Plastic Surgery - Dr. Moulton

Management of Cutaneous Malignancies
Safest is best
Rex Moulton-Barrett, MD
Plastic and Reconstructive Surgery,
Otolaryngology Head & Neck Surgery
4th Floor, Doctor’s Offices Alameda Hospital
1280 Central Blvd, Suite J-5, Brentwood
Wait and see
The 8 Aspects of Plastic Surgery
• Congenital: clefts, nevi, vascular tumors
ear reconstruction, hand anomalies
• Hand: nerve compression, tumors/soft tissue, trauma
• Burn Reconstruction
• General Reconstruction: truck, abdomen, lower limb
• Breast: reduction, reconstruction
• Cosmetic
• Head and Neck: resection and reconstructive surgery
• Skin cancer: excision and reconstruction
Tumors In Question
Basal Cell
Squamous Cell
The differential diagnosis:
non-pigmented benign
pigmented benign
non-pigmented pre-malignant
pigmented pre-malignant
soft tissue tumors
metastatic lesions
Skin Cancer
• Basal (75%) > Squamous (25%) > melanoma
except organ transplant opposite ratio
SCCA 20-65 times more common
• 50% with basal or squamous will develop the other in 5 years
• Intense > prolonged sun exposure: UVB>A, SPF 15, < 20 yrs age
• Genetic predisposition: more pigment is protective
Common Non-pigmented
Benign Lesions
• Seborrheic Keratoses
• Syringomas
• Xantheloma Palpebrum
• Premalignant Actinic Keratoses
Common non-pigmented
benign lesions
• Syringomas: peri-ocular , small, fleshy and nodular
Common non-pigmented
benign lesions
• Xantheloma Palpebrum: periocular, drop like & semi-cheezy
rarely associated with hyperlipidaemia
ie planar xanthomatadysbetalipoproteinemia
or hypercholesterolemia
Common non-pigmented
benign lesions
• Trichoepitheliomas: periocular, drop like
Common non-pigmented
benign lesions
• Milia: periocular, drop like & semi-cheezy
Common non-pigmented
• Actinic Keratoses: 20% SCCA, dry, crusty
• really pre-malignant
Pigmented Benign Lesions
• Blue Nevus
• Pigmented Seborrheic Keratosis
• Giant Nevus
Pigmented benign lesions
• Blue Nevus: intradermal and subcutaneous
not pre-malignant
Pigmented benign lesions
• Pigmented Seborrheic Keratosis: waxy, soft
can rub off a little
Non-Pigmented Pre-malignant Lesions
• Bowen’s Disease: red scaly patch of
Squamous Cell Carcinoma in situ
Pigmented Benign & Pre-malignant Lesions
• Giant Nevus:
1-2 % population
Risk of developing melanoma related to size:
> 20cm diameter adult
> 2 palm size / body 5-20 % by 10, peak at 3-5 yrs
> 1 palm size / face 5-20 % by 10, peak at 3-5 yrs
Role for topical anti-mitotic agents
 5-fluorouracil
 imiquimod 5% cream ( Aldara )
 aminolevulinic acid photodynamic therapy
Quick Time™ a nd a
TIFF ( Un compr ess ed ) de co mp res sor
ar e n eed ed to s ee this pic tur e.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Role for topical anti-mitotic agents
0.5% 5-fluorouracil ( 5gram $100 )
effective for actinic keratoses
small in-situ lesions: BCCA
not for invasive small = electrodesiccation/curettage
or excision
RNA analogue precursor & progressive DNA labelling
Contraindicated in pregnancy: teratogenic VSD’s
Role for Topical anti-mitotic agents
Imiquimod 5% cream ( Aldara )
Immunomodulator: activates monocytes,macrophages, Langerhan’s
cells, T cell infiltrates, cytokines: interferons, interlekins, TNF
effective for: actinic keratoses
superficial basal cell carcinoma*
probably no role for squamous cell ca*
frequency related reactions are common
*3 nights/ week for 6 weeks: 73% clearance rate
at 12 weeks: higher clearance rates
Actinic Cheilitis (AC)
Smith et al, 2002: J AM Acad Dermatol
• 15 pts with biopsy proven AC
• 3 x weekly for 4-6 weeks
• 4 weeks later all lesions cleared
• Specific Side effects continued in some
cases throughout therapy:
• pain, redness, swelling, ulceration
Qu ickTime™ and a
TIFF (Uncompressed) dec ompressor
are nee ded to see this picture.
Role for topical anti-mitotic agents
Aminolevulinic acid photodynamic therapy
Levulan Kerastick 20% solution
• 17 minute blue light exposures
• 69% failure for superficial SCCA at 8 months
• 44% failure for superficial BCCA at 8 months
Fink-Puches, et al, 1998
Arch Dermatol 134, 821-826.
