients (53.3%) were less than 4 mm. The postoperative surgical contours of the SCC-diagnosed lesions were negative. Of the 112 patients diagnosed with BCC, 10 patients (9%) had positive surgical contours in their postoperative specimens; reexcision was performed for these patients. One patient with BCC (20%) suffered 2 recurrences due to surgical margin positivity. No recurrences were observed in cases with MTC or BSC, and no significant association was found between the rate of recurrence and the location of lesions. A primary excision with local flap reconstruction was performed in cases in which the lesions presented in the nasal region, with no additional treatment (Table 1).
TABLE 2. Histopathologic Diagnosis of Lesions Located in the Auricular Region and the Reconstructions
Lesion Location Preauricular region
Postauricular region
Infra-auricular region
Auricular region
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No. Patients (%)
Primary Suture, n (%)
BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
10 (63) 6 (37)
6 (60) 4 (66)
3 (50) 1 (16) 1 (16) 1 (16) 4 (80) 1 (20)
3 (100)
10 (31) 20 (63) 1 (3) 1 (3)
10 (100) 11 (55)
Advancement Flap, n (%)
Rotation Flap, n (%)
Rhomboid Flap, n (%)
Lateral Temporal flap, n (%)
4 (40) 2 (33)
1 (100) 1 (100) 1 (100) 3 (75)
1 (25) 1 (100)
4 (20) 1 (100) 1 (100)
5 (25)
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
All 6 cases (100%) with SCC located at the preauricular region had superficial parotidectomies added to their treatments. Selective ND (SND) II-IV was added to the treatment of one (16%) of the patients. No metastasis was identified in the pathological specimen. A level II-Va posterolateral ND was performed on 3 patients (100%) with tumors located in the postauricular region with the diagnoses of SCC, BSC, and MTC. These 3 patients had more than 1 pathological lymph node invasion in the ND specimens, located in the lateral neck. Radiotherapy was planned as an additional treatment in these patients. One patient with an SCC located in the infra-auricular region (100%) had a superficial parotidectomy and SND II-IV added to its treatment, and a pathological lymph node invasion was made in the ND specimens. An SND II-IV was added to the treatment of 5 cases (25%) with SCC, 1 case (100%) with MTC, and 1 case (100%) with BSC for patients with lesions located on the auricular skin who had undergone total auricular excisions. All patients with ND had metastatic lymph node involvement proven by histopathologic examinations, and radiotherapy was planned in these patients because of the large size of the primary tumors. Patients with tumors located in the auricular skin region, on the other hand, most frequently underwent primary sutures, whereas cases with total auricular excisions underwent reconstruction with wide musculocutaneous flaps (Table 2). A superficial parotidectomy was added to the treatment of 2 cases (100%) with SCC and in 1 case (100%) with MTC located in the frontal region of the head with no pathological lymph node involvement. An SND I-IV was performed on 4 patients (100%) with SCC located on the cheeks with no pathological lymph node involvement. Reconstructions following the removal of tumors located in areas other than the nasal and auricular regions were carried out with rhomboid flaps because of large surface areas involved (Table 3).
TABLE 3. Histopathologic Diagnosis of Lesions Other Than Nasal and Auricular Region and the Reconstructions
Lesion Location Frontal region
Zygomatic region
Cheek
Glabellar region
Infraorbital region
No. Patients Histopathology (%) BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC BCC SCC MTC BSC
Primary Suture, n (%)
4 (57) 2 (28) 1 (14)
4 (100)
1 (33) 2 (66)
1 (100) 2 (100)
1 (20) 4 (80)
1 (100) 4 (100)
2 (100)
2 (100)
1 (50) 1 (50)
1 (100)
Advancement Rhomboid Flap, n (%) Flap, n (%)
2 (100) 1 (100)
1 (100)
Brief Clinical Studies
DISCUSSION Nonmelanoma skin tumors are the most common in the human body and are most frequently found in the head and neck region. Of these, BCCs are the most common,13 with MTCs and BSCs seen in less than 5% of cases. In a study of head and neck tumors, the number of patients with SCC exceeds all others.1 Basal cell carcinomas, SCCs, MTCs, and BSCs were identified in 112 (63%), 55 (31%), 5 (3%), and 6 (3%) patients, respectively, among the 178 cases studied. This distribution of incidences was in concordance with previously reported data in literature. The numbers of males (n = 125, 70%) and females (n = 53, 30%) of this study were also consistent with previous studies.2,3,6 Skin tumors in the head and neck region can be seen in different anatomic localizations according to their histopathologic types. Basal cell carcinoma lesions are more commonly located in the nasal region, whereas SCCs are most often found in the auricular region.6 In this series, the lesions of 76 cases (67%) with BCC were located in the nasal region, whereas the lesions of 20 cases (36%) were located in the auricular, which is in accordance with previous literature. The establishment