The problem of reconstruction in potential persistent malignancy: A foresight saga

Abstract

Summary 1.A case is reported of basal-cell epithelioma of the nose and cheek, proven at 18 years, starting from a burn in infancy. Ineffectually treated for eight years with heavy irradiation elsewhere, the patient was under the writer's personal observation and care for nineteen years, with apparent elimination by excision on four occasions, and with three reconstructions of the nose and cheek, the last being eight and a half years ago with no signs of reappearance. Reappearance of tumour was believed to be a new malignant growth as a late effect of irradiation. 2.Irradiation may (a) cure the disease, (b) imprison tumour cells that may later become active, or (c) stimulate tissues to neoplastic growth. Tissue that has been irradiated is more difficult to cure and more difficult to repair. 3.In a large majority of instances adequate surgical excision followed by plastic surgical repair is preferable to treatment by irradiation, as the excised tissue can be examined for adequacy of margin, and there will be no sequel˦ of irradiation, such as discomfort to the patient, damage to the tissues, and stimulus of neoplastic activity. 4.If surgery is used in malignancy of the face the excision should be sufficiently wide at the first attack to remove all of the tumour. This should be checked by localised specimens and a competent pathologist. 5.Immediate reconstruction may be started at the operation of excision if the diseased area is small, does not involve structures that cannot be readily repaired, and has not been previously treated, particularly by irradiation. 6.Where the tumour is possibly scattered over a considerable area, has been previously unsuccessfully treated, particularly by irradiation, where skeletal structures and the nasal and oral cavities are involved, and where there is a question of adequacy of excision, coverage of the defect by thick tissues should be delayed until adequate time has elapsed to warrant a definitive reconstruction. Thin skin grafts may be applied to close over the defects in the interim so that these areas can be under observation for the appearance of any neoplastic growth. 7.The surgeon who makes the repair should be the surgeon who excises the diseased tissue, provided he has the training and ability to do both. He should be safer because he can afford to be adequately radical. With his choice of possible pre-excisional procedures, the immediate application of flaps and free skin grafts, he may speed repair, avoid discomfort for the patient, and facilitate later reconstruction. 8.It is not always possible to have the foresight to anticipate all eventualities in complicated cases.