Basal cell carcinoma of the head and neck: Surgical management and postoperative strategies - A researcher's perspective

Reconstructive techniques

The reconstruction of surgical defects following BCC excision in the head and neck region represents a core component of functional and aesthetic patient outcomes [3, 5, 14] (Figure 2). Figure 2 provides a structured algorithm guiding flap selection based on defect size, anatomical subunit reconstruction principles, and patient comorbidities. Notably, practice patterns vary significantly—particularly in perinasal and medial cheek defects—where surgeon experience, tissue laxity, and patient-related factors influence the decision between nasolabial, bilobed, advancement, or paramedian forehead flaps. Variability in surgical preference reflects both anatomical complexity and heterogeneity in available comparative evidence. Given the anatomical complexity and cosmetic importance of the face, reconstructive planning must be individualized, taking into account defect location, size, depth, skin laxity, and patient comorbidities [14, 15]. A widely adopted principle in modern facial reconstruction is the subunit-based approach. This concept dictates that when more than 50% of a recognized aesthetic subunit (such as the nasal tip, alar lobule, or upper lip) is lost, the entire subunit should be excised and reconstructed to maintain harmonious contours and prevent patchwork deformity [15, 16]. Such strategic resection allows for the use of well-matched adjacent tissue, ultimately improving aesthetic integration. Local flap techniques are the mainstay for most small- to medium-sized defects due to their superior match in skin tone, texture, and thickness [16, 17]. These include advancement flaps for linear extension of adjacent tissue, rotation flaps to pivot skin around a defect, and transposition flaps such as bilobed and rhomboid flaps for defects of the nose, cheek, and temple. Island flaps and perforator-based designs (e.g., V-Y advancement flaps) are especially valuable in perioral and perinasal areas, allowing for mobility with minimal donor-site morbidity [15, 17]. In elderly patients, particularly those with limited healing capacity or extensive sun-damaged skin, dermal regeneration templates followed by delayed split-thickness grafting can provide durable and cosmetically acceptable results, especially for concave surfaces or large scalp defects [15, 17].

Figure 2. Institutional algorithm for reconstructive decision-making following excision of basal cell carcinoma in the head and neck region

For larger or deeply infiltrative tumors, such as giant basal cell carcinomas involving the cheek, forehead, or scalp, the reconstructive challenge intensifies [14, 17]. Here, the use of tissue expansion can allow for primary closure with native skin after tumor clearance. In more extensive cases, free flap reconstruction—such as radial forearm or anterolateral thigh (ALT) flaps - is necessary to restore contour, volume, and skin coverage. Preoperative virtual planning with 3D modeling has emerged as a valuable adjunct to guide flap selection, contouring, and symmetry, especially when bilateral or multi-subunit defects are involved [8, 17, 18]. In all cases, the goal is to restore both appearance and function while minimizing donor site morbidity. Mastery of a broad reconstructive repertoire, along with attention to subunit principles, enables the surgical team to tailor outcomes to individual patient anatomy and expectations.

Wound care and early recovery

Immediately post-surgery, wound care protocols are based on the reconstructive modality [14, 19]. For primary closures and local flaps, the use of non-adherent dressings and scheduled suture removal (typically 5–7 days for facial areas) is standard [19]. For skin grafts, bolstering techniques are applied to secure graft adherence, and monitoring for hematoma or graft necrosis is essential during the first 48–72 hours. Topical antibiotic ointments and sterile coverage are used routinely until epithelialization is complete [14, 15, 17]. In patients who undergo complex reconstructions, such as regional or free flaps, monitoring flap viability is a central aspect. Parameters such as color, capillary refill, temperature, and doppler signals are evaluated at regular intervals during the first postoperative week. In high-risk flaps, hospital admission may be necessary for observation [10, 15, 17]. Pain management should be individualized and adjusted according to defect size and surgical extent. Non-opioid analgesics such as acetaminophen or NSAIDs are often sufficient, though deeper reconstructions may require short-term opioid use [19, 20].

Scar management and functional rehabilitation

Once wounds are stable, the emphasis shifts toward scar modulation [19]. Silicone gel sheeting, massage therapy, and sun protection are initiated approximately two weeks postoperatively [15, 19]. In hypertrophic or cosmetically significant scars, intralesional corticosteroids or laser therapy may be employed [21]. Contracture prevention, especially near the perioral or periocular region, involves early mobilization, physical therapy, and in some cases, revision surgery [15, 21]. Patients with flaps involving dynamic facial units may benefit from targeted physiotherapy to retrain mimic musculature and minimize asymmetry [15, 16]. In elderly patients or those with neuromuscular deficits, functional recovery may require more time and interprofessional input.

Oncologic surveillance

Oncological follow-up is based on risk stratification. High-risk patients - those with aggressive histology, perineural invasion, incomplete excision, or recurrent tumors—require more intensive surveillance. Clinical examination is advised every 3–6 months in the first two years, then every 6–12 months up to five years [10, 12].

Dermoscopy can aid in early detection of subtle recurrences. In select patients, especially those with extensive prior BCC history, digital total-body photography and serial imaging may be warranted [7].

For patients treated with adjuvant radiotherapy, late effects such as fibrosis, telangiectasia, and radiation dermatitis must be monitored [11, 22]. Coordination with radiation oncology is key, particularly in the assessment of irradiated flap viability and secondary tumor development [11].

Integration of systemic therapy

Systemic therapies are particularly relevant for patients with advanced, recurrent, or inoperable BCC. Hedgehog pathway inhibitors (vismodegib, sonidegib) have been approved for locally advanced or metastatic BCC, showing response rates between 43% and 60% in pivotal trials [23, 24]. Common adverse effects include muscle cramps, alopecia, and dysgeusia. In tumors refractory to these agents, the PD-1 inhibitor cemiplimab offers an additional option with response rates near 30% in early-phase trials [25, 26]. Importantly, neoadjuvant use of systemic therapies has enabled surgical downstaging in selected patients, allowing for function-preserving resections. Integration into surgical planning requires close collaboration between surgical oncology and dermatology/oncology. Neoadjuvant systemic therapy is considered when tumor size or anatomical location would otherwise necessitate multi-stage or high-morbidity reconstruction. Reduction in tumor volume may allow for single-stage closure or avoidance of free-tissue transfer.

Psychosocial and quality-of-life aspects

BCC treatment, particularly involving the face, may have profound psychological and social implications. Early referral to psycho-oncologic services is advisable for patients exhibiting distress, body image disturbance, or depression. Patient-reported outcome tools, such as the FACE-Q Skin Cancer Module, can support tailored postoperative counseling and guide future reconstructive interventions [13, 27].

In summary, postoperative management is a dynamic, multidisciplinary effort that extends beyond wound closure. It encompasses structured follow-up, scar care, functional training, and holistic patient support to achieve optimal long-term outcomes. Successful treatment of facial BCC often depends on interdisciplinary collaboration among dermatologists, oncologists, pathologists, plastic surgeons, and radiation oncologists. For patients with advanced, recurrent, or inoperable BCC, systemic therapies like Hedgehog inhibitors (vismodegib, sonidegib) and emerging PD-1 inhibitors provide new therapeutic avenues [6, 10].

Plastic surgeons must be aware of the dermatologic and oncologic implications of systemic therapy, as neoadjuvant strategies can downsize tumors and allow for less morbid resections. In elderly patients with multiple comorbidities, a conservative, coordinