Skin cancer remains one of the most prevalent malignancies in Australia, with effective treatment occasionally requiring a multidisciplinary approach.
Among the treatment options, reconstructive surgery plays a pivotal role in restoring both function and appearance after excision of cancerous lesions.
Skin cancer treatments such as wide local excisions, often leave significant defects, particularly when tumours are located in cosmetically or functionally sensitive areas such as the face, neck, or hands. Reconstructive surgery bridges the gap between successful oncological treatment and the restoration of the patient’s quality of life, with the aim to strike a balance between form and function.
Beyond aesthetics, reconstructive procedures aim to maintain functionality, minimise scarring, and prevent complications such as contractures or impaired mobility.
Principles and techniques of reconstructive surgery
Reconstructive surgery in skin cancer follows several core principles (owing to the modern day father of plastic surgery Sir Harold Gillies) to ensure optimal outcomes:
- Oncological safety: Reconstruction is planned only after achieving clear margins to prevent recurrence.
- Minimal morbidity: Techniques prioritise minimising donor site morbidity, especially in complex reconstructions.
- Functional preservation: Surgeons focus on restoring functionality, particularly in areas like the eyelids, lips or nose.
- Aesthetic outcome: Reconstructive efforts aim to blend scars into natural lines and contours for a harmonious appearance.
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A variety of reconstructive techniques are available, ranging from simple to complex (now known as the so-called reconstructive elevator). The choice depends on the size and location of the defect, patient-specific factors, and surgeon expertise.
- Primary closure: For small defects, direct suturing of the wound edges can provide excellent results with minimal disruption to surrounding tissues.
- Skin grafting: This technique is suitable for larger defects where primary closure is not possible. Split-thickness or full-thickness grafts are harvested from donor sites and transplanted to the affected area. While effective, grafts may have a less natural appearance compared to
local flaps. - Local flaps: Local tissue is repositioned to cover the defect, ensuring a better colour and texture match. Common examples include rotational, advancement, and transposition flaps. Local flaps are often used for facial reconstructions.
- Free tissue transfer (free flaps): For extensive or deep defects, tissue is transferred along with its vascular supply from a distant site. This technique demands microsurgical expertise and is ideal for complex reconstructions requiring robust vascularisation.
- Composite reconstruction: Combining techniques, such as a flap with a graft, is sometimes necessary for intricate defects involving multiple tissue layers.
Advances and challenges in reconstruction
The field of reconstructive surgery has benefited from technological and procedural innovations. For example, bioengineered scaffolds and dermal matrices facilitate tissue regeneration and provide good integration in certain complex reconstructions. Similarly, advancements in surgical planning, including the use of 3D imaging and virtual simulation, allow for more precise and tailored approaches for the complex microsurgical reconstructions.
Despite advancements, reconstructive surgery faces several challenges. Achieving oncological safety while minimising reconstruction-associated complications can be difficult, especially in high-risk patients with comorbidities. Managing patient expectations regarding aesthetic outcomes and recovery timelines is another critical aspect of the reconstructive process.
A practical case example illustrates the importance of reconstructive techniques: An elderly patient underwent a wide local excision of a biopsy proven squamous cell carcinoma on the right pre-auricular region (Figure 1). Post-excision, the defect was approximately 5x7cm in size requiring reconstruction (Figure 2). A large cervicofacial flap was utilised to reconstruct the defect and is shown here at only three weeks post-surgery (Figure 3).
The success of reconstructive surgery in skin cancer is measured not only in oncological terms but also in the patient’s satisfaction with their functional and cosmetic outcomes. Early intervention and tailored reconstructive plans significantly improve long-term results, ensuring patients regain confidence and normalcy in their lives.
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Key messages
- Reconstructive surgery is integral to comprehensive skin cancer treatment
- It restores what cancer takes away—function, form, and confidence
- As techniques evolve, the synergy between oncological treatment and reconstruction continues to offer hope and healing to patients, reaffirming the critical role of this specialty in modern medicine.
Author competing interest – nil
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