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Microsurgical Reconstruction of Large, Locally Advanced Cutaneous Malignancy of the Head and Neck

Microsurgical Reconstruction of Large, Locally Advanced Cutaneous Malignancy of the Head and Neck Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 415219, 5 pages doi:10.1155/2011/415219 Review Article Microsurgical Reconstruction of Large, Locally Advanced Cutaneous Malignancy of the Head and Neck Joseph L. Hill and Brian Rinker Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY 40536-0284, USA Correspondence should be addressed to Brian Rinker, brink2@email.uky.edu Received 15 March 2011; Revised 28 July 2011; Accepted 22 August 2011 Academic Editor: AndreM ´ .Eckardt Copyright © 2011 J. L. Hill and B. Rinker. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Large, locally advanced cutaneous malignancy of the head and neck region is rare. However, when present, they impart a significant reconstructive challenge. These cancers have a tendency to invade peripheral tissues covering a large surface area as well as expose deeper structures such as skull, dura, orbit, and sinus after resection. Complicating the reconstructive dilemma is the high incidence of individuals who have undergone previous surgery in the region as well as adjuvant radiation therapy, which may preclude the use of local flaps or skin graft. Free tissue transfer provides a reconstructive surgeon the ability to provide well- vascularized tissue with adequate volume not limited by arc of rotation. 1. Background described as “advanced,” “massive,” “complex,” “gigantic,” and “horrifying [7].” The main reasons that patients present Skin cancer is the most common type of cancer in fair with such extensive tumors are failure of primary treatment skinned individuals [1]. Basal cell carcinoma is the most and patient neglect [7]. common type of skin cancer, affecting approximately 2 mil- lion Americans per year [2]. Basal cell carcinoma is followed 2. Reconstructive Dilemma closely in incidence by squamous cell carcinoma, which accounts for 20% of all skin cancers, with approximately Fortunately, these types of advanced skin cancers are rare 700,000 new cases identified per year [2, 3]. Basal cell and [6, 8]. As an example, the incidence of giant basal cell carci- squamous cell cancers are more common in sun-exposed nomas (>5 cm diameter) is less than 1% of all basal cell car- areas of the body, including the head and neck region [3, cinomas [8]. Despite their infrequent presentation, defects 4]. Other less common types of cutaneous malignancy in following resection of large cutaneous malignancies present the head and neck region include melanoma, Merkel cell a marked reconstructive challenge [9]. These cancers have carcinoma, sebaceous carcinoma, eccrine carcinoma, and a tendency to invade peripheral tissues covering a large dermatofibrosarcoma protuberans. surfaceareaaswellasinvadedeeperstructuressuchasskull, The head and neck region is a well-visualized region dura, orbit, and sinus [7]. Complicating the reconstructive of the body. Skin cancers in this region are usually easily dilemma is the high incidence of individuals who have un- identifiable with patients typically presenting early in the dergone previous surgery in the region as well as adjuvant ra- clinical course of the disease [5]. These skin cancers are ame- diation therapy, which may preclude the use of local flaps or nable to simple resection followed by reconstruction with skin grafts [5]. Moreover, regional flaps often lack adequate a skin graft, local flap, or healing by secondary intention volume to reconstruct large defects and are limited by their [5, 6]. Most patients heal uneventfully with good restoration arcofrotation[7, 10]. As a result, large, locally advanced of function and appearance [5, 6]. Occasionally, however, cancers of the head and neck region were once considered patients with skin cancers present much later in the clinical nonoperable secondary to a lack of reconstructive options course of the disease [7]. These types of cancers have been [7, 10]. The advent of microsurgical free tissue transfer 2 International Journal of Surgical Oncology (a) (b) (c) (d) (e) (f) Figure 1: A 65-year-old male with a large, locally advanced left scalp squamous cell carcinoma. (a) Left scalp lesion; (b) excised lesion scalp side; (c) excised lesion cranial side showing parietal cranium; (d) titanium mesh cranioplasty; (e) inset-free latissimus muscle flap with split thickness skin graft; (f) 1-month followup. changed the management of these advanced cutaneous a long vascular pedicle with adequate caliber and contain malignancies allowing for complete resection of tumor with- variable types of tissue. The ALT flap, for example, has out compromise of tumor margin [5, 10]. Free tissue transfer become the workhorse flap for soft-tissue reconstruction for provides well-vascularized tissue