Evidence-Based Medicine:

Facial Skin Malignancy

Matthew L. Iorio, M.D.
Ryan P. Ter Louw, M.D. C.
Lisa Kauffman, M.D.
Steven P. Davison, D.D.S., M.D
• Disclosure: The authors have no financial interests in any of the
products or techniques mentioned and have received no external
support related to this study.
Objectives:
After studying this article, the participant should be able to:
• Identify common precancerous and malignant cutaneous growths of
the head and neck.
• Recommend surgical treatment, including margins, based on
consensus guidelines.
• Counsel patients as to available evidence for expected recurrence,
follow-up, and morbidity.
• Cutaneous malignancies are the most frequent type of cancer in the
world.
• Cutaneous lesion removal is the most common procedure performed
by plastic surgeons.
• Surgical excision - both a tissue diagnosis and definitive treatment in a
single stage.
• Resection margin - planned area of tissue excision that is clinically and
histologically free of cellular atypia.
Actinic Keratosis
• Most common precancerous lesion of the
epidermis.
• Chronic sun exposure.
• Scaly, hyperkeratotic plaque on sun-exposed
areas of fair-skinned individuals.
• Hallmark: atypical keratinocytes located
within the basal layers of the skin.
• 6-10% risk of malignant transformation to
SCCA.
Actinic Keratosis
Nonsurgical
• Cryosurgery, 5-fluorouracil, imiquimod, and photodynamic therapy.
• Photodynamic therapy (88%) was superior to 5-FU (11%) in achieving complete resolution
(Perrett et al.) ; both leave a diffuse, erythematous healing patch over the affected area for 1
week.
• Cryosurgery with liquid nitrogen – 98% clearance rate.

Surgical
• larger lesions, rapidly changing lesions, failed topical treatment.
• Because of the high rate of incipient squamous cell carcinoma in recalcitrant or
recurrent actinic keratoses, resection margins should be based on an early squamous
cell carcinoma diagnosis at 4 mm.
Bowen Disease
• Squamous cell carcinoma in situ.
• Chronic sun exposure.
• Auricular, nasal, and perioral regions.
• Erythematous scaly plaques that exhibit slow
growth and surface fissures.
• Hallmark: normal basal cells, and slow lateral
extension frequently allows atypical cells to be
found beyond the periphery of clinical
margins.
• 3-8% risk of malignant transformation to SCCA.
Bowen Disease: Treatment
• Frequently treated nonsurgically.
• However, the current margin for surgical excision of large, invasive, or
recurrent Bowen disease is 4 to 6 mm.
• 5-fluorouracil, photodynamic therapy, and cryotherapy.
• Topical 5-FU: applied 2x day for 4-8 weeks until superficial erosion or
ulceration is present.
• Imiquimod: 73% of patients disease free after 16 weeks.
• Cryotherapy 10%
• Photodynamic therapy 12%
Basal Cell Carcinoma
• Most common cutaneous malignancy on
the face; 85%.
• 146 in 100,000
• Nodular, superficial spreading,
pigmented, and sclerosing morpheaform.
• Slow growth with rare metastasis.
• Likely to appear on the upper lip.
Trichoepithelioma
• Flesh-colored papules occurring
either in groups or as solitary lesions.
• Childhood
• Exhibits rare ulceration, a well-
circumscribed base, and rare
inflammatory cell infiltrates.
• Malignant degeneration is
exceedingly rare.
Basal Cell Carcinoma: Treatment
• Chren et al: destruction with electrodesiccation and curettage versus
standard excision or Mohs excision, 5-year ff-up
• 4.9% recurrence rate for destruction
• 3.5% for excision
• 2.1% for Mohs

• Mosterd et al: photodynamic therapy compared with a 3-mm surgical

excision, 36-month ff-up
• treatment failure within 5 mm of the original lesion was noted in 2.3% of the
surgical excision group
• 30.3% of the photodynamic therapy group
Basal Cell Carcinoma: Treatment
• Carbon dioxide laser
• Adams and Price: 50% recurrence rate in a single-pass application
• Iyer et al: 3.2% recurrence rate, 500-mJ pulse set at 10 Hz, 2-8 passes/lesion

