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Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical Treatment of 102 Patients

Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical... Hindawi Journal of Skin Cancer Volume 2019, Article ID 4798510, 5 pages https://doi.org/10.1155/2019/4798510 Clinical Study Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical Treatment of 102 Patients Carlos Alberto Ferreira de Freitas , Andreza Negreli Santos, Guilherme Canho Bittner, Baltazar Dias Sanabria, Maria Margarida Morena Domingos Levenhagen, and Günther Hans-Filho Department of Dermatology, University Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul, Medical School, Brazil Correspondence should be addressed to Carlos Alberto Ferreira de Freitas; caff2004@hotmail.com Received 1 May 2019; Accepted 11 June 2019; Published 26 June 2019 Academic Editor: Arash Kimyai-Asadi Copyright © 2019 Carlos Alberto Ferreira de Freitas et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. To evaluate the surgical treatment results of a consecutive series of patients with nonmelanoma skin cancer in critical facial regions such as the nose, lip, eyelid, ear, forehead, cheek, and chin. Methods. This was a prospective observational cohort study evaluating the surgical treatment results of 102 patients with nonmelanoma skin cancer who underwent surgical excision and required some type of reconstruction. eTh reconstruction strategy used, histological type and margins, aesthetic result, and complications were evaluated. Results. eTh most common facial site was the nose (48.01%), followed by the eyelid, ear, cheek, forehead, and lip. The most frequently used type of reconstruction was the advancement flap (30.39%), followed by transposition flap (27,45%), rotation flap (14.70%), and grafts (10.78%). Basal ce ll carcinoma was the most frequent histological type, accounting for 90.19% of the sample, with 54.90% of these cases being of the nodular subtype. Disease-free margins were obtained in 94.11% of the patients, and only one patient presented compromised margins and underwent marginal extension. A good cosmetic result was found in 93.13% of the participants. Conclusion. Surgical treatment can provide excellent oncological, functional, and cosmetic results in the treatment of patients with nonmelanoma skin cancer at critical facial sites. 1. Introduction include sun exposure, particularly in childhood; lighter phototypes; immunosuppression; and genetic predisposition Excision of malignant skin lesions located on the face with [7]. In addition to surgical excision, there are other thera- safe margins and adequate reconstruction can present a peutic options such as photodynamic therapy, cryotherapy, challengetothesurgeon[1,2].Theprimary objectiveisthe radiotherapy, imiquimod, 5-fluorouracil, and intralesional excision of the lesion with oncological margins to preserve injection of interferon [8, 9]. However, surgical treatment, the function of the aeff cted organ while seeking the best when possible, yields the lowest recurrence rates and is possible cosmetic result [2]. Nonmelanoma skin cancer preferred by most researchers [10]. NMSC is considered to (NMSC) is the most common malignancy in the world [3], be high risk when located in the ear or central part of the and its incidence is increasing [4]. In Brazil, 195,000 new cases face [7] and may be more difficult to treat when located near were estimated in 2016 [5], with basal cell carcinoma (BCC) the natural head orifices and neck, where resection, margin being the most frequent, accounting for 75% of all cases [6], followed by squamous cell carcinoma (SCC; 20%) and control, and defect reconstruction may be more difficult [11]. melanoma (<5%). NMSC aeff cts individuals of all ages but For this reason, research on flaps and grasft for resolving has a higher incidence aer ft the h decade of life. Risk factors these cases is increasingly encouraged. This study analyzes the fift 2 Journal of Skin Cancer (a) (b) Figure 1: Nasal BCC, aer ft previous marking of dermatoscopy and margin borders (a), and closure with a neighboring flap in transposition. (b) Result with 7 days of evolution. surgical strategies used in treating 102 consecutive