with excellent volume for this group and can, therefore, be used in the reconstruction reconstruction of complex defects of the head and neck of several subareas in the head and neck region. The ALT flap region [10]. is based on the descending branch of the lateral circumflex femoral artery. The pedicle length has been documented as being up to 18 cm long. The flap can contain vastus lateralis 3. Flap Selection muscle for added bulk, tensor fascia lata for strength, or can be thinned to skin and subcutaneous fat [10]. The flap Flap selection is an important component in planning can be de-epithelialized and used to fill volume and can a successful head and neck reconstruction after tumor also be made into a sensate flap via the anterior branch ablation. Defects in the head and neck can be classified into of the lateral cutaneous nerve of the thigh [10]. Perhaps six anatomical subareas for reconstructive considerations: more importantly, however, donor site morbidity is kept to intraoral, mandibular, midfacial, cranial, cutaneous, and a minimum after harvest of an ALT flap and does not require scalp [10]. Upon completion of the resection, the location, patient repositioning as is the case when utilizing a similar the size, the tissue components (skin, soft tissue, or bone) type of flap for reconstruction like the parascapular flap [11]. excised, and the compartments (maxilla, orbit, cranium, and mandible) involved are noted [10]. After this analysis, a suitable flap can be selected. 4. Craniectomy Unfortunately, it is difficult for an individual surgeon to be comfortable with all of the potential free flaps available for Defects in the cranial vault are not uncommon after excision use in the head and neck [10]. As a result, numerous authors of large, locally advanced cutaneous malignancies of the scalp have developed algorithms which simplify flap selection [11]. and forehead. In doing so, underlying dura or brain paren- Jones et al. identified seven free flaps suitable for head and chyma become exposed, which, at the very least, requires neck reconstruction. These flaps are jejunum, radial forearm, soft-tissue coverage. Due to the size of these re-sections and rectus abdominis, latissimus dorsi, scapula/parascapular, the limited amount of healthy tissue from local and regional fibula, and iliac crest [11]. Disa et al. refined this algorithm to sources, free tissue transfer is necessary [9]. Muscle flaps only include the radial forearm, fibula, myocutaneous rectus which are commonly used for scalp or forehead reconstruc- abdominus, and jejunum [12]. tion after large tumor ablation include the latissimus dorsi Wong and Wei had refined this algorithm further in head and rectus abdominus muscle flaps or latissimus dorsi and and neck reconstruction to include the anterolateral thigh rectus abdominus myocutaneous flaps [9]; see Figures 1(a)– (ALT) flap, radial forearm, jejunum, and fibula [10]. Accord- 1(f). Fasciocutaneous flaps, which have been described for ing to Wei, these flaps were chosen because they provide use after these types of resections, include the ALT flap, International Journal of Surgical Oncology 3 (a) (b) (c) (d) Figure 2: A 56-year-old male with a locally invasive left facial basal cell carcinoma. (a) Maxillectomy plus orbital exenteration; (b), (c) vertical rectus abdominus myocutaneous (VRAM) flap; (d) inset-free VRAM. scapular/parascapular flaps, and radial forearm flap [9]. Each sonably assume the loss of resistance in brain tissue lacking a of these flaps can cover large surface areas and have long protective skull also occurs following craniectomy for other vascular pedicles [9]. reasons and, therefore, could contribute to brain herniation It should be noted, however, that craniectomy for any through a cranial bone defect following tumor ablation reason, including tumor ablation, is not without complica- [15]. tion. Known complications include brain herniation, subdu- ral effusion, syndrome of trephined (ST), infection, hema- 5. Cranioplasty toma, hydrocephalus, and cerebrospinal fluid leak [13]. ST is a known complication of craniectomy consisting of severe Cranioplasty is utilized to prevent some of the long term headache, dizziness, undue fatigability, poor memory, irri- sequelae of craniectomy. Indications for cranioplasty accord- tability, convulsions, mental depression, and intolerance to ing to Lee et al. is to protect the cerebrum and for cosmetic vibration [14]. purposes [16]. More recently, many authors believe ST is an In a study by Yang et al. [13], 108 patients who suffered indication for cranioplasty [14]. closed traumatic brain injury ultimately requiring decom- Materials available for cranioplasty fall into two cate- pressive craniectomy were retrospectively reviewed. Compli- gories: autologous or alloplastic. Autogenous bone sources cations occurred in 54 of the 108 patients. More than one include split calvarial bone graft, iliac