of a balance between functional and aesthetic concerns in the surgical approach to these tumoral lesions, whenever needed, is imperative, and thus the excision of the mass and the reconstruction should be planned accordingly.14 Surgeons perform different reconstruction techniques depending on the location and dimensions of the tumors and, more importantly, according to their own experience.15,16 An attempt has been made to standardize the reconstructions performed according to the location of the lesions, and surgical interventions have been carried out accordingly with satisfying results in both function and aesthetics, both for the clinic and the patients. Bilobar flap reconstructions following the removal of nasal skin lesions have been reported with very low complication rates and satisfying aesthetic results.6,16 In a study of nasal skin tumors and their reconstructions, bilobar flaps were used in nasal skin reconstructions with adequate aesthetic results and no reported alar retractions.17 In the study, bilobar flaps were applied in some reconstructions of the skin lesions located at the nasal tip and in the alar region that were not advance-stage tumors, with no complications and satisfactory aesthetic results. In a study of 70 patients with alar defects, alar reconstructions were carried out using auricular composite grafts, with satisfactory results.7 Composite auricular flaps were applied to 3 patients (1%) in the study who had developed necrosis of the skin on the cartilage. In all cases, which were subsequently debrided, the wounds healed with secondary epithelialization. Rhomboid flaps were used in the reconstruction of nasal, forehead, and lip lesions with lesser rates of complication, such as dog ear formation, and achieved better aesthetic results.8 No complications were encountered in cases of rhomboid flap reconstruction in this study. Advancement flaps, used for different regions of the facial skin,9,18 and nasolabial flaps, used for nasal region defects,11,19 both recorded low complication rates and yielded satisfying results in terms of both function and aesthetic appearance. Minor dog ear deformities were seen in only the nasolabial flap reconstructions, which were treated with minor surgical interventions. Parotidectomies and ND are added to the treatment of advancestage auricular BCC, MTC, and SCC, because the risk of regional metastases is high. Metastases in the fifth region were identified in a study analyzing auricular lesions, and thus it was reported that this region had to be added to the ND.20 Among the patients who underwent ND, 1 patient (1%) had an infra-auricular SCC, 5 (2%) had an SCC with advanced stages, 1 BSC (1%) and 1 MTC patient (1%) with auricular localization, 4 patients (2%) had SCC on the cheeks, and 1 patient (1%) each had an SCC, BSC, or MTC in a postauricular location. All of the patients
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Brief Clinical Studies
who had ND added to their treatments for lesions on their auricular, infra-auricular, and postauricular skin had metastatic lymph node involvement in their pathological specimens. For this reason, it is suggested that ND should be included in the treatment of lesions in this region. No pathologic lymph nodes were encountered in the follow-up of cases with lesions in other areas. On rare occasions, regional metastases were reported in cases with BCC13; however, no further metastasis was encountered in the patients during follow-up consultations. Depths of invasion greater than 4 mm in cases with SCC and auricular localization are reported as significant factors in increased rates of local recurrence and regional metastasis.1 Recurrence developed in 10 (18%) of the 55 SCC patients. Invasion depths in these patients with recurrence were between 7 and 30 mm. In 21 (46%) of the 45 patients without recurrence, invasion depths were between 4 and 30 mm, whereas the invasion depths in the other 24 patients (53.3%) were below 4 mm. The effect of the depth of invasion on the potential for recurrence was statistically significant in this study (P = 0.004). These results concord with previous literature.
CONCLUSIONS We suggest the principal use of bilobar flaps for tumors in the nasal region, composite auricular flaps in patients with alar cartilage resections, and advancement flaps and rhomboid flaps in tumors of the preauricular region, on the other hand, in terms of functionality and aesthetic appearance. Metastatic lymph node involvement was found during histopathologic examinations of the ND materials in patients with lesions localized on the skin of the auricular, preauricular, postauricular, and infra-auricular skin, who had SND I-IV added to their treatments. On the other hand, no metastatic involvement was present in their parotidectomy specimens. Thus, we recommend an additional parotidectomy and ND to mass excisions in these localizations, depending on the size of the lesions. Statistics show that depths of invasion greater than 4 mm in cases with SCC lead significantly to recurrences in this study.
