Principles of Treatment

The extent of surgical resection for scalp tumors depends largely upon the depth of infiltration by the tumor. Excision through partial thickness of the scalp can be carried out for superficial tumors while excision through the entire thickness of the scalp including the periosteum may be necessary in deeply infiltrating tumors. On the other hand, tumors that are adherent to or involve the underlying cranium must have removal of the outer table of skull or a through-and-through resection up to and including the dura if necessary. The extent of the surgical procedure that would be required for tumors of the scalp depends on the extent and depth of invasion by the tumor as shown in Figure 4-2.

Small lesions of the skin of the face are excised in the direction of the cleavage planes which are at right angles to the pull of the facial muscles. A brief review of the skin lines of the face is important prior to embarking upon excision of a facial skin lesion. Generally, an elliptical incision is best suited for small lesions. Configuration of the facial skin lines and potential directions for elliptical incisions are shown in Figure 18-4. Remember that the facial skin lines are at right angles to the muscle fibers of the underlying muscles of facial expression (Figure 4-3). By asking the patient to grimace, the line of direction of the long axis for elliptical incision is established. These lines are horizontal on the forehead and around the bridge of the nose and the outer canthus of the eye. Near the cheek the tension lines run obliquely or perpendicularly; near the lips they run radially from the mouth opening, and on the chin they run horizontally on the midline and obliquely perpendicular at the sides. On the sides of the neck, the wrinkles and tension lines run obliquely downward and forward. Horizontal elliptical excision of a small growth of the lower eyelid or the upper eyelid is perfectly suitable, but larger excisions of the lower eyelid performed in this manner result in ectropion. Meticulous attention should be paid to approximation of subcutaneous tissues using absorbable interrupted sutures, and the skin should

Figure 4-3. Facial skin lines are at right angles to the muscle fibers of the underlying muscles of facial expression.

be closed with fine sutures, which can be removed as early as 4 days postoperatively. Alternatively one may elect to use a subcuticular suture, particularly in the area of the eyelids where the skin is very thin.

Application of split- or full-thickness skin graft is best suited to that part of the face with minimal facial motion such as the lateral aspect of the bridge of the nose or the temple. Similarly, a skin graft can be used in the parotid region because the facial movement in this area is minimal and cosmetic disfigurement is minimal. The most suitable donor sites for obtaining full-thickness skin grafts are from the retroauricular or supraclavicular regions.

Flaps from the immediate neighborhood of the defect are most desirable from both the functional and esthetic points of view. Primary closure of the donor site defect can usually be accomplished with ease by proper planning of local skin flaps. When repair of a surgical defect demands more adequate full-thickness reconstruction, local flaps are best suited for this purpose. The blood supply of facial skin and soft tissues is extremely rich, as the terminal branches of the external carotid artery provide a major source of blood to the facial skin. In addition to this, there is an extensive subdermal anastomotic network, which facilitates the use of several random flaps with relative ease. Some flaps carry an identifiable axial blood supply while others are more random. Examples of axial skin flaps are: nasolabial, glabellar, Mustarde cheek, and temporal forehead; examples of random flaps are: cervical, rhomboid, and bilobed. If local flaps are not suitable, then consideration should be given to regional or distant microvascular free flaps for appropriate repair of large surgical defects in the facial region.

Metastatic dissemination to regional lymph nodes from primary cutaneous malignancies of the scalp and face is infrequent. In general, squamous carcinomas less than 2 cm in diameter have an exceedingly low risk of metastatic potential and therefore elective treatment of regional lymph nodes is not recommended. Lesions larger than 2 cm have a proportionately higher risk of regional lymphatic dissemination. In general, however, elective resection of regional lymphatics does not offer significant therapeutic advantage. Slight improvement in prognosis is observed with elective dissection of regional lymph nodes for intermediate thickness malignant melanomas of cutaneous origin.

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