crest, and rib. Autoge- complication occurred in 25.9%. Herniation of parenchyma nous bone has been advocated by some secondary to its abil- through the cranial bone defect was found in 27.8% of ity to become incorporated as living tissue and, therefore, has patients, which commonly leads to venous infarction. This an improved ability to resist infection [16]. Disadvantages of figure included seven out of eighteen patients with small autogenous bone include potential donor site morbidity and craniectomy defects, thus implicating the dimensions of the increased length of time for harvest [17]. craniectomy as a contributing factor to brain herniation [13]. Examples of alloplastic materials include titanium mesh, In Stiver’s review of the literature, increased brain swell- hydroxyapatite, methyl methacrylate, and porous polyethy- ing is common following decompressive craniectomy [15]. lene [17]; see Figure 1(d). Alloplastic materials have the Brain swelling results from hyperperfusion in the adjacent advantage of being in abundant supply and have no donor brain parenchyma as well as loss of resistance in brain site morbidity. However, they are contraindicated in compro- tissue lacking a protective skull. This loss of resistance in- mised or infected wound beds [16]. vokes a higher hydrostatic pressure gradient that may per- Cranioplasty is not without its own set of complications. mit transcapillary leakage of edema fluid. While these two These complications include infection, epidural or subdural physiological sequelae of craniectomy are documented to fluid collection, seizures, and fixed nenrological deficits occur following decompressive craniectomy, one could rea- [18]. 4 International Journal of Surgical Oncology (a) (b) (c) (d) (e) Figure 3: A 61-year-old male with a poorly controlled left facial basal cell carcinoma. (a) Maxillectomy defect; (b), (c), (d) ALT-free flap with long vascular pedicle; (e) inset of ALT-free flap. 6. Orbital Exenteration including the extent of the resection, the need for adjuvant radiation, and the desire for a prosthesis. The extent of the Another consideration after ablation of large cutaneous resection ranges from globe and soft tissue only to globe, soft malignancy in the head and neck region is reconstruction tissue, bony orbit, and finally, to include all of the above plus options following orbital exenteration. Orbital exenteration the maxilla. Skin grafting should only be utilized for limited involves the removal of orbital contents including the globe, resection, no adjuvant radiation therapy, and patient desire extraocular muscles, periorbital soft-tissue, and varying for a prosthesis. The need for a free flap is determined by the portions of the orbit. It is usually undertaken for orbital and extent of the resection such that orbital exenteration with a periorbital malignancies including basal cell and squamous maxillectomy requires free flap reconstruction [19]. cell carcinoma. The primary goal of reconstruction is to line or fill 7. Maxillectomy the orbit with durable tissue that excludes the nasal cavity, paranasal sinuses, and dura. The reconstruction may need Lastly, cutaneous malignancies sometimes extend into the to be able to withstand the harmful effects of radiation and maxilla and nasal cavity necessitating maxillectomy. As indi- to accommodate a prosthesis. Options for reconstruction cated by Wells and Luce, these resections are more common include split thickness skin graft, full thickness skin graft, with primary sinus malignancy [20]. Nonetheless, the need regional flap, and free flap depending on the tissue compo- for reconstructing the maxilla can be an issue following nents that remain or are exposed following orbital exentera- resection of large, locally advanced cutaneous malignancies. tion. Free flaps which have been documented to be utilized in Reconstructive goals include wound closure, the restoration reconstruction following orbital exenteration include rectus of the barrier between the sinonasal cavity and the anterior abdominus muscle flap, split thickness skin graft, rectus cranial fossa, the separation of the oral and sinonasal cavities, abdominus myocutaneous flap, and the anterolateral thigh flap [19]; see Figures 2(a)–2(d). support of orbital contents, maintenance of ocular globe po- sition, oral continence, speech, mastication, avoidance of According to Hanasono et al. [19], selection of the most suitable reconstructive option depends on several factors, ectropion, maintenance of a patent nasal airway, and lastly, International Journal of Surgical Oncology 5 facial appearance [21]. Maxillary defects range from limited scalp and forehead,” Annals of Plastic Surgery, vol. 48, no. 6, pp. 600–606, 2002. maxillectomy to total maxillectomy with orbital exenteration [21]. Reconstructive options include free radial forearm flap [10] C. H. Wong and F. C. Wei, “Microsurgical free flap in head and neck reconstruction,” Head and Neck, vol. 32, no. 9, pp. 1236– fasciocutaneous flap, ALT flap, and vertical rectus myocuta- 1245, 2010. neous flap with or without bone grafting depending on the degree of resection [21]; see Figures 3(a)–3(e). [11] B. S. Lutz and F. C. Wei, “Microsurgical workhorse flaps in head and neck reconstruction,” Clinics in Plastic Surgery, vol. 32, no. 3, pp. 421–430, 2005. 