REFERENCES 1. Tarallo M, Cigna E, Sorvillo V, et al. Metatypical carcinoma. A review of 327 cases. Ann Ital Chir 2011;82:131Y135 2. Adinarayan M, Krishnamurthy SP. Clinicopathological evaluation of nonmelanoma skin cancer. Indian J Dermatol 2011;56:670Y672 3. Butler ST, Fosko SW. Increased prevalence of left-sided skin cancers [published online ahead of print March 11, 2010]. J Am Acad Dermatol 2010;63:1006Y1010 4. Berger E, Hunt R, Tzu J, et al. Squamous-cell carcinoma in situ in a patient with oculocutaneous albinism. Dermatol Online J 2011;17:22 5. Samarasinghe V, Madan V. Nonmelanoma skin cancer. J Cutan Aesthet Surg 2012;5:3Y10 6. Salgarelli AC, Cangiano A, Sartorelli F, et al. The bilobed flap in skin cancer of the face: our experience on 285 cases. J Craniomaxillofac Surg 2010;38:460Y464 7. Teltzrow T, Arens A, Schwipper V. One-stage reconstruction of nasal defects: evaluation of the use of modified auricular composite grafts. Facial Plast Surg 2011;27:243Y248 8. Wu HL, Le SJ, Zheng SS. Double opposing-rhomboid flaps for closure of a circular facial defect in a special position. Aesthetic Plast Surg 2009;33:523Y526 9. Rapstine ED, Knaus WJ 2nd, Thornton JF. Simplifying cheek reconstruction: a review of over 400 cases. Plast Reconstr Surg 2012;129:1291Y1299
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10. Sclafani AP, Sclafani JA, Sclafani AM. Successes, revisions, and postoperative complications in 446 Mohs defect repairs. Facial Plast Surg 2012;28:358Y366 11. Ceylan C, Ozdemir F, Erboz S, et al. Topical photodynamic therapy of basal cell carcinoma. Turkderm 1999;33:153Y157 12. Ermertcan AT, Hellings PW, Cingi C. Nonmelanoma skin cancer of the head and neck: nonsurgical treatment. Facial Plast Surg Clin North Am 2012;20:445Y454 13. Tirelioglu S, Ozgenel GY, Filiz G. Retrospective analysis of 576 cases with basal cell cancer. Turk J Plast Surg 2004;12 14. Bogle M, Kelly P, Shenaq J, et al. The role of soft tissue reconstruction after melanoma resection in the head and neck. Head Neck 2001;23:8 15. Eskiizmir G, Hircin HZ, Celik O, et al. Our experience in nasal reconstruction with local nasal and regional flaps. Turk J Ear Nose Throat 2011;21:1Y9 16. Steiger JD. Bilobed flaps in nasal reconstruction. Facial Plast Surg Clin North Am 2011;19:107Y111 17. Xue CY, Li L, Guo LL, et al. The bilobed flap for reconstruction of distal nasal defect in Asians. Aesthetic Plast Surg 2009;33:600Y604 18. Eker E, Tellioglu AT, Menevse GT, et al. Repair of soft tissue defects of the nose. Turk J Ear Nose Throat 2010;20:64Y70 19. Masic T, Lincender I, Dizdarevic D. Reconstruction of total and subtotal nose defects. Med Arh 2010;64:110Y112 20. Peiffer N, Kutz JW Jr, Myers LL, et al. Patterns of regional metastasis in advanced stage cutaneous squamous cell carcinoma of the auricle. Otolaryngol Head Neck Surg 2011;144:36Y42
Self-Mutilation of the Tongue in a Patient With Schizophrenia Jin-Myung Hong, MD, Seok-Chan Eun, MD Abstract: Attempts at tongue replantation are rare, possibly because of the friable nature of the tongue vasculature. We describe the successful replantation of the tongue in a patient with schizophrenia who attempted self-mutilation. Anastomosis of the right deep lingual artery and vein was performed under microscopy. To ensure that the patient did not make another mutilation attempt, he was kept under sedation in the intensive care unit, and a Denhardt mouth gag was placed for 5 days. Currently, his pronunciation is close to normal, and he has recovered some degree of somatic and gustatory sensation. It may be argued that the amputated tongue should be discarded; however, successful replantation can be achieved with high satisfaction for the patient and family, especially in a psychiatric patient. Key Words: Tongue, replantation, schizophrenia, self-mutilation
A
ttempts at replantation of the tongue are rare, possibly because the friable nature of the tongue vasculature makes replantation difficult. Some individuals are believed to practice self-mutilation From the Department of Plastic & Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. Received July 22, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Seok-Chan Eun, MD, Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000447
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
