Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin—Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma
Abstract
Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.
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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