8. Summary [12] J. J. Disa,A.L.Pusic,D.H.Hidalgo, andP.G.Cordeiro, “Simplifying microvascular head and neck reconstruction: a Large, locally advanced cutaneous malignancy of the head rational approach to donor site selection,” Annals of Plastic and neck generally occurs secondary to patient neglect and Surgery, vol. 47, no. 4, pp. 385–389, 2001. because of a failure of primary treatment. Fortunately, these [13] X. F. Yang, L. Wen, F. Shen et al., “Surgical complications sec- types of skin cancers are rare. When they do occur, they ondary to decompressive craniectomy in patients with a head pose a significant reconstructive challenge, because they can injury: a series of 108 consecutive cases,” Acta Neurochirurgica, expose cranium, dura, orbit, and sinus. Free tissue transfer vol. 150, no. 12, pp. 1241–1247, 2008. has been a significant advance in the management of these [14] P. A. Winkler, W. Stummer, R. Linke, K. G. Krishnan, and K. tumors. It provides well-vascularized tissue that can with- Tatsch, “Influence of cranioplasty on postural blood flow reg- stand the detrimental effects of adjuvant radiation therapy ulation, cerebrovascular reserve capacity, and cerebral glucose as well as provide tissue with adequate volume not limited metabolism,” Journal of Neurosurgery, vol. 93, no. 1, pp. 53–61, by arc of rotation. Most importantly, however, free tissue transfer allows an oncologist the ability to completely resect [15] S. I. Stiver, “Complications of decompressive craniectomy for tumor without compromising surgical margins. traumatic brain injury,” Neurosurgical Focus,vol. 26, no.6, pp. 1–16, 2009. [16] C. Lee, O. M. Antonyshyn, and C. R. Forrest, “Cranioplasty: Acknowledgments indications, technique, and early results of autogenous split skull cranial vault reconstruction,” Journal of Cranio-Maxillo- The authors acknowledge the assistance of Assistant Profes- Facial Surgery, vol. 23, no. 3, pp. 133–142, 1995. sor James Liau for access to his patient records and Linda [17] Y. R. Cho and A. K. Gosain, “Biomaterials in craniofacial re- Combs for her help in reviewing this paper. construction,” Clinics in Plastic Surgery, vol. 31, no. 3, pp. 377– 385, 2004. References [18] V. Chang, P. Hartzfeld, M. Langlois, A. Mahmood, and D. Seyfried, “Outcomes of cranial repair after craniectomy,” Jour- [1] D.L.Narayanan,R.N.Saladi, andJ.L.Fox,“Ultravioletradi- nal of Neurosurgery, vol. 112, no. 5, pp. 1120–1124, 2010. ation and skin cancer,” International Journal of Dermatology, vol. 49, no. 9, pp. 978–986, 2010. [19] M. M. Hanasono,J.C.Lee,J.S.Yang, R. J. Skoracki,G.P. [2] P. Robins, “Skin Cancer,” http://www.skincancer.org/. Reece, and B. Esmaeli, “An algorithmic approach to recon- [3] A. Culliford and A. Hazen, “Dermatology for plastic sur- structive surgery and prosthetic rehabilitation after orbital ex- enteration,” Plastic and Reconstructive Surgery, vol. 123, no. 1, geons,” in Grabb & Smith’s Plastic Surgery,C.H.Thorne, R. W. Beasley, S. J. Aston, S. P. Bartlett,G.C.Gurtner,and S. pp. 98–105, 2009. L. Spear, Eds., pp. 105–114, Lippincott Williams & Wilkins, [20] M. D. Wells and E. A. Luce, “Reconstruction of midfacial de- Phliadelphia, Pa, USA, 2006. fects after surgical resection of malignancies,” Clinics in Plastic [4] R. M. Barton, “Malignant tumors of the skin,” in Plastic Surgery, vol. 22, no. 1, pp. 79–89, 1995. Surgery, S. J. Mathes, Ed., pp. 273–304, Elsevier, Philadelphia, [21] C. M. McCarthy and P. G. Cordeiro, “Microvascular recon- Pa, USA, 2005. struction of oncologic defects of the midface,” Plastic and [5] M. K. Wax, B. B. Burkey, D. Bascom, and E. L. Rosenthal, “The Reconstructive Surgery, vol. 126, no. 6, pp. 1947–1959, 2010. role of free tissue transfer in the reconstruction of massive neglected skin cancers of the head and neck,” Archives of Facial Plastic Surgery, vol. 5, no. 6, pp. 479–482, 2003. [6] H. Levine, “Cutaneous carcinoma of the head and neck: management of massive and previously uncontrolled lesions,” Laryngoscope, vol. 93, no. 1, pp. 87–105, 1983. [7] N. Ford Jones, R. A. Hardesty, W. M. Swartz, S. S. Ramasastry, F. R. Heckler, and E. D. Newton, “Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction,” Plastic and Reconstruc- tive Surgery, vol. 82, no. 6, pp. 937–950, 1988. [8] P. L. Lackey, L. A. Sargent, L. Wong, M. Brzezienski, and J. W. Kennedy, “Giant basal cell carcinoma surgical management and reconstructive challenges,” Annals of Plastic Surgery, vol. 58, no. 3, pp. 250–254, 2007. [9] D.McCombe,R.Donato, S. 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Microsurgical Reconstruction of Large, Locally Advanced Cutaneous Malignancy of the Head and Neck