patients 3. Results and the initial results obtained. The group consisted of 102 patients, including 36 (35.29%) men and 66 (64.71%) women, aged between 31 and 96 years (mean age, 69.2 years). Their skin type distribution indicated 2. Methods a predominance of phototypes I to III (82.0%), followed by type IV (18.0%), and no patients had type V. Regarding In this prospective cohort study, lesion excision and subse- themostcommonsiteonthe face,48.01%ofthepatients quent surgical reconstruction strategies in 102 consecutive presented lesions on the nose (Figure 1), 17.64% on the eyes patients with facial BCC and SCC were analyzed, along with (eyelids) (Figure 2), 14.70% on the ear (Figure 3), 7.84% on the initial histopathological and cosmetic results and possible theforehead,and7.8%onthe cheeks.Theremaining 6.66% complications. of the patients presented lesions on the lips and chin. The Dermatoscopy was used to delimit the lesions and mark most commonly used facial reconstruction technique was an the margins: whenever possible minimum width of 5mm and advancement flap in 31 patients (30.39%), including 17 island 6mm to BCC sclerodermiform. All patients had previously flaps and six Rintala flaps. Transposition flaps were used in 28 undergone a biopsy and received a diagnosis of NMSC. patients (27.45%), and rotation flaps were used in 15 patients At histopathological analysis, margins larger than 2mm (14.70%). A partial skin graft was used in 11 patients (10.78%). were considered as free, and margins equal to or less than Regarding the histological type, the majority of the cases 1mm were considered as coincident and as compromised in were BCC (90.19%), and the most common subtypes were cases where there was a lack of margins. the following: nodular (54.90%), pigmented (16.66%), and Patients with facial lesions whose treatment required sclerodermiform (12.74%). SCC was diagnosed in 6.86% of some type of reconstruction with a flap or graft were included the patients, with 3.92% and 1.92% of the cases being of grade in the study. eTh second-intention wound healing technique I and grade II, respectively. Adequate margins were obtained was not used in any case. in 94.11% (larger than 2mm) of the patients. Five patients The research project was submitted to and approved by the Human Research Ethics Committee, and all patients who had overlapping margins or margins smaller than 1 mm. agreed to participate signed an informed consent form. eTh se patients were followed up and have not shown signs Journal of Skin Cancer 3 (a) (b) (c) (d) Figure 2: Lower eyelid BCC. (a) Aspect of the lesion. (b) Resection with margin and preparation of the eyebrow flap. (c) Immediate aspect. (d) Aspect with efift en days of evolution. of recurrence to date. One patient presented compromised other forms of treatment in terms of treatment time and margins and was reoperated to extend the margins. None of results achieved. An extensive literature review revealed that the patients presented recurrence during the follow-up of two surgical excision was the most effective strategy for NMSC to 36 months. eTh cosmetic result was considered good and treatment [8]. Surgical excision and margin control are the fair in 93.13% and 6.87% of the patients studied, respectively. gold standard of BCC treatment [12, 13]. In this series, Results were considered poor by either the research team dermatoscopy was used to define the lesion boundaries, a or patients in presence of unaesthetic scar, retraction, or 5-mm margin whenever possible and 6mm to BCC sclero- alteration in organ function or symmetry. The most common dermiform. A study recommended the use of dermatoscopy complication was partial graft or flap loss, which occurred in for demarcating the lesion boundaries and stated that the 6.86% of the cases. Two patients presented surgical wound technique can improve the surgical results regarding margin infection (1.96%), and two patients presented with scar control, especially in places where Mohs surgery is not retraction. All patients were treated with localized care and available [14]. In a reference center for skin cancer treatment, made satisfactory progress. One patient with nodular BCC on clinical diagnosis, mainly of