Facial skin cancer

Timelines for the various types of malignant skin lesion (BCC, SCC or melanoma), vary according to the pathology, site, spread, reconstruction and need for radiotherapy.

BCC, basal cell carcinoma, can usually be cured by wide local excision with a clear microscopic margin of 2 to 5 mm and the short term issues are largely influenced by the site and reconstruction (if any).

Excision and primary repair with sutures will be followed by swelling and discomfort, particularly a sensation of tightness across the suture line. Depending on the location there may be some difficulty in, for example, seeing clearly if surgery is around the eyelid. Once the sutures are removed, the main issues are healing of the scar which follows a fairly predictable sequence of events over an 18 month period to reach full scar maturity and best final aesthetic result.

Excision and skin graft is similar although a pressure dressing called a ‘bolster’ is sewn across the graft to hold it in place, usually for 10 days. This can interfere with hair washing and vision depending on the site of surgery for that period. Medium to long term healing is similar to primary closure, except for the donor site of the graft.

If a full thickness skin graft is used it will be taken from loose areas of skin around the face and neck where the scar can be hidden, the donor site heals in the same way as an excision and primary closure (see above).

A split thickness skin graft heals by secondary intention and involves longer. Wrap-around dressings, often on the thigh, are used for 3 to 4 weeks and the donor site is very often itchy and uncomfortable for many weeks. Although split skin grafts take more easily than full thickness grafts, the match to the face is not as good and the donor site can be very irritating. They are avoided for this reason unless large areas of coverage are needed.

With sun-damage related skin cancers on the face, scalp, and neck it is wise to use grafts in younger patients as the likelihood of further skin cancers with age is ever present and the use of local flaps early can use up available tissue for later in life.

Local flaps often offer the best tissue match for facial skin cancer defects and heal in the same way as primary excision and closure but with slightly unusual shapes of scar. Therefore, they follow essentially the same timelines.

SCC, squamous cell carcinoma, treatment timeline follows that for BCC with some exceptions.

SCC, particularly of the external ear is much more likely to metastasize It is quite rare that a facial or scalp (or particularly ear) SCC may require a neck dissection to address cervical (neck) metastasis; the timeline for this is covered in the timeline for the treatment of mouth cancer. If extracapsular spread or multiple nodes are involved, or if the primary site demonstrates unusually aggressive or poor prognosis features, then external beam radiotherapy may be added to the treatment. This is generally less radical and problematic than the issues described in timelines for mouth cancer.

Long term issues are also present around new cancers developing as sun damage plays a major role in skin cancer. There is a higher (although still small) risk of recurrence of the original cancer.

Melanoma is a more aggressive form of skin cancer and has a higher risk of both recurrence and metastasis. It therefore warrants a slightly different approach. Although similar issues to BCC and SCC apply in the short term, different long-term considerations over monitoring for recurrence or metastasis apply as, although curable, there is a higher incidence of recurrence and metastasis than for SCC. Uniquely among the skin cances specific (genomic) typing of melanoma is useful. This is done on the histological specimen. Typing is important in case immunotherapy based systemic treatment could be of value in the event of systemic disease (there is growing evidence that it is).