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Copyright © 2011 Joseph L. Hill and Brian Rinker. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 415219, 5 pages doi:10.1155/2011/415219 Review Article Microsurgical Reconstruction of Large, Locally Advanced Cutaneous Malignancy of the Head and Neck Joseph L. Hill and Brian Rinker Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY 40536-0284, USA Correspondence should be addressed to Brian Rinker, brink2@email.uky.edu Received 15 March 2011; Revised 28 July 2011; Accepted 22 August 2011 Academic Editor: AndreM ´ .Eckardt Copyright © 2011 J. L. Hill and B. Rinker. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Large, locally advanced cutaneous malignancy of the head and neck region is rare. However, when present, they impart a significant reconstructive challenge. These cancers have a tendency to invade peripheral tissues covering a large surface area as well as expose deeper structures such as skull, dura, orbit, and sinus after resection. Complicating the reconstructive dilemma is the high incidence of individuals who have undergone previous surgery in the region as well as adjuvant radiation therapy, which may preclude the use of local flaps or skin graft. Free tissue transfer provides a reconstructive surgeon the ability to provide well- vascularized tissue with adequate volume not limited by arc of rotation. 1. Background described as “advanced,” “massive,” “complex,” “gigantic,” and “horrifying [7].” The main reasons that patients present Skin cancer is the most common type of cancer in fair with such extensive tumors are failure of primary treatment skinned individuals [1]. Basal cell carcinoma is the most and patient neglect [7]. common type of skin cancer, affecting approximately 2 mil- lion Americans per year [2]. Basal cell carcinoma is followed 2. Reconstructive Dilemma closely in incidence by squamous cell carcinoma, which accounts for 20% of all skin cancers, with approximately Fortunately, these types of advanced skin cancers are rare 700,000 new cases identified per year [2, 3]. Basal cell and [6, 8]. As an example, the incidence of giant basal cell carci- squamous cell cancers are more common in sun-exposed nomas (>5 cm diameter) is less than 1% of all basal cell car- areas of the body, including the head and neck region [3, cinomas [8]. Despite their infrequent presentation, defects 4]. Other less common types of cutaneous malignancy in following resection of large cutaneous malignancies present the head and neck region include melanoma, Merkel cell a marked reconstructive challenge [9]. These cancers have carcinoma, sebaceous carcinoma, eccrine carcinoma, and a tendency to invade peripheral tissues covering a large dermatofibrosarcoma protuberans. surfaceareaaswellasinvadedeeperstructuressuchasskull, The head and neck region is a well-visualized region dura, orbit, and sinus [7]. Complicating the reconstructive of the body. Skin cancers in this region are usually easily dilemma is the high incidence of individuals who have un- identifiable with patients typically presenting early in the dergone previous surgery in the region as well as adjuvant ra- clinical course of the disease [5]. These skin cancers are ame- diation therapy, which may preclude the use of local flaps or nable to simple resection followed by reconstruction with skin grafts [5]. Moreover, regional flaps often lack adequate a skin graft, local flap, or healing by secondary intention volume to reconstruct large defects and are limited by their [5, 6]. Most patients heal uneventfully with good restoration arcofrotation[7, 10]. As a result, large, locally advanced of function and appearance [5, 6]. Occasionally, however, cancers of the head and neck region were once considered patients with skin cancers present much later in the clinical nonoperable secondary to a lack of reconstructive options course of the disease [7]. These types of cancers have been [7, 10]. The advent of microsurgical free tissue transfer 2 International Journal of Surgical Oncology (a) (b) (c) (d) (e) (f) Figure 1: A 65-year-old male with a large, locally advanced left scalp squamous cell carcinoma. (a) Left scalp lesion; (b) excised lesion scalp side; (c) excised lesion cranial side showing parietal cranium; (d) titanium mesh cranioplasty; (e) inset-free latissimus muscle flap with split thickness skin graft; (f) 1-month followup. changed the management of these advanced cutaneous a long vascular pedicle with adequate caliber and contain malignancies allowing for complete resection of tumor with- variable types of tissue. The ALT flap, for example, has out compromise of tumor margin [5, 10]. Free tissue transfer become the workhorse flap for soft-tissue reconstruction for provides well-vascularized tissue with excellent volume