• Wide local excision or Mohs surgery

• Standard for minimizing recurrence
• 3 mm may represent the optimum margin for 95 percent clearance in well-
demarcated, small, nonmorpheaform basal cell carcinomas.
Basal Cell Carcinoma: Treatment
Mohs surgery
• In high risk lesions: prospective trial compared to surgical excision 
demonstrated a significant decrease in recurrence for 204 aggressive subtype
or recurrent basal cell carcinomas.
• Compared with 3-mm excision in 408 primary lesions, no statistical difference
in recurrence noted at the 2-year follow-up.
• Associated with a smaller final defect size and higher operative cost  Mohs
surgery should be reserved for high-risk or recurrent lesions.
Basal Cell Carcinoma: Treatment
Squamous Cell Carcinoma
• 75% - head and neck
• Ultraviolet radiation exposure, fair skin, immunosuppression.
• Variable appearance: patches, plaques, ulcers, nodules, exophytic
tumors.
• Full- thickness loss of polarity, with islands and strands of tumor
extending into the dermis, and aggressive forms often invading into
neurovascular structures.
• Metastatic potential: lip  ear  non-exposed sites irradiation,
thermal injury, or chronic wounds.
Squamous Cell Carcinoma
• 30 to 50% chance of developing a second primary tumor within 5
years
• If recurrence occurs, 70-80% will recur within 2 years of initial treatment
• Brantsch et al: 43 month ff up
• <2.0mm – no metastasis
• 2.1 – 6.0 – 4% metastasized
• >6.0mm – 16% metastasized
Squamous Cell Carcinoma
Squamous Cell Carcinoma
• Basosquamous cell carcinoma
• overlap of synchronous squamous cell and
basal cell carcinoma.
• risk and incidence of metastasis is most
dependent on the squamous cell component
Squamous Cell Carcinoma: Treatment
• Lesion diameter and depth of invasion are prognostic for overall risk
of recurrence and metastasis.
• >2cm – twice as likely to recur (15.2%) ; 3x likely to metastasize
(30.3%)
• Subcutaneous tissue invasion or >4mm depth – 45.7% metastatic rate
• Recurrence rates:
• Low-risk lesions: 5-8%
• >2cm: 15.7%
• Poorly differentiated lesions: 25%
Squamous Cell Carcinoma: Treatment
• “High-risk” lesions, characterized by poor histologic differentiation,
periocular/perioral location, or a diameter greater than 2 cm, require
a 6-mm margin to clear 95 percent, as compared with only 4 mm in
“low- risk” lesions.
Squamous Cell Carcinoma: Treatment
• Mohs surgery
• aesthetically sensitive areas
• lesions at high-risk for recurrence: failed primary treatment, poorly
delineated clinical borders, diameters larger than 2 cm, perineural
involvement, or critical anatomical locations such as the eyelid.

• Leibovitch et al – 5 yr recurrence rate

• 3.9% failure rate for Mohs micrographic surgery
Squamous Cell Carcinoma: Treatment
• Adjuvant radiotheraphy: high- risk lesions that cannot be safely
resected ; medical comorbidity precludes resection.
• Dry mouth, tissue atrophy, esophagitis, and dental carries.
• Kyrgidis et al: wide local excision and radiation therapy
• 3 yr ff up: 87% disease free
• 5 yr ff up: 69% disease free
• 92 percent reduced risk of recurrence compared with treatment without
radiation therapy.
Melanoma
• 20% - head and neck
• 4 subtypes:
• Lentigo maligna - melanoma in situ; occurs most
frequently on the face.
• Superficial spreading – most common; trunk or
extremities
• Nodular - trunk and extremities; blue/black hue;
greater tendency for vertical growth.
• Acral lentiginous - darker pigmented individuals on
the hands, feet, and nail beds
Melanoma: Lentigo Maligna
• Horizontal growth
• Atypical melanocytes on the basal epidermis.
• Spread beyond the epidermal basement membrane zone and
progress to lentigo maligna melanoma.
Melanoma: Desmoplastic Melanoma
• Nonpigmented plaque or nodule.
• Misdiagnosed as basal cell carcinoma.
• Histology: spindle cells surrounded by abundant collagen.
• High propensity for local recurrence, with aggressive behavior.
• Prompt surgical excision is the treatment of choice - 1-cm surgical
margin of excision.
Melanoma: Staging
• Thickness - most powerful prognostic indicator
• <0.5mm: 96% survival rate
• >6mm: 42% survival rate

