cance s
A icle
Full-Thickness Tumo Resec ion o O al Cance In ol ing he
Facial Skin—Mic osu gical Recons uc ion o Ex ensi e De ec s
a e Radical T ea men o Ad anced Squamous Cell Ca cinoma
Julius Mo a in 1,* , Jan M osek 1, Dominik Ho n 2, Ka l Me zge 1, Oli e Ris ow 1, S en Zi el 1,
Michael Engel 1, Kolja F eie 2, Jue gen Ho mann 1and Ch is ian F eudlspe ge 1


Ci a ion: Mo a in, J.; M osek, J.;
Ho n, D.; Me zge , K.; Ris ow, O.;
Zi el, S.; Engel, M.; F eie , K.;
Ho mann, J.; F eudlspe ge , C.
Full-Thickness Tumo Resec ion o
O al Cance In ol ing he Facial
Skin—Mic osu gical Recons uc ion
o Ex ensi e De ec s a e Radical
T ea men o Ad anced Squamous
Cell Ca cinoma. Cance s 2021,13,
2122. h ps://doi.o g/10.3390/
cance s13092122
Academic Edi o : Ch is ian Simon
Recei ed: 15 Ma ch 2021
Accep ed: 27 Ap il 2021
Published: 28 Ap il 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Depa men o O al and C anio-Maxillo acial Su ge y, Uni e si y o Heidelbe g, Im Neuenheime Feld 400,
D-69120 Heidelbe g, Ge many; jan.m [email p o ec ed] (J.M.);
[email p o ec ed] (K.M.); oli e [email p o ec ed] (O.R.);
[email p o ec ed] (S.Z.); [email p o ec ed]g.de (M.E.);
jue gen.ho [email p o ec ed] (J.H.); ch is ian. [email p o ec ed]g.de (C.F.)
2Depa men o O al and C anio-Maxillo acial Su ge y, Saa land Uni e si y Hospi al, Ki be ge S aße,
D-66424 Hombu g, Ge many; [email p o ec ed] (D.H.); kolja. [email p o ec ed] (K.F.)
*Co espondence: [email p o ec ed]g.de; Tel.: +49-6211-39795
Simple Summa y:
Ad anced malignan umo s o he o al ca i y a e challenging because hey
impose se ious oncological and unc ional equi emen s on he ea men specialis . Depending on
he localiza ion and he ex en o he p ima y umo , a ull- hickness esec ion a ec ing he acial
skin may be necessa y o achie e a comple e umo esec ion. The esul ing de ec s need adequa e
econs uc ion in o de o es o e he aes he ics and unc ionali y o he o o acial sys em. In his
e ospec i e analysis, he au ho s aimed o e alua e ea men echniques o hese umo s and
analyze he clinical ou come o he ela ed p ocedu es. Full- hickness umo esec ion wi h ee lap
econs uc ion due o ad anced cance was pe o med in 33 pa ien s.
Abs ac :
Ad anced umo s o he head and neck a e challenging o he ea men specialis due o
he need o syne gize oncological and unc ional equi emen s. F ee lap econs uc ion has been
es ablished as he s anda d o ca e o de ec s ollowing umo esec ion. Howe e , depending on he
a ec ed ana omic subsi e, ad anced umo s may impose speci ic di icul ies ega ding econs uc ion,
especially when ull- hickness esec ion is equi ed. This s udy aimed o e alua e econs uc i e
s a egies and oncological ou comes in pa ien s wi h ull- hickness esec ion o he o al ca i y. A
o al o 33 pa ien s wi h ex ensi e de ec s due o squamous cell ca cinoma o he o al ca i y we e
iden i ied. Indica ions, econs uc i e p ocedu es, and clinical ou come we e e alua ed. Thi y- wo
pa ien s (97%) p esen ed locally ad anced umo s (T3/T4). Comple e umo esec ion was achie ed
in 26 pa ien s (78.8%). The an e ola e al high lap was he mos equen ly used lap (47.1%), and he
p ima y lap success a e was 84.8%. The coho demons a ed a good local con ol a e and mode a e
o e all and p og ession- ee su i al a es. Mos pa ien s egained ull compe ence ega ding o al
alimen a ion and speech. Full- hickness umo esec ions o he head and neck a ea may be necessa y
due o ad anced umo s in c i ical ana omic a eas. In many cases, adical su gical ea men leads
o good oncological esul s. F ee lap econs uc ion has been shown o be a sui able op ion o
ex ensi e de ec s in aes he ically challenging egions.