for this group and can, therefore, be used in the reconstruction reconstruction of complex defects of the head and neck of several subareas in the head and neck region. The ALT flap region [10]. is based on the descending branch of the lateral circumflex femoral artery. The pedicle length has been documented as being up to 18 cm long. The flap can contain vastus lateralis 3. Flap Selection muscle for added bulk, tensor fascia lata for strength, or can be thinned to skin and subcutaneous fat [10]. The flap Flap selection is an important component in planning can be de-epithelialized and used to fill volume and can a successful head and neck reconstruction after tumor also be made into a sensate flap via the anterior branch ablation. Defects in the head and neck can be classified into of the lateral cutaneous nerve of the thigh [10]. Perhaps six anatomical subareas for reconstructive considerations: more importantly, however, donor site morbidity is kept to intraoral, mandibular, midfacial, cranial, cutaneous, and a minimum after harvest of an ALT flap and does not require scalp [10]. Upon completion of the resection, the location, patient repositioning as is the case when utilizing a similar the size, the tissue components (skin, soft tissue, or bone) type of flap for reconstruction like the parascapular flap [11]. excised, and the compartments (maxilla, orbit, cranium, and mandible) involved are noted [10]. After this analysis, a suitable flap can be selected. 4. Craniectomy Unfortunately, it is difficult for an individual surgeon to be comfortable with all of the potential free flaps available for Defects in the cranial vault are not uncommon after excision use in the head and neck [10]. As a result, numerous authors of large, locally advanced cutaneous malignancies of the scalp have developed algorithms which simplify flap selection [11]. and forehead. In doing so, underlying dura or brain paren- Jones et al. identified seven free flaps suitable for head and chyma become exposed, which, at the very least, requires neck reconstruction. These flaps are jejunum, radial forearm, soft-tissue coverage. Due to the size of these re-sections and rectus abdominis, latissimus dorsi, scapula/parascapular, the limited amount of healthy tissue from local and regional fibula, and iliac crest [11]. Disa et al. refined this algorithm to sources, free tissue transfer is necessary [9]. Muscle flaps only include the radial forearm, fibula, myocutaneous rectus which are commonly used for scalp or forehead reconstruc- abdominus, and jejunum [12]. tion after large tumor ablation include the latissimus dorsi Wong and Wei had refined this algorithm further in head and rectus abdominus muscle flaps or latissimus dorsi and and neck reconstruction to include the anterolateral thigh rectus abdominus myocutaneous flaps [9]; see Figures 1(a)– (ALT) flap, radial forearm, jejunum, and fibula [10]. Accord- 1(f). Fasciocutaneous flaps, which have been described for ing to Wei, these flaps were chosen because they provide use after these types of resections, include the ALT flap, International Journal of Surgical Oncology 3 (a) (b) (c) (d) Figure 2: A 56-year-old male with a locally invasive left facial basal cell carcinoma. (a) Maxillectomy plus orbital exenteration; (b), (c) vertical rectus abdominus myocutaneous (VRAM) flap; (d) inset-free VRAM. scapular/parascapular flaps, and radial forearm flap [9]. Each sonably assume the loss of resistance in brain tissue lacking a of these flaps can cover large surface areas and have long protective skull also occurs following craniectomy for other vascular pedicles [9]. reasons and, therefore, could contribute to brain herniation It should be noted, however, that craniectomy for any through a cranial bone defect following tumor ablation reason, including tumor ablation, is not without complica- [15]. tion. Known complications include brain herniation, subdu- ral effusion, syndrome of trephined (ST), infection, hema- 5. Cranioplasty toma, hydrocephalus, and cerebrospinal fluid leak [13]. ST is a known complication of craniectomy consisting of severe Cranioplasty is utilized to prevent some of the long term headache, dizziness, undue fatigability, poor memory, irri- sequelae of craniectomy. Indications for cranioplasty accord- tability, convulsions, mental depression, and intolerance to ing to Lee et al. is to protect the cerebrum and for cosmetic vibration [14]. purposes [16]. More recently, many authors believe ST is an In a study by Yang et al. [13], 108 patients who suffered indication for cranioplasty [14]. closed traumatic brain injury ultimately requiring decom- Materials available for cranioplasty fall into two cate- pressive craniectomy were retrospectively reviewed. Compli- gories: autologous or alloplastic. Autogenous bone sources cations occurred in 54 of the 108 patients. More than one include split calvarial bone graft, iliac crest, and