• Secondary prognostic factors:

• ulceration, mitotic rate, and regional/distant lymph node metastasis.
Melanoma: Treatment
• Surgical excision is the standard of care.
• Imiquimod, radiation therapy.
• Surgical margins – Breslow scale or depth of tumor invasion beyond
the granular layer of epidermis.
• Currently, for melanoma in situ and melanoma less than 1 mm in
depth, resection margins of 5 mm and 1 cm have been
recommended, respectively.
Melanoma: Treatment
• Mohs Surgery
• A prospective series of 1072 patients treated with Mohs surgery found an
86% clearance rate with a 6-mm margin and a 98.9% clearance rate with a 9-
mm margin.
• Mohs surgery may be optimal in regions where repeated excision would
sacrifice tumor control or aesthetic results, with excisional margins
approximating early invasive melanoma for aggressive in situ subtypes
Melanoma: Treatment
• Wide (2-3cm) vs narrow (≤1cm) excision
• No significant difference in overall survival or recurrence.
• Balch et al. : 6- to 8-fold increase in local recurrence in ulcerated lesions
• This evidence supports the recommendation that thin, nonulcerated melanomas
1.0 to 2.0 mm thick should be resected with a 1-cm margin, and that thicker
lesions or ulcerated thin lesions are optimally treated with a 2-cm margin.
• US Intergroup Surgical Trial: thicker melanomas at 2 to 4 mm and determined 2-
cm margins to be adequate, with larger margins not significantly impacting
recurrence rate.
Melanoma: Lymph Node Evaluation
• 10-15% occult nodal metastasis.
• Sentinel lymph node biopsy should be considered for disease staging in lesions
0.76 to 0.85 mm thick with ulceration and greater than one mitoses. Sentinel
lymph node biopsy should also be performed for any lesion greater than 0.85
mm in thickness.
• Elective or therapeutic lymph node dissection : clinically positive nodes on PE
or following sentinel lymph node biopsy.
• Lens et al: no added benefit regarding survival.
Merkel Cell Carcinoma
• Neuroendocrine tumor
• High rate of treatment failure and local
recurrence.
• Older, immunocompromised, fair-skinned
women.
• 50% - head and neck  5-10% occurring on
the eyelids.
• 80% - polyomavirus infection
• firm and painless fleshy nodule with a red or
blue discoloration, likely to occur on sun-
exposed areas.
Merkel Cell Carcinoma
• Node negative: 83% 5 yr survival rate
• Nodal disease: 58% 5 yr survival rate
• Staging:
• 2 cm defined as the difference between stage 1 and stage 2. Nodal or distant
metastasis will upstage to stages 3 and 4, respectively.
• Allen et al. - disease stage at presentation can be correlated as an
independent predictor of survival
• Stage 1 – 81%
• Stage 2 – 67%
• Stage 3 – 52%
• Stage 4 – 11%
Merkel Cell Carcinoma: Treatment
• Surgical resection with wide location excision or Mohs therapy.
• Wide surgical excision margins are recommended, with a 1-cm mar- gin for
lesions less than 2 cm in clinical size, and a 2-cm margin for those larger than
2 cm.
• Sentinel lymph node biopsy is recommended at the time of resection
for all tumor sizes.
• Adjuvant radiotherapy
• demonstrated a 3.7-fold decrease in recurrence following resection