Reconstruction Options for Lip, Cheek, Forehead, and Scalp Melanoma

Abstract

Primary malignant melanoma of the lip is exceedingly rare, with less than 60 cases reported. It frequently is confused with a myriad of benign lesions of the lip, and frequently there is a delay in diagnosis. There is often nodal involvement at the time of diagnosis. Lesions of the vermillion, therefore, have a more serious prognosis. There are reports of a 40% local recurrence rate and a 60% mortality.

Recommendations for resection are varied (1–5 cm margins) (Wingerden et al. SAJS. 45: 66–71, 2007). Additionally, the American Joint Committee on Cancer staging manual 7th edition (2010) upstages the disease so that all lesions are T3. There is also some controversy about the accuracy of normal histological criteria (Breslow’s and ulceration) in primary melanoma of the vermillion (Lamichhane et al. BMC Open Access. 8: 499, 2015).

Because of the serious nature of these lesions recommendations for a “wide local excision” are common, although there is no agreement as to what constitutes such an excision. Many cases present late and may involve most of the lip.

The lower lip is almost entirely functional. Repairs should be sensate and should provide enough lip length so that the patient can eat normally. Up to one-quarter of the upper and lower lips can be excised and closed primarily with little functional loss. In the elderly up to 30% of the lower lip can be resected. This represents about a 1.5 1.8-2 cm resection. Excisions in excess of this will require moving tissue into the defect to provide a functional and aesthetically acceptable lip. There are no authors who are willing to suggest if anything other than skin or mucosa need be resected.

The upper lip has not only functional but also aesthetic properties. It has three subunits, and as a result, surgeons should be prepared to fully reconstruct an entire subunit of the lip.

As a result, surgeons should be prepared to have to reconstruct an entire subunit of the lip. This chapter contains an algorithm for reconstruction using regional or local tissue.

The lip is also not commonly involved with malignant melanoma. While about 20% of melanomas occur in the head and neck, only melanoma of the lip is a rare presentation (about 1–4% of all melanomas). The prognosis is very much better than mucosal melanoma (85%) at 5 years and 77% at 10 years. Patients with positive sentinel lymph nodes had a worse prognosis (60%) at 3 years (Jones et al. Am J Surg. 206: 307–313, 2013). “Wide local excision” was used with no recommended margins. Studies have been done to determine if melanoma in the head and neck area could have “wide local excisions” which are smaller than those recommended for the trunk and extremities. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick; and 2 cm for lesions thicker than 2 mm. Rawlani et al. performed a study in which the margins were reduced by half (0.5 cm for lesions >1 mm; 0.5–1 cm for lesions 1–2 mm thick; and 1.0 cm in lesions thicker than 2 mm). They had 79 patients in the series with 42 cases with recommended margins and 37 with reduced margins. They found no statistically significant difference in survival in this fairly small sample (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). “The American Academy of Dermatology” published recommendations in 2011 based on both evidence from prospective randomized control studies and consensus opinion:

• 1. Wide excision for melanoma is associated with reduced recurrence.

• 2. For thin melanomas, currently there is no high-quality evidence to support excisions of more than a 1 cm margin in improving survival or local recurrence rates

• 3. For primary melanomas of any thickness, there is no evidence to suggest that margin excision of more than 2 cm provides any additional benefit in terms of survival or local recurrence rates.

• 4. The actual recommendations: In situ: 0.5–1 cm; >1 mm to 1 cm; 1–2 mm to 1–2 cm; >2 mm to 2 cm.

If these guidelines are followed, excision size in the face would leave defects between 1 and 4 cm in diameter. In the case of the lips such an excision would require complicated reconstruction (Cheriyan et al. J Surg Clin North Am. 94: 1091–1113, 2014).

There is obviously still some controversy about the issue of margins and larger series are needed specifically for malignant melanoma of the face.

The primary treatment for melanoma involving the cheeks, forehead, scalp, and nose remains somewhat controversial. The current National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline recommends 0.5 cm for in situ lesions; 1 cm for lesions >1.0 mm thick; 1–2 cm for lesions 1–2 mm thick; and 2 cm for lesions thicker than 2 mm (Jones et al. Am J Surg. 206: 307–313, 2013). Other authors have studied reducing these margins when treating facial melanoma by ½ and in small series report no difference in survival (Rawlani et al. J Surg Oncol. 111: 795–799, 2015). While an excision of 4 cm on the forehead or scalp is still a challenge, such an excision on the nose or cheek requires considerable reconstructive skills. Wide local excision, using whatever criteria are selected, should not be incompatible with a normal appearance.

This chapter will illustrate an approach to repairing defects between 1 and 4 cm in diameter in the lip, scalp, forehead, and cheeks. Multiple options based on the availability of local and regional tissue will be discussed. The goal is to restore the patient’s appearance so that they can confidently go about their lives after excision of melanoma. Options such a skin grafts, flaps, local tissue rearrangement, and regional tissue transfers will be presented.