rib. Autoge- complication occurred in 25.9%. Herniation of parenchyma nous bone has been advocated by some secondary to its abil- through the cranial bone defect was found in 27.8% of ity to become incorporated as living tissue and, therefore, has patients, which commonly leads to venous infarction. This an improved ability to resist infection [16]. Disadvantages of figure included seven out of eighteen patients with small autogenous bone include potential donor site morbidity and craniectomy defects, thus implicating the dimensions of the increased length of time for harvest [17]. craniectomy as a contributing factor to brain herniation [13]. Examples of alloplastic materials include titanium mesh, In Stiver’s review of the literature, increased brain swell- hydroxyapatite, methyl methacrylate, and porous polyethy- ing is common following decompressive craniectomy [15]. lene [17]; see Figure 1(d). Alloplastic materials have the Brain swelling results from hyperperfusion in the adjacent advantage of being in abundant supply and have no donor brain parenchyma as well as loss of resistance in brain site morbidity. However, they are contraindicated in compro- tissue lacking a protective skull. This loss of resistance in- mised or infected wound beds [16]. vokes a higher hydrostatic pressure gradient that may per- Cranioplasty is not without its own set of complications. mit transcapillary leakage of edema fluid. While these two These complications include infection, epidural or subdural physiological sequelae of craniectomy are documented to fluid collection, seizures, and fixed nenrological deficits occur following decompressive craniectomy, one could rea- [18]. 4 International Journal of Surgical Oncology (a) (b) (c) (d) (e) Figure 3: A 61-year-old male with a poorly controlled left facial basal cell carcinoma. (a) Maxillectomy defect; (b), (c), (d) ALT-free flap with long vascular pedicle; (e) inset of ALT-free flap. 6. Orbital Exenteration including the extent of the resection, the need for adjuvant radiation, and the desire for a prosthesis. The extent of the Another consideration after ablation of large cutaneous resection ranges from globe and soft tissue only to globe, soft malignancy in the head and neck region is reconstruction tissue, bony orbit, and finally, to include all of the above plus options following orbital exenteration. Orbital exenteration the maxilla. Skin grafting should only be utilized for limited involves the removal of orbital contents including the globe, resection, no adjuvant radiation therapy, and patient desire extraocular muscles, periorbital soft-tissue, and varying for a prosthesis. The need for a free flap is determined by the portions of the orbit. It is usually undertaken for orbital and extent of the resection such that orbital exenteration with a periorbital malignancies including basal cell and squamous maxillectomy requires free flap reconstruction [19]. cell carcinoma. The primary goal of reconstruction is to line or fill 7. Maxillectomy the orbit with durable tissue that excludes the nasal cavity, paranasal sinuses, and dura. The reconstruction may need Lastly, cutaneous malignancies sometimes extend into the to be able to withstand the harmful effects of radiation and maxilla and nasal cavity necessitating maxillectomy. As indi- to accommodate a prosthesis. Options for reconstruction cated by Wells and Luce, these resections are more common include split thickness skin graft, full thickness skin graft, with primary sinus malignancy [20]. Nonetheless, the need regional flap, and free flap depending on the tissue compo- for reconstructing the maxilla can be an issue following nents that remain or are exposed following orbital exentera- resection of large, locally advanced cutaneous malignancies. tion. Free flaps which have been documented to be utilized in Reconstructive goals include wound closure, the restoration reconstruction following orbital exenteration include rectus of the barrier between the sinonasal cavity and the anterior abdominus muscle flap, split thickness skin graft, rectus cranial fossa, the separation of the oral and sinonasal cavities, abdominus myocutaneous flap, and the anterolateral thigh flap [19]; see Figures 2(a)–2(d). support of orbital contents, maintenance of ocular globe po- sition, oral continence, speech, mastication, avoidance of According to Hanasono et al. [19], selection of the most suitable reconstructive option depends on several factors, ectropion, maintenance of a patent nasal airway, and lastly, International Journal of Surgical Oncology 5 facial appearance [21]. Maxillary defects range from limited scalp and forehead,” Annals of Plastic Surgery, vol. 48, no. 6, pp. 600–606, 2002. maxillectomy to total maxillectomy with orbital exenteration [21]. Reconstructive options include free radial forearm flap [10] C. H. Wong and F. C. Wei, “Microsurgical free flap in head and neck reconstruction,” Head and Neck, vol. 32, no. 9, pp. 1236– fasciocutaneous flap, ALT flap, and vertical rectus myocuta- 1245, 2010. neous flap with or without bone grafting depending on the degree of resection [21]; see Figures 3(a)–3(e). [11] B. S. Lutz and F. C. Wei, “Microsurgical workhorse flaps in head and neck reconstruction,” Clinics in Plastic Surgery, vol. 32, no. 3, pp. 421–430, 2005. 