Skin malignancy and the reconstructive plastic surgeon

Skin malignancy represents at least 25% of the plastic surgeon's workload. The commonest tumour, the basal cell carcinoma, usually arises in the skin of elderly patients who are frequently managed by surgery under local anaesthetic, often as outpatients. The recurrent basal cell carcinoma poses a difficult problem regardless of the primary therapy. Skin repair with direct closure or skin grafts is usually simple, but skin flaps will be needed when bone, cartilage or major neurovascular structures are exposed, or where tissue vascularity has been reduced by irradiation fibrosis. Squamous cell carcinomas of lip, ear and hand may recur as lymph node metastases despite clinical and histological clearance. Malignant melanoma continues to present as advanced disease (thick tumours) in this country, and this largely dictates prognosis, since tumour thickness is recognised as the single most important dominant prognostic variable. Incisional biopsy compromises histological microstaging and should be avoided. Indirect evidence from narrow margin excision of invasive head and neck cutaneous melanomas suggests no detriment, and narrow margin excision of melanomas is increasingly being practised.