Keywo ds: o al cance ; ee laps; HNSCC
1. In oduc ion
Head and neck squamous cell ca cinomas (HNSCCs) a e among he se en mos
common malignan umo s global and a signi ican po ion o hese umo s a ises om
he mucosa o he o al ca i y [
1
]. Despi e ecen ad ances in he he apy o HNSCC by he
Cance s 2021,13, 2122. h ps://doi.o g/10.3390/cance s13092122 h ps://www.mdpi.com/jou nal/cance s
Cance s 2021,13, 2122 2 o 12
in oduc ion o immune checkpoin inhibi ion o ecu en /me as a ic umo s, su ge y
and/o p ima y (chemo-) adio he apy emain he only p ima y he apeu ic op ions o
mos pa ien s [
2
–
4
]. Ad anced umo s, in pa icula , impose a challenge o bo h he pa ien s
su e ing om he disease and he ea ing specialis , due o a ade-o be ween oncological
necessi ies, and unc ional and aes he ic equi emen s, ha is ine i able in many cases o
head and neck umo he apy. Al hough p ima y chemo- adia ion is a ele an op ion o
head and neck cance pa ien s, ac o s including umo localiza ion, p io adju an he apy
in cases o ecu en umo s, o he medical easons, o he indi idual decisions o pa ien s
and ea ing specialis s, lea e su ge y as he only cu a i e he apy o ad anced umo s in
many cases.
The need o a comple e esec ion o o al umo s wi h sa e su gical ma gins may lead
o ex ensi e de ec s including ull- hickness pe o a ions in ol ing he acial o he ce ical
skin. While small de ec s a e su gical umo abla ion may be es o ed using local wound
closu e, spli skin g a s, o egional laps, ex ensi e de ec s in mos cases equi e he use o
ee laps o achie e an adequa e esul in e ms o unc ion and aes he ics [5–9].
Al hough econs uc i e su ge y o he head and neck egion is a well-es ablished
ield in many cen e s, he p epa edness and he expe ise o ex ensi e esec ions esul ing
in ull- hickness de ec s and consequen econs uc ions may a y. This may lead o
unde ea men o pa ien s, a ec ing bo h oncologic and unc ional ou comes in e ms
o pos - he apeu ic quali y o li e. The pu pose o he p esen ed s udy, he e o e, was
o p esen an o e iew o econs uc i e s a egies and clinical ou comes in a coho o
pa ien s wi h ull- hickness umo esec ions o squamous cell ca cinomas o he o al ca i y.
2. Resul s
2.1. Pa ien s
A o al o 33 pa ien s we e included in he analysis; 12 (36.4%) we e emale and 21
(63.6%) we e male, wi h a mean age o 67
±
13.7 yea s and a ange om 25 o 95 yea s.
All pa ien s ecei ed su gical he apy in he Depa men o O al and C anio-Maxillo acial
Su ge y o he Heidelbe g Uni e si y Hospi al. Twen y- wo (66.7%) pa ien s su e ed om
p ima y o al squamous cell ca cinoma and 11 (33.3%) we e ea ed because o a local o
loco egional umo ecu ence. Table 1p o ides de ailed in o ma ion on demog aphic,
clinical, and pa hological ea u es o he in es iga ed coho .
Table 1. Desc ip i e da a ega ding demog aphic and clinical ea u es o he in es iga ed coho .
Pa ame e Numbe o Cases (%)
Gende
Female 12 (36.4)
Male 21 (63.6)
Age
Mean: 67 ±13.7 yea s
Range: 25–95 yea s
Risk Fac o s
Tobacco 17 (51.5)
Alcohol 10 (30.3)
P ima y o Recu en Tumo
P ima y umo 21 (63.6)
Recu en umo (local ecu ence) 12 (36.4)
Cance s 2021,13, 2122 3 o 12
Table 1. Con .