Category C : unknown side-effects pregnancy or breast feeding
Not if porphyria
Not if taking: oral hypoglycemic agents, sulpha, grseofulvin,
phenothiazines, doxycycline, HCTZ diuretics
Basal Cell Carcinoma
incisional biopsy
• Basal Cell: elliptical wedge is better than shave
punch biopsies work well if: adequate in width and depth
preferably not from center
Basal cell carcinoma
excisional biopsy
• 1 high power field under frozen section/ Moh’s surgery
• 3-5 mm margin from the clinical edge: rolled to flat
Squamous cell Biopsy
• Squamous Cell:
elliptical wedge:
from periphery towards center
better than shave
6-10 mm margin if excisional biopsy
Excisional Biopsy
• Melanoma:
• Sarcomas:
• Adnexal :
• Metastatic:
closest margin to remove the lesion,
do not shave, or wedge
may use punch if completely excise
closest margin to remove the lesion
closest margin to remove the lesion
closest margin to remove the lesion
Excisional Biopsy
• Melanoma:
closest margin to remove* the lesion,
do not shave, or wedge
may use punch if completely excise
Superficial spreading
Lentigo maligna
Acral lentinous
Management of Melanoma
• <0.75 mm deep: 1cm margin
• 0.75cm - 1.25mm deep: 1cm margin & ? sentinel node
• 1.25 mm-4mm deep: 1-2cm margin & sentinel node biopsy
• >4mm deep: 1cm margin and use of lymphadenectomy
S/P Shave of Melanoma
2 schools of thought
1. Excisional biopsy and based on depth decide on size
of margin using same parameters
2. Excise based at least the depth of the shave
ie 1-2 cm margin, when in doubt take larger margin
Excisional Biopsy
• Kaposi’s Sarcomas: closest margin to remove*
HIV with CD4 <200/mm3
Excisional Biopsy
• Adnexal/appendage:
ductal or non-ductal
closest margin to remove
Qu ickTime™ an d a
TIFF (Unco mpressed) d ecompresso r
are ne eded to see this picture.
mixed tumor
Excisional Biopsy
• Metastatic: closest margin to remove the lesion*
Moh’s Surgery
• Microscopic margin is preferable to macroscopic margin
ie face in the ‘H zone’
reduced visible scar
may reduce incidence of false negative margin
• Recurrent lesions: depth and width defined prior to closure
• Availability of service
Dangerous Problems
• Midline Lesions
glioma ( 15% CNS communication ) or
encephalocele ( 100% commun )
dermoid( 15% crista galli communication),
( not lateral brow dermoid- no communication )
• Back:
myelocele, meningomyelocele
occiput and neck: encephalocele
Difficult Problems Problems
• Zygomatic Arch to Angle of the Mandible
Parotid tumors
Lymph nodes: atypical TB
metastatic node if > 1.5cm adult
Branchial Cleft Cysts
( < 1-2 yrs: congenital, >2-15 yrs inflammatory, > 15 yrs neoplastic )
Difficult Problems
• Merkel Cell Tumors
• Subungal Pigmentation
• Sebaceous Adenoma
Difficult Problems
• Merkel Cell Tumors: biopsy if excisional will require later
larger margin and possible lymph node dissection, may need
metastatic work-up and tumor conference presentation
Difficult Problems
• Subungal Pigmentation
Acquired melanocytic nevus
Difficult Problems
• Sebaceous Adenoma
Warty lesion often in the scalp, can be salmon colored
present at birth,
> 10 yrs : will form BCCA and 19% form syringocystadenoma
Surgical Principles
» I. Have a plan:: H & P, iodine allergy, tetanus toxoid, irrigation, instruments, suture
and needle, define the defect, method of closure, drain, dressing, antibiotics, post-op
wound care and when to remove sutures.
» II. Always have a lifeboat:: If closure does not work out have a second plan in mind,
including placing a skin graft
» III. Acknowledge cosmetic units: The face can be divided sub-units. Within each unit
there are favorable skin tension lines ( with the pt. in the sitting position and
animated ) which form at 90 degrees to the mimetic muscles. Scars are less
conspicuous if they lie parallel to these natural creases.
» IV. Control tension: Place all the tension below the epidermis or in the fascia. The
majority of the blood supply is in the subdermal plexus ( SDP ): superficial to the
subcutaneous fat. Undermine to distribute the tension over a wider area.
Clinical Examples
A. 5mm chronic ulcer of the hand in a wrinkled 90 yr man
a. important history
duration, bleeding, numbness, other medical problems, medications,
pacemaker, adenopathy, associated skin lesions
b. important physical characteristics
wipe lesion and look at shape: ulcer with irregular border,
little pigmentation
c. type of biopsy
punch or wedge using lidocaine with epinephrine.
single suture for hemostatis.
d. definitive management
path: SQ cell ca. If margin clear 6mm ellipse transversely
( using 3 to 1 rule length to width excision ) with local
and tag margin for orientation.
If final pathology margin positive or close ( < 5MM ) re-excise in OR
with frozen section.
3mm pigmented lesion on the lateral neck of a 33 yr old male
Caucasian computer programmer
• a. important history
duration, bleeding, numbness, other medical problems, medications, pacemaker
• b. important physical characteristics of lesion to make the diagnosis
adenopathy, associated skin lesions, shape, elevation, border, pigmentation and
texture: irregular border, irregular pigmentation, not raised and smooth
• c. type of biopsy
excise using 4mm punch full thickness into subcutaneous fat or elliptical excision
(using 3 to 1 rule ) with lidocaine with epinephrine.
3 sutures for closure.
• d. definitive management
path: Malignant Melanoma depth 0.72 mm no evidence of intra-vascular invasion.
ellipse 1cm margin favorable skin tension lines.
check final pathology to confirm clear of tumor.
present in tumor board.
C. 3cm chronic elevated lesion on the
cheek of a 55 yr old lady
• a. important history
duration, bleeding, numbness, medical problems, medications, pacemaker
• b. important physical characteristics of lesion to make the diagnosis
adenopathy, associated skin lesions, wipe lesion, look at shape, ulcer with
irregular border, little pigmentation
c. type of biopsy
biopsy punch or wedge using lidocaine with epinephrine. Do not use silver
nitrate on face, use battery cautery, hyfercator or a single suture for
d. definitive management: in operating room with frozen section
path: basal cell ca. Take >3mm margin
and close wound along favorable tension lines with a local flap
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