8. Summary [12] J. J. Disa,A.L.Pusic,D.H.Hidalgo, andP.G.Cordeiro, “Simplifying microvascular head and neck reconstruction: a Large, locally advanced cutaneous malignancy of the head rational approach to donor site selection,” Annals of Plastic and neck generally occurs secondary to patient neglect and Surgery, vol. 47, no. 4, pp. 385–389, 2001. because of a failure of primary treatment. Fortunately, these [13] X. F. Yang, L. Wen, F. Shen et al., “Surgical complications sec- types of skin cancers are rare. When they do occur, they ondary to decompressive craniectomy in patients with a head pose a significant reconstructive challenge, because they can injury: a series of 108 consecutive cases,” Acta Neurochirurgica, expose cranium, dura, orbit, and sinus. Free tissue transfer vol. 150, no. 12, pp. 1241–1247, 2008. has been a significant advance in the management of these [14] P. A. Winkler, W. Stummer, R. Linke, K. G. Krishnan, and K. tumors. It provides well-vascularized tissue that can with- Tatsch, “Influence of cranioplasty on postural blood flow reg- stand the detrimental effects of adjuvant radiation therapy ulation, cerebrovascular reserve capacity, and cerebral glucose as well as provide tissue with adequate volume not limited metabolism,” Journal of Neurosurgery, vol. 93, no. 1, pp. 53–61, by arc of rotation. Most importantly, however, free tissue transfer allows an oncologist the ability to completely resect [15] S. I. Stiver, “Complications of decompressive craniectomy for tumor without compromising surgical margins. traumatic brain injury,” Neurosurgical Focus,vol. 26, no.6, pp. 1–16, 2009. [16] C. Lee, O. M. Antonyshyn, and C. R. Forrest, “Cranioplasty: Acknowledgments indications, technique, and early results of autogenous split skull cranial vault reconstruction,” Journal of Cranio-Maxillo- The authors acknowledge the assistance of Assistant Profes- Facial Surgery, vol. 23, no. 3, pp. 133–142, 1995. sor James Liau for access to his patient records and Linda [17] Y. R. Cho and A. K. Gosain, “Biomaterials in craniofacial re- Combs for her help in reviewing this paper. construction,” Clinics in Plastic Surgery, vol. 31, no. 3, pp. 377– 385, 2004. References [18] V. Chang, P. Hartzfeld, M. Langlois, A. Mahmood, and D. Seyfried, “Outcomes of cranial repair after craniectomy,” Jour- [1] D.L.Narayanan,R.N.Saladi, andJ.L.Fox,“Ultravioletradi- nal of Neurosurgery, vol. 112, no. 5, pp. 1120–1124, 2010. ation and skin cancer,” International Journal of Dermatology, vol. 49, no. 9, pp. 978–986, 2010. [19] M. M. Hanasono,J.C.Lee,J.S.Yang, R. J. Skoracki,G.P. [2] P. Robins, “Skin Cancer,” http://www.skincancer.org/. Reece, and B. Esmaeli, “An algorithmic approach to recon- [3] A. Culliford and A. Hazen, “Dermatology for plastic sur- structive surgery and prosthetic rehabilitation after orbital ex- enteration,” Plastic and Reconstructive Surgery, vol. 123, no. 1, geons,” in Grabb & Smith’s Plastic Surgery,C.H.Thorne, R. W. Beasley, S. J. Aston, S. P. Bartlett,G.C.Gurtner,and S. pp. 98–105, 2009. L. Spear, Eds., pp. 105–114, Lippincott Williams & Wilkins, [20] M. D. Wells and E. A. Luce, “Reconstruction of midfacial de- Phliadelphia, Pa, USA, 2006. fects after surgical resection of malignancies,” Clinics in Plastic [4] R. M. Barton, “Malignant tumors of the skin,” in Plastic Surgery, vol. 22, no. 1, pp. 79–89, 1995. Surgery, S. J. Mathes, Ed., pp. 273–304, Elsevier, Philadelphia, [21] C. M. McCarthy and P. G. Cordeiro, “Microvascular recon- Pa, USA, 2005. struction of oncologic defects of the midface,” Plastic and [5] M. K. Wax, B. B. Burkey, D. Bascom, and E. L. Rosenthal, “The Reconstructive Surgery, vol. 126, no. 6, pp. 1947–1959, 2010. role of free tissue transfer in the reconstruction of massive neglected skin cancers of the head and neck,” Archives of Facial Plastic Surgery, vol. 5, no. 6, pp. 479–482, 2003. [6] H. Levine, “Cutaneous carcinoma of the head and neck: management of massive and previously uncontrolled lesions,” Laryngoscope, vol. 93, no. 1, pp. 87–105, 1983. [7] N. Ford Jones, R. A. Hardesty, W. M. Swartz, S. S. Ramasastry, F. R. Heckler, and E. D. Newton, “Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction,” Plastic and Reconstruc- tive Surgery, vol. 82, no. 6, pp. 937–950, 1988. [8] P. L. Lackey, L. A. Sargent, L. Wong, M. Brzezienski, and J. W. Kennedy, “Giant basal cell carcinoma surgical management and reconstructive challenges,” Annals of Plastic Surgery, vol. 58, no. 3, pp. 250–254, 2007. [9] D.McCombe,R.Donato, S. 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