BCC, aided by dermatoscopy the ear presented moderate bleeding, requiring reoperation had high accuracy rates [15]. eTh incidence of compromised to control the bleeding, and progressed well without flap loss. margins on the eyelid may reach 39% [6]. In our series, by using dermatoscopy to define the limits of the lesion and margin, the occurrence of compromised margins was very 4. Discussion and Conclusions low, even in lesions located on the eyelid. Only one patient Surgical treatment of patients with NMSC is preferred by presented compromised margins, which represented a good mostresearchers[10]because it hassomeadvantagesover initial oncological result. eTh use of dermatoscopy apparently 4 Journal of Skin Cancer (a) (b) (c) (d) Figure 3: Patient with basal cell carcinoma of the left ear. (a) Boundaries and margins. (b) Retroauricular retail. (c) Immediate result. (d) Final appearance after 30 days. aided in the control of surgical margins. eTh recurrence of in central part of lesion last. The presence of compromised BCC on the face when margins are free is very low (<3%) [12]. margins requires immediate surgical reassessment [17]. The cosmetic result was good in most cases. Complications TreatmentofNMSConthe face,atcriticalsites such as were rare, and patients progressed well with localized care. the eyelids, nose, ears, forehead, lips, and chin, is a challenge The use of various types of flaps demonstrates the difficulty to surgeons and is based on achieving the best oncological, of closing defects on the face, which are sometimes small but functional, and cosmetic results [2]. Surgery and adequate oen ft near natural and mucous orifices, which always makes surgical reconstruction are an ideal treatment modality and margin control and aesthetic and functional closure difficult. may yield good results, as demonstrated in this consecutive The most common histological type is BCC. In this series, series of treated patients. Dermatoscopy aids in the clinical its incidence was even higher, approximately 90%, than the diagnosis and margin control in BCC. mean incidence in the literature (75%) [6]. In an extensive sample of 500 patients with head and neck NMSC, a study Data Availability revealed a BCC incidence of 72% and SCC incidence of 28% [16]. eTh data used to supportthe nfi dingsofthisstudy are Mohs techniqueisconsideredidealtopreservenormal included within the article. tissue, being thus most recommended to the head and neck nonmelanoma skin cancer treatment. Besides, it allows better three-dimensional control of deep margins. When it is not Conflicts of Interest available, macroscopic margins control can be performed by beginning resection at lateral margins leaving the deep one eTh authors declare that they have no conflicts of interest. Journal of Skin Cancer 5 References [17] I.Tourli,D.Langner,G.Haroske,G.Tchernev, T.Lotti, andU. Wollina, “Basal cell carcinoma of the head neck region: a single [1] A. Sapthavee, N. Munaretto, and D. M. Toriumi, “Skin Grafts vs center analysis of 1750 tumors,” Georgian Med News,vol.1,no. Local Flaps for reconstruction of nasal defects a Retrospective 250, pp. 33–39, 2016. Cohort study,” JAMA Facial Plastic Surgery,vol.17, no.4,pp. 270–273, 2015. [2] C.Comparin,B.C. Santos,M.M.Rodrigues,and C. A.F. Freitas, “recontruc¸ao ˜ complexa em hemiface direita: o desafio de dois carcinomas basocelulares sincronicos, ˆ ” Surg Cosmet Dermatol,vol.8,pp. 271–273, 2016. [3] T. Ho and P. J. Byrne, “Evaluation and Initial Management of the Patient with Facial Skin Cancer,” Facial Plastic Surgery Clinics of North America,vol.17, no.3,pp. 301–307, 2009. [4] R. L. Bariani, F. X. Nahas, M. V. Jardini Barbosa, A. B. Farah, and L. M. Ferreira, “Basal cell carcinoma: an updated epidemio- logical and therapeutically profile of an urban population,” Acta Cirurgica Brasileira,vol.21, no.2,pp. 66–73, 2006. [5] INCA, “Estimate 2016 Cancer Incidence in Brazil,” http:// www.inca.gov.br/estimativa/2016/estimativa-2016-v11.pdf, 2016. [6] L.A.Rossato,R.C.Carneiro,E.A. S. Macedo,P.P.Lima,A. A. Miyazaki, and S. Matayoshi, “Diagnosis of agressive subtypes ofeyelidbasalcellcarcinoma by2-mm punchbiopsy:prospec- tive and comparative study,” Revista do Coleg ´ io Brasileiro de Cirurgioe ˜ s, vol. 43, pp. 263–269, 2016. [7] C. Newlands, R. Currie, A. Memon, S. Whitaker, and T. Wool- ford, “Non-melanoma skin cancer: united kingdom national multidisciplinary guidelines,” The Journal of Laryngology & Otology,vol.130,no.2, pp.S125–S132,2016. [8] R. Lv and Q. Sun, “A network meta-analysis of non-melanoma skin cancer (nmsc) treatments: efficacy and safety assessment,” Journal of Cellular Biochemistry,vol.118,no. 11, pp.3686–3695, [9] D.A.LeeandS.J.Miller,“Nonmelanomaskincancer,” Facial Plastic Surgery Clinics of North America,vol.17,no.3,pp.309– 324, 2009. [10] L. Ferrandiz and A. Ruiz-de-Casas, “Trakatelli M and colls,” Assessing Physician’S Preferences On Skin Cancer Treatment in Europe. BJD,vol.167,pp.29–35,2012. [11] H. Leon, A. Lima, J. C. Rojas, and M. Ramirez, “Colgajos em La reconstruccion ´ facial em dos pacientes com carcinoma basocelular,” Rev Venez Oncol, vol. 23, pp. 100-101, 2011. [12] C. Berking, A. Hauschild, O. Ko¨lbl,G.Mast,andR.Gutzer, “Basal cell carcinoma – treatment for the commonest skin cancer,” Dtsch Arztebl Int, vol. 111, pp. 389–395, 2014. [13] Z.I.Zlatarova,B.N.Nenkova,andE. B. Sooft va,“Eyelid reconstruction with full thickness skin grafts aer ft carcinoma excision,” Folia Medica,vol.58, no.1,pp. 42–46,2016. [14] C. Comparim, C. A. F. Freitas, and G. Hans Filho, “Der- matoscopy as a tool in detection of presurgical margins of basal cell carcinomas,” Revista Brasileira de Cirurgia de Cabe¸a c e Pesco¸o c ,vol.42,pp.47–52,2013. [15] P.Stathopoulos,D.Igoumenakis,J.Shuttleworthetal.,“Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology,vol.123,no. 2, pp.183–187,2017. [16] A. Dalal, J.Ingham,B.Collard,andG. Merrick,“Reviewofout- comes of 500 consecutive cases of non-melanoma skin cancer of theheadandneckmanagedinanoralandmaxillofacialsurgical unit in a District General Hospital,” British Journal of Oral and Maxillofacial Surgery,vol.56,no.9,pp. 805–809, 2018. 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Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical Treatment of 102 Patients

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Copyright © 2019 Carlos Alberto Ferreira de Freitas et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2019/4798510
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Abstract

Hindawi Journal of Skin Cancer Volume 2019, Article ID 4798510, 5 pages https://doi.org/10.1155/2019/4798510 Clinical Study Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical Treatment of 102 Patients Carlos Alberto Ferreira de Freitas , Andreza Negreli Santos, Guilherme Canho Bittner, Baltazar Dias Sanabria, Maria Margarida Morena Domingos Levenhagen, and Günther Hans-Filho Department of Dermatology, University Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul, Medical School, Brazil Correspondence should be addressed to Carlos Alberto Ferreira de Freitas; caff2004@hotmail.com Received 1 May 2019; Accepted 11 June 2019; Published 26 June 2019 Academic Editor: Arash Kimyai-Asadi Copyright © 2019 Carlos Alberto Ferreira de Freitas et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. To evaluate the surgical treatment results of a consecutive series of patients with nonmelanoma skin cancer in critical facial regions such as the nose, lip, eyelid, ear, forehead, cheek, and chin. Methods. This was a prospective observational cohort study evaluating the surgical treatment results of 102 patients with nonmelanoma skin cancer who underwent surgical excision and required some type of reconstruction. eTh reconstruction strategy used, histological type and margins, aesthetic result, and complications were evaluated. Results. eTh most common facial site was the nose (48.01%), followed by the eyelid, ear, cheek, forehead, and lip. The most frequently used type of reconstruction was the advancement flap (30.39%), followed by transposition flap (27,45%), rotation flap (14.70%), and grafts (10.78%). Basal ce ll carcinoma was the most frequent histological type, accounting for 90.19% of the sample, with 54.90% of these cases being of the nodular subtype. Disease-free margins were obtained in 94.11% of the patients, and only one patient presented compromised margins and underwent marginal extension. A good cosmetic result was found in 93.13% of the participants. Conclusion. Surgical treatment can provide excellent oncological, functional, and cosmetic results in the treatment of patients with nonmelanoma skin cancer at critical facial sites. 1. Introduction include sun exposure, particularly in childhood; lighter phototypes; immunosuppression; and genetic predisposition Excision of malignant skin lesions located on the face with [7]. In addition to surgical excision, there are other thera- safe margins and adequate reconstruction can present a peutic options such as photodynamic therapy, cryotherapy, challengetothesurgeon[1,2].Theprimary objectiveisthe radiotherapy, imiquimod, 5-fluorouracil, and intralesional excision of the lesion with oncological margins to preserve injection of interferon [8, 9]. However, surgical treatment, the function of the aeff cted organ while seeking the best when possible, yields the lowest recurrence rates and is possible cosmetic result [2]. Nonmelanoma skin cancer preferred by most researchers [10]. NMSC is considered to (NMSC) is the most common malignancy in the world [3], be high risk when located in the ear or central part of the and its incidence is increasing [4]. In Brazil, 195,000 new cases face [7] and may be more difficult to treat when located near were estimated in 2016 [5], with basal cell carcinoma (BCC) the natural head orifices and neck, where resection, margin being the most frequent, accounting for 75% of all cases [6], followed by squamous cell carcinoma (SCC; 20%) and control, and defect reconstruction may be more difficult [11]. melanoma (<5%). NMSC aeff cts individuals of all ages but For this reason, research on flaps and grasft for resolving has a higher incidence aer ft the h decade of life. Risk factors these cases is increasingly encouraged. This study analyzes the fift 2 Journal of Skin Cancer (a) (b) Figure 1: Nasal BCC, aer ft previous marking of dermatoscopy and margin borders (a), and closure with a neighboring flap in transposition. (b) Result with 7 days of evolution. surgical strategies used in treating 102 consecutive patients 3. Results and the initial results obtained. The group consisted of 102 patients, including 36 (35.29%) men and 66 (64.71%) women, aged between 31 and 96 years (mean age, 69.2 years). Their skin type distribution indicated 2. Methods a predominance of phototypes I to III (82.0%), followed by type IV (18.0%), and no patients had type V. Regarding In this prospective cohort study, lesion excision and subse- themostcommonsiteonthe face,48.01%ofthepatients quent surgical reconstruction strategies in 102 consecutive presented lesions on the nose (Figure 1), 17.64% on the eyes patients with facial BCC and SCC were analyzed, along with (eyelids) (Figure 2), 14.70% on the ear (Figure 3), 7.84% on the initial histopathological and cosmetic results and possible theforehead,and7.8%onthe cheeks.Theremaining 6.66% complications. of the patients presented lesions on the lips and chin. The Dermatoscopy was used to delimit the lesions and mark most commonly used facial reconstruction technique was an the margins: whenever possible minimum width of 5mm and advancement flap in 31 patients (30.39%), including 17 island 6mm to BCC sclerodermiform. All patients had previously flaps and six Rintala flaps. Transposition flaps were used in 28 undergone a biopsy and received a diagnosis of NMSC. patients (27.45%), and rotation flaps were used in 15 patients At histopathological analysis, margins larger than 2mm (14.70%). A partial skin graft was used in 11 patients (10.78%). were considered as free, and margins equal to or less than Regarding the histological type, the majority of the cases 1mm were considered as coincident and as compromised in were BCC (90.19%), and the most common subtypes were cases where there was a lack of margins. the following: nodular (54.90%), pigmented (16.66%), and Patients with facial lesions whose treatment required sclerodermiform (12.74%). SCC was diagnosed in 6.86% of some type of reconstruction with a flap or graft were included the patients, with 3.92% and 1.92% of the cases being of grade in the study. eTh second-intention wound healing technique I and grade II, respectively. Adequate margins were obtained was not used in any case. in 94.11% (larger than 2mm) of the patients. Five patients The research project was submitted to and approved by the Human Research Ethics Committee, and all patients who had overlapping margins or margins smaller than 1 mm. agreed to participate signed an informed consent form. eTh se patients were followed up and have not shown signs Journal of Skin Cancer 3 (a) (b) (c) (d) Figure 2: Lower eyelid BCC. (a) Aspect of the lesion. (b) Resection with margin and preparation of the eyebrow flap. (c) Immediate aspect. (d) Aspect with efift en days of evolution. of recurrence to date. One patient presented compromised other forms of treatment in terms of treatment time and margins and was reoperated to extend the margins. None of results achieved. An extensive literature review revealed that the patients presented recurrence during the follow-up of two surgical excision was the most effective strategy for NMSC to 36 months. eTh cosmetic result was considered good and treatment [8]. Surgical excision and margin control are the fair in 93.13% and 6.87% of the patients studied, respectively. gold standard of BCC treatment [12, 13]. In this series, Results were considered poor by either the research team dermatoscopy was used to define the lesion boundaries, a or patients in presence of unaesthetic scar, retraction, or 5-mm margin whenever possible and 6mm to BCC sclero- alteration in organ function or symmetry. The most common dermiform. A study recommended the use of dermatoscopy complication was partial graft or flap loss, which occurred in for demarcating the lesion boundaries and stated that the 6.86% of the cases. Two patients presented surgical wound technique can improve the surgical results regarding margin infection (1.96%), and two patients presented with scar control, especially in places where Mohs surgery is not retraction. All patients were treated with localized care and available [14]. In a reference center for skin cancer treatment, made satisfactory progress. One patient with nodular BCC on clinical diagnosis, mainly of BCC, aided by dermatoscopy the ear presented moderate bleeding, requiring reoperation had high accuracy rates [15]. eTh incidence of compromised to control the bleeding, and progressed well without flap loss. margins on the eyelid may reach 39% [6]. In our series, by using dermatoscopy to define the limits of the lesion and margin, the occurrence of compromised margins was very 4. Discussion and Conclusions low, even in lesions located on the eyelid. Only one patient Surgical treatment of patients with NMSC is preferred by presented compromised margins, which represented a good mostresearchers[10]because it hassomeadvantagesover initial oncological result. eTh use of dermatoscopy apparently 4 Journal of Skin Cancer (a) (b) (c) (d) Figure 3: Patient with basal cell carcinoma of the left ear. (a) Boundaries and margins. (b) Retroauricular retail. (c) Immediate result. (d) Final appearance after 30 days. aided in the control of surgical margins. eTh recurrence of in central part of lesion last. The presence of compromised BCC on the face when margins are free is very low (<3%) [12]. margins requires immediate surgical reassessment [17]. The cosmetic result was good in most cases. Complications TreatmentofNMSConthe face,atcriticalsites such as were rare, and patients progressed well with localized care. the eyelids, nose, ears, forehead, lips, and chin, is a challenge The use of various types of flaps demonstrates the difficulty to surgeons and is based on achieving the best oncological, of closing defects on the face, which are sometimes small but functional, and cosmetic results [2]. Surgery and adequate oen ft near natural and mucous orifices, which always makes surgical reconstruction are an ideal treatment modality and margin control and aesthetic and functional closure difficult. may yield good results, as demonstrated in this consecutive The most common histological type is BCC. In this series, series of treated patients. Dermatoscopy aids in the clinical its incidence was even higher, approximately 90%, than the diagnosis and margin control in BCC. mean incidence in the literature (75%) [6]. In an extensive sample of 500 patients with head and neck NMSC, a study Data Availability revealed a BCC incidence of 72% and SCC incidence of 28% [16]. eTh data used to supportthe nfi dingsofthisstudy are Mohs techniqueisconsideredidealtopreservenormal included within the article. tissue, being thus most recommended to the head and neck nonmelanoma skin cancer treatment. Besides, it allows better three-dimensional control of deep margins. When it is not Conflicts of Interest available, macroscopic margins control can be performed by beginning resection at lateral margins leaving the deep one eTh authors declare that they have no conflicts of interest. Journal of Skin Cancer 5 References [17] I.Tourli,D.Langner,G.Haroske,G.Tchernev, T.Lotti, andU. Wollina, “Basal cell carcinoma of the head neck region: a single [1] A. Sapthavee, N. Munaretto, and D. M. Toriumi, “Skin Grafts vs center analysis of 1750 tumors,” Georgian Med News,vol.1,no. Local Flaps for reconstruction of nasal defects a Retrospective 250, pp. 33–39, 2016. Cohort study,” JAMA Facial Plastic Surgery,vol.17, no.4,pp. 270–273, 2015. [2] C.Comparin,B.C. Santos,M.M.Rodrigues,and C. A.F. Freitas, “recontruc¸ao ˜ complexa em hemiface direita: o desafio de dois carcinomas basocelulares sincronicos, ˆ ” Surg Cosmet Dermatol,vol.8,pp. 271–273, 2016. [3] T. Ho and P. J. Byrne, “Evaluation and Initial Management of the Patient with Facial Skin Cancer,” Facial Plastic Surgery Clinics of North America,vol.17, no.3,pp. 301–307, 2009. [4] R. L. Bariani, F. X. Nahas, M. V. Jardini Barbosa, A. B. Farah, and L. M. Ferreira, “Basal cell carcinoma: an updated epidemio- logical and therapeutically profile of an urban population,” Acta Cirurgica Brasileira,vol.21, no.2,pp. 66–73, 2006. [5] INCA, “Estimate 2016 Cancer Incidence in Brazil,” http:// www.inca.gov.br/estimativa/2016/estimativa-2016-v11.pdf, 2016. [6] L.A.Rossato,R.C.Carneiro,E.A. S. Macedo,P.P.Lima,A. A. Miyazaki, and S. Matayoshi, “Diagnosis of agressive subtypes ofeyelidbasalcellcarcinoma by2-mm punchbiopsy:prospec- tive and comparative study,” Revista do Coleg ´ io Brasileiro de Cirurgioe ˜ s, vol. 43, pp. 263–269, 2016. [7] C. Newlands, R. Currie, A. Memon, S. Whitaker, and T. Wool- ford, “Non-melanoma skin cancer: united kingdom national multidisciplinary guidelines,” The Journal of Laryngology & Otology,vol.130,no.2, pp.S125–S132,2016. [8] R. Lv and Q. Sun, “A network meta-analysis of non-melanoma skin cancer (nmsc) treatments: efficacy and safety assessment,” Journal of Cellular Biochemistry,vol.118,no. 11, pp.3686–3695, [9] D.A.LeeandS.J.Miller,“Nonmelanomaskincancer,” Facial Plastic Surgery Clinics of North America,vol.17,no.3,pp.309– 324, 2009. [10] L. Ferrandiz and A. Ruiz-de-Casas, “Trakatelli M and colls,” Assessing Physician’S Preferences On Skin Cancer Treatment in Europe. BJD,vol.167,pp.29–35,2012. [11] H. Leon, A. Lima, J. C. Rojas, and M. Ramirez, “Colgajos em La reconstruccion ´ facial em dos pacientes com carcinoma basocelular,” Rev Venez Oncol, vol. 23, pp. 100-101, 2011. [12] C. Berking, A. Hauschild, O. Ko¨lbl,G.Mast,andR.Gutzer, “Basal cell carcinoma – treatment for the commonest skin cancer,” Dtsch Arztebl Int, vol. 111, pp. 389–395, 2014. [13] Z.I.Zlatarova,B.N.Nenkova,andE. B. Sooft va,“Eyelid reconstruction with full thickness skin grafts aer ft carcinoma excision,” Folia Medica,vol.58, no.1,pp. 42–46,2016. [14] C. Comparim, C. A. F. Freitas, and G. Hans Filho, “Der- matoscopy as a tool in detection of presurgical margins of basal cell carcinomas,” Revista Brasileira de Cirurgia de Cabe¸a c e Pesco¸o c ,vol.42,pp.47–52,2013. [15] P.Stathopoulos,D.Igoumenakis,J.Shuttleworthetal.,“Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology,vol.123,no. 2, pp.183–187,2017. [16] A. Dalal, J.Ingham,B.Collard,andG. Merrick,“Reviewofout- comes of 500 consecutive cases of non-melanoma skin cancer of theheadandneckmanagedinanoralandmaxillofacialsurgical unit in a District General Hospital,” British Journal of Oral and Maxillofacial Surgery,vol.56,no.9,pp. 805–809, 2018. 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Journal

Journal of Skin CancerHindawi Publishing Corporation

Published: Jun 26, 2019

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