Pa ame e Numbe o Cases (%)
Tumo Localiza ion
Mandible + Floo o he mou h 20 (60.6)
Buccal mucosa 8 (24.2)
Maxilla 5 (15.2)
T S age
T1 -
T2 1 (3.0)
T3 6 (18.2)
T4 26 (78.8)
N S age
0 21 (63.6)
1 1 (3.0)
2a -
2b 1 (3.0)
2c 2 (6.1)
3 8 (24.2)
M S age
0 33 (100)
1 -
UICC S age
1 -
2 -
3 4 (12.1)
4 29 (87.9)
His opa hological Tumo Fea u es
Lympha ic in asion 15 (45.5)
Vascula in asion 4 (12.1)
Pe ineu al in asion 12 (36.4)
2.2. The apeu ic P ocedu es
All pa ien s unde wen su gical he apy due o p ima y o ecu en squamous cell
ca cinoma o he o al ca i y. Comple e umo esec ion (R0) was achie ed in 26 pa ien s
(78.8%), incomple e umo esec ion (R1) was pe o med in six pa ien s (18.2%). In one
pa ien (3.0%) esec ion s a us was unclea (Rx) due o a agmen ed p epa a ion. Mos
cases o incomple e umo esec ions (5/6, 83.3%) we e ela ed o umo s o he loo o he
mou h/mandible.
The whole coho o 33 pa ien s had an indica ion o pos ope a i e adju an he apy
due o ad anced umo s age, he p esence o neck node me as ases, incomple e umo
esec ion s a us, his opa hological isk ac o s (L+, V+, pN+), o a combina ion o se e al
ac o s. In ac , only 15 pa ien s (45.5%) ecei ed pos ope a i e (chemo-) adia ion. The
emaining pa ien s did no ecei e adju an ea men due o a his o y o p io adio he apy
(n= 11/33.3%), educed medical condi ion o incomple e wound healing a e su ge y
(n= 3/9.1%), and pa ien s’ e usal (n= 4/12.1%).
2.3. Su gical Technique
All pa ien s ecei ed ull- hickness umo esec ion due o an in ol emen o he
ex e nal acial/ce ical skin by he umo mass and he in en ion o ob ain umo - ee
esec ion ma gins. The mos commonly a ec ed a ea was he cheek (n= 23/69.7%),
ollowed by he submen al/submandibula egion (n= 10/30.3%), whe eas he mos
Cance s 2021,13, 2122 4 o 12
commonly a ec ed p ima y umo si es we e he mandible, including he loo o he
mou h (n= 20/60.6%) and he buccal mucosa (n= 8/24.2%) (Table 1).
F ee lap econs uc ion was pe o med in all pa ien s. P ima y econs uc ion was
success ul in 28 pa ien s (84.8%) and lap loss occu ed in i e pa ien s (15.2%). In all
pa ien s wi h a ailu e o he i s lap, a second ee lap econs uc ion was pe o med
success ully using an ALT lap (n= 5). The ypes o ee laps used o de ec es o a ion
included he an e ola e al high lap (ALT, n= 24/82.7%), he adial o ea m lap (RFF,
n= 3/9.1%),
he scapula lap (n= 3/9.1%), he ibula lap (n= 2/6.1%), and he la issimus
do si lap (n= 1/3%). So - issue laps we e p epa ed o he es o a ion o ull- hickness
de ec s by pa ial de-epi heliza ion o c ea e wo sepa a ed skin paddles (Figu e 1).
Cance s 2021, 13, x FOR PEER REVIEW 5 o 12
Figu e 1. Schema ic diag am o a pa ially de-epi helialized ALT lap and an os eosyn hesis pla e
o he econs uc ion o a ull- hickness de ec a e umo esec ion wi h segmen al esec ion o
he le -sided mandible. A e segmen al esec ion and he indi idualiza ion o an os eosyn hesis
pla e, he ALT lap was ha es ed. The p epa ed lap hen unde wen pa ial de-epi helializa ion
in o de o c ea e wo skin paddles o es o a ion o he o al and he acial de ec .
2.4. Pe iope a i e Managemen
The mean hospi aliza ion pe iod o all pa ien s was 23.1 ± 10.9 days wi h a ange
om 9 o 53 days. Two pa ien s (6.1%) died du ing hei hospi aliza ion pe iod due o
pos ope a i e complica ions. A o al o 24 pa ien s (72.7%) we e empo a ily dependen
on a acheos omy o a mean du a ion o 23.4 ± 32.4 days. Twel e pa ien s (36.4%) we e
empo a ily o cons an ly dependen on a pe cu aneous endoscopic gas os omy (PEG).
2.5. Ou come
2.5.1. Oncological Ou come
The mean ollow-up pe iod was 21 ± 23 mon hs wi h a ange om 1 o 91 mon hs.
O e all su i al, p og ession- ee su i al and he local con ol a e o he in es iga ed
coho a e depic ed in Figu e 2. Twel e pa ien s (36.4%) expe ienced disease p og ession
and 12 pa ien s (36.4%) died du ing ollow-up. The pa ien s wi h disease p og ession de-
eloped a local ecu ence in six cases (50%), egional ecu ence in wo cases (16.7%), and
dis an me as ases in ou cases (33.3%), all o which we e loca ed in he lung.
Figu e 1.
Schema ic diag am o a pa ially de-epi helialized ALT lap and an os eosyn hesis pla e
o he econs uc ion o a ull- hickness de ec a e umo esec ion wi h segmen al esec ion o he
le -sided mandible. A e segmen al esec ion and he indi idualiza ion o an os eosyn hesis pla e,
he ALT lap was ha es ed. The p epa ed lap hen unde wen pa ial de-epi helializa ion in o de
o c ea e wo skin paddles o es o a ion o he o al and he acial de ec .
Tables 2and 3p o ide an o e iew o ypes o ee laps used o econs uc ion
a e ull- hickness esec ion and co esponding success- a es and Table 4p o ides a se o
conside a ions ega ding he ALT lap as echnique o choice o ull- hickness de ec s o
he head and neck a ea.
Cance s 2021,13, 2122 5 o 12
Table 2.
O e iew o econs uc i e s a egies and success a es in ela ion o a ec ed ana omical
subsi e o he o al ca i y.
A ec ed Subsi e o he O al Ca i y F ee Flap (no.) Success Ra e
Mandible + Floo o he Mou h
ALT (n= 15) 12/15 (80%)
RFF (n= 1) 1/1 (100%)
Scapula (n= 1) 1/1 (100%)
Fibula (n= 2) 2/2 (100%)
Buccal Mucosa
ALT (n= 7) 7/7 (100%)
RFF (n= 1) 1/1 (100%)
Maxilla
ALT (n= 2) 2/2 (100%)
RFF (n= 1) 1/1 (100%)
Scapula (n= 2) 0/2 (0%)
Table 3.
O e iew on ee laps used o he es o a ion o ull- hickness de ec s wi h e ision and
success a es.
Type o F ee Flap Re ision Ra e Success Ra e
ALT 4/24 (16.7%) 21/24 (87.5%)
RFF 0/3 3/3 (100%)
Scapula 3/3 (100%) 1/3 (33.3%)
Fibula 0/2 2/2 (100%)
La issimus do si 0/1 1/1 (100%)
Table 4.
Conside a ions ega ding he ALT lap as econs uc i e echnique o choice o ull- hickness
de ec s o he head and neck a ea.
Ad an ages o ALT Flaps
•Good pedicle leng h
•Especially sui able o ex ensi e de ec s due o i s bulkiness
•Pa ial de-epi heliza ion allows o he es o a ion o se e al neighbo ing de ec s, e en i
only one pe o a o is ound
•Low dono -si e mo bidi y and high a e o p ima y closu e o dono -si es
•Low su ge y imes due o he possibili y o a wo- eam app oach
Disad an ages o ALT Flaps
•Risk o aes he ic and unc ional impai men i a bulky lap is used o na ow de ec s
•Risk o comp omising he pe o a o i ALT is used o he co e age o me al pla es
•Need o seconda y osseous econs uc ion in cases o mandibula esec ions
2.4. Pe iope a i e Managemen
The mean hospi aliza ion pe iod o all pa ien s was 23.1
±
10.9 days wi h a ange
om 9 o 53 days. Two pa ien s (6.1%) died du ing hei hospi aliza ion pe iod due o
pos ope a i e complica ions. A o al o 24 pa ien s (72.7%) we e empo a ily dependen
on a acheos omy o a mean du a ion o 23.4
±
32.4 days. Twel e pa ien s (36.4%) we e
empo a ily o cons an ly dependen on a pe cu aneous endoscopic gas os omy (PEG).

Cance s 2021,13, 2122 6 o 12
2.5. Ou come
2.5.1. Oncological Ou come
The mean ollow-up pe iod was 21
±
23 mon hs wi h a ange om 1 o 91 mon hs.
O e all su i al, p og ession- ee su i al and he local con ol a e o he in es iga ed
coho a e depic ed in Figu e 2. Twel e pa ien s (36.4%) expe ienced disease p og ession
and 12 pa ien s (36.4%) died du ing ollow-up. The pa ien s wi h disease p og ession
de eloped a local ecu ence in six cases (50%), egional ecu ence in wo cases (16.7%),
and dis an me as ases in ou cases (33.3%), all o which we e loca ed in he lung.
Cance s 2021, 13, x FOR PEER REVIEW 6 o 12
(a)
(b)
Figu e 2. Con .
Cance s 2021,13, 2122 7 o 12
Cance s 2021, 13, x FOR PEER REVIEW 7 o 12
(c)
Figu e 2. Kaplan–Meie cu es depic ing (a) o e all su i al, (b) p og ession- ee su i al, and (c) local con ol a e o he
in es iga ed coho wi h ull- hickness esec ions ollowing ad anced o al squamous cell ca cinoma du ing a ollow-up
pe iod o up o 60 mon hs. O e all and p og ession- ee su i al a es exhibi a dec ease o abou 50% a e 20–30 mon hs,
he local con ol a e shows a dec ease o abou 75% a e 20 mon hs.
2.5.2. Func ional Ou come
In all pa ien s, adequa e econs uc ion was achie ed using a ee lap. Al hough 12
pa ien s (36.4%) we e empo a ily dependen on a pe cu aneous gas os omy, he emain-
ing pa ien s (n = 21/63.6%) we e able o main ain su icien o al nu i ion pos ope a i ely.
Figu e 2 exempli ies he p eope a i e si ua ion, su gical p ocedu es, and pos ope a i e
ou come o a pa ien wi h ecu en squamous cell ca cinoma o he maxilla. Figu es 3 and
4 exempli y he p eope a i e si ua ion, and pos ope a i e ou come o wo pa ien s wi h
ad anced squamous cell ca cinoma o he o al ca i y.
Figu e 2.
Kaplan–Meie cu es depic ing (
a
) o e all su i al, (
b
) p og ession- ee su i al, and (
c
) local con ol a e o he
in es iga ed coho wi h ull- hickness esec ions ollowing ad anced o al squamous cell ca cinoma du ing a ollow-up
pe iod o up o 60 mon hs. O e all and p og ession- ee su i al a es exhibi a dec ease o abou 50% a e 20–30 mon hs,
he local con ol a e shows a dec ease o abou 75% a e 20 mon hs.
2.5.2. Func ional Ou come
In all pa ien s, adequa e econs uc ion was achie ed using a ee lap. Al hough 12 pa-
ien s (36.4%) we e empo a ily dependen on a pe cu aneous gas os omy, he emaining
pa ien s (n= 21/63.6%) we e able o main ain su icien o al nu i ion pos ope a i ely.
Figu e 2exempli ies he p eope a i e si ua ion, su gical p ocedu es, and pos ope a i e ou -
come o a pa ien wi h ecu en squamous cell ca cinoma o he maxilla.
Figu es 3and 4
exempli y he p eope a i e si ua ion, and pos ope a i e ou come o wo pa ien s wi h
ad anced squamous cell ca cinoma o he o al ca i y.
Cance s 2021, 13, x FOR PEER REVIEW 7 o 12
(c)
Figu e 2. Kaplan–Meie cu es depic ing (a) o e all su i al, (b) p og ession- ee su i al, and (c) local con ol a e o he
in es iga ed coho wi h ull- hickness esec ions ollowing ad anced o al squamous cell ca cinoma du ing a ollow-up
pe iod o up o 60 mon hs. O e all and p og ession- ee su i al a es exhibi a dec ease o abou 50% a e 20–30 mon hs,
he local con ol a e shows a dec ease o abou 75% a e 20 mon hs.
2.5.2. Func ional Ou come
In all pa ien s, adequa e econs uc ion was achie ed using a ee lap. Al hough 12
pa ien s (36.4%) we e empo a ily dependen on a pe cu aneous gas os omy, he emain-
ing pa ien s (n = 21/63.6%) we e able o main ain su icien o al nu i ion pos ope a i ely.
Figu e 2 exempli ies he p eope a i e si ua ion, su gical p ocedu es, and pos ope a i e
ou come o a pa ien wi h ecu en squamous cell ca cinoma o he maxilla. Figu es 3 and
4 exempli y he p eope a i e si ua ion, and pos ope a i e ou come o wo pa ien s wi h
ad anced squamous cell ca cinoma o he o al ca i y.
Figu e 3.
Male pa ien wi h ecu en squamous cell ca cinoma o he le -sided maxilla wi h in il a ion o he maxilla y
sinus and acial skin. (
a
) CT scan depic ing he in il a ion o he pa anasal sinus and he acial skin. (
b
) Full- on al image
o he p eope a i e si ua ion wi h umo p og ession o he le cheek. (
c
) Full- on al image o he pos ope a i e si ua ion
a e ull- hickness umo esec ion and econs uc ion wi h ALT lap.
Cance s 2021,13, 2122 8 o 12
Cance s 2021, 13, x FOR PEER REVIEW 8 o 12
Figu e 3. Male pa ien wi h ecu en squamous cell ca cinoma o he le -sided maxilla wi h in il a ion o he maxilla y
sinus and acial skin. (a) CT scan depic ing he in il a ion o he pa anasal sinus and he acial skin. (b) Full- on al image
o he p eope a i e si ua ion wi h umo p og ession o he le cheek. (c) Full- on al image o he pos ope a i e si ua ion
a e ull- hickness umo esec ion and econs uc ion wi h ALT lap.
Figu e 4. Male pa ien wi h p ima y squamous cell ca cinoma o he igh -sided mandible wi h in il a ion o he acial
skin. (a) Tumo in il a ion o he igh cheek. (b) CT scan depic ing he umo o he igh -sided mandible wi h in il a ion
o he acial skin. (c) Full- on al image o he pos ope a i e si ua ion a e ull- hickness umo esec ion and econs uc-
ion wi h ALT lap.
3. Discussion
Despi e ad ances in sc eening and diagnosis o head and neck cance , a signi ican
p opo ion o pa ien s p esen s wi h locally ad anced disease [10,11]. As su gical he apy
emains he p ima y modali y o he ea men o locally ad anced o al squamous cell
ca cinomas (OSCCs), he ex en o umo esec ion has o be ca e ully balanced agains
possible unc ional and aes he ic impai men s a ec ing he pa ien ’s quali y o li e. In pa-
ien s in which o al ca i y umo s exhibi in ol emen o he ex e nal skin, in pa icula ,
ex ensi e esec ion migh be challenging and usually equi es he use o ee laps o e-
cons uc ion. As esidual disease is accompanied by wo se o e all and p og ession- ee
su i al, a c i ical goal o su ge y mus be he achie emen o clea oncologic ma gins
[12]. None heless, adical su gical in e en ion may lead o unc ional and aes he ic im-
pai men s.
Hence, he p esen manusc ip exclusi ely ocuses on pa ien s wi h locally ad anced
OSCCs in ol ing he ex e nal skin, independen o hei medical his o y ega ding he
sequence o he disease. This he e ogeneous coho in eg a ing pa ien s wi h p ima y and
ecu en disease was chosen because i o e s he possibili y o exempli y and discuss
aspec s o syne gism be ween su gical oncology and econs uc i e su ge y.
The main objec i e o oncological su ge y is o c ea e umo - ee ma gins, which in
his coho was success ully achie ed in 78.8% o he cases. Al hough his a e gene ally
migh be c i ically discussed, i has o be conside ed unde he aspec o he dominance o
ad anced umo s in his coho (97% T3/T4 umo s), including 36.4% ecu en umo s
and a his o y o p io mul i-modali y- ea men in 33.3% o he pa ien s. The apeu ic con-
side a ions o pa ien s wi h p ima y disease a e gene ally di e en om hose wi h e-
cu en disease, especially ega ding po en ial al e na i es. Howe e , he p esen ed co-
ho o e s ce ain peculia i ies ha should be espec ed conce ning ea men planning.
Al hough p ima y adio he apy is a aluable op ion o adia ion-nai e pa ien s su e ing
om head and neck cance ha o e s good local and egional con ol a es, he e a e ad-
an ages o a p ima y su gical app oach ha should be conside ed [13]. These include he
possibili y o u he imp o e he ou come i comple e umo esec ion is achie ed, o
guide adju an he apy by possibly de ec ing occul lymph node me as ases, and o e-
s o e a eas whe e ex ensi e umo g ow h may lead o de ec healing i p ima y adio-
Figu e 4.
Male pa ien wi h p ima y squamous cell ca cinoma o he igh -sided mandible wi h in il a ion o he acial skin.
(
a
) Tumo in il a ion o he igh cheek. (
b
) CT scan depic ing he umo o he igh -sided mandible wi h in il a ion o he
acial skin. (
c
) Full- on al image o he pos ope a i e si ua ion a e ull- hickness umo esec ion and econs uc ion wi h
ALT lap.
3. Discussion
Despi e ad ances in sc eening and diagnosis o head and neck cance , a signi ican
p opo ion o pa ien s p esen s wi h locally ad anced disease [
10
,
11
]. As su gical he apy
emains he p ima y modali y o he ea men o locally ad anced o al squamous cell
ca cinomas (OSCCs), he ex en o umo esec ion has o be ca e ully balanced agains pos-
sible unc ional and aes he ic impai men s a ec ing he pa ien ’s quali y o li e. In pa ien s
in which o al ca i y umo s exhibi in ol emen o he ex e nal skin, in pa icula , ex ensi e
esec ion migh be challenging and usually equi es he use o ee laps o econs uc ion.
As esidual disease is accompanied by wo se o e all and p og ession- ee su i al, a c i i-
cal goal o su ge y mus be he achie emen o clea oncologic ma gins [
12
]. None heless,
adical su gical in e en ion may lead o unc ional and aes he ic impai men s.
Hence, he p esen manusc ip exclusi ely ocuses on pa ien s wi h locally ad anced
OSCCs in ol ing he ex e nal skin, independen o hei medical his o y ega ding he
sequence o he disease. This he e ogeneous coho in eg a ing pa ien s wi h p ima y and
ecu en disease was chosen because i o e s he possibili y o exempli y and discuss
aspec s o syne gism be ween su gical oncology and econs uc i e su ge y.
The main objec i e o oncological su ge y is o c ea e umo - ee ma gins, which in
his coho was success ully achie ed in 78.8% o he cases. Al hough his a e gene ally
migh be c i ically discussed, i has o be conside ed unde he aspec o he dominance o
ad anced umo s in his coho (97% T3/T4 umo s), including 36.4% ecu en umo s and
a his o y o p io mul i-modali y- ea men in 33.3% o he pa ien s. The apeu ic conside a-
ions o pa ien s wi h p ima y disease a e gene ally di e en om hose wi h ecu en
disease, especially ega ding po en ial al e na i es. Howe e , he p esen ed coho o e s
ce ain peculia i ies ha should be espec ed conce ning ea men planning. Al hough
p ima y adio he apy is a aluable op ion o adia ion-nai e pa ien s su e ing om head
and neck cance ha o e s good local and egional con ol a es, he e a e ad an ages o a
p ima y su gical app oach ha should be conside ed [
13
]. These include he possibili y o
u he imp o e he ou come i comple e umo esec ion is achie ed, o guide adju an
he apy by possibly de ec ing occul lymph node me as ases, and o es o e a eas whe e
ex ensi e umo g ow h may lead o de ec healing i p ima y adio he apy is applied.
As o he he apeu ic app oaches including he newly in oduced immune-checkpoin
inhibi ion a e, a p esen , es ic ed o pallia i e se ings and he apeu ic esponse is lim-
i ed o a ac ion o pa ien s, he a ec ed pa ien s need p o ound guidance ega ding he
implica ions o he p oposed he apies and hei ejec ion [4,14].
Se e al e ospec i e and p ospec i e s udies e alua ed he concep o sal age su ge y
o pa ien s su e ing om ecu en head and neck cance , mos ly ad oca ing he use o
Cance s 2021,13, 2122 9 o 12
ee laps o he econs uc ion o la ge issue de ec s [
14
–
18
]. Al hough he e m “sal age
su ge y” mos ly applies o umo esec ions wi h cu a i e in en in pa ien s wi h ecu en
umo s and a his o y o p e ious ( adio-) he apies, and consequen ly lacking al e na i es
o he su gical app oach, he ocus o he p esen s udy lies on ex ensi e esec ions o head
and neck umo s i espec i e o he sequence o p io he apy o exempli y he possibili ies
and limi a ions o umo su ge y o he head and neck in gene al. Consequen ly, he
p esen ed coho is he e ogeneous ega ding he medical his o y o he pa ien s and limi ed
in size due o he ocus on cases wi h a need o pe o m ull- hickness umo esec ions.
Al hough mos o he men ioned publica ions ocus on sal age su ge y app oaches, he
gene al conside a ions mos ly also apply o pa ien s wi h ad anced p ima y umo s in
sensi i e localiza ions. In e e y case, c i ical balancing o he pa ien ’s indi idual si ua ion
and wishes is u gen ly wa an ed, including p ognosis, he pa ien ’s physical and men al
capaci y, and he chance o he apeu ic success.
The oncological esul s in ou analysis demons a e a high local con ol a e and,
al hough he o e all and p og ession- ee su i al a e is ypical o a coho o pa ien s
su e ing om ad anced head and neck cance , only six cases (18.2%) o local ecu ence
occu ed, and he emaining six cases o disease ecu ence we e a ibu able o egional
o dis an me as ases. These esul s, al hough d awn om a small coho , a e compa able
o hose epo ed in he a ailable li e a u e and con i m he alidi y o ou da a [
19
,
20
].
Fu he mo e, in many o he p esen ed cases, su ge y was he only a ailable cu a i e
he apeu ic op ion due o a his o y o adio he apy in he cases o ecu en umo s. In
o he cases, a de ini i e adio(-chemo)- he apy was abandoned because o he umo ’s
icini y o i s mani es in il a ion o sensi i e s uc u es wi h a high isk o pos ope a i e
os eonec osis (e.g., he mandible) [
21
]. Addi ionally, ex ensi e umo s ca y a isk o a de ec
healing a e adio he apy, especially i hey cause a connec ion be ween he o al ca i y
and he acial skin. In hose cases, a p ima y su gical app oach o es o e he ana omic
in eg i y o he o al ca i y and he acial skin appea s sensible o ob ious aes he ic and
unc ional easons, because he e is ple ho a o publica ions on he highe complica ion a e
o econs uc i e su gical app oaches in pa ien s wi h a his o y o adio he apy [22–24].
The ALT was he mos equen ly used lap in ou coho . I is a e sa ile op ion
o he ex ensi e de ec s due o i s olume, good pedicle leng h, and compa ably low
dono si e mo bidi y [
25
–
28
]. I is especially sui able o ull- hickness de ec s, because
pa ial de-epi heliza ion o he lap allows o he c ea ion o sepa a e skin paddles ha
may be unneled h ough he de ec and may be used o he es o a ion o he in a- and
ex ao al pa s o he de ec e en i only one pe o a o is p esen . O he laps used in ou
coho we e he adial o ea m lap, he scapula lap, he ibula lap, and he la issimus
do si lap. The o e all lap success a e in ou coho was 84.8%, which is in e io o ha
epo ed by o he au ho s [
18
,
24
]. Flap success a es we e di e en be ween pa ien s wi h
p ima y ( lap success: 90.5%) and ecu en disease (75%), which may be explained by he
o - epo ed endency owa ds highe complica ion a es in pa ien s wi h a his o y o p io
econs uc i e app oaches and adio he apy [
24
,
29
,
30
]. Addi ionally, he gene al need o
bigge laps o ull- hickness de ec s may ca y an inc eased isk o lap ailu e.
Se e al au ho s ha e epo ed on echniques o he es o a ion o acial ull- hickness
de ec s. They p oposed ee laps including he ALT, he ibula lap, and he adial
o ea m lap, alone o in combina ion wi h o a ional laps o he ex ao al pa s o
he
de ec [31–34].
As mos o he epo ed s udies ocused on small numbe s o pa-
ien s, o he bes o ou knowledge his a icle desc ibes one o he la ges coho s wi h
ull- hickness de ec s.
Al hough he e was an accumula ion o umo s in dis inc subsi es o he o al ca i y
(mandible/ loo o he mou h, buccal mucosa, maxilla) e en ually leading o ull- hickness
umo esec ion, each pa ien needs indi idual ea men planning and, hus, pa ien s wi h
simila expec ed de ec s may equi e di e en econs uc i e app oaches o achie e an
op imal o a leas sa is ying ou come. Se e al ac o s a e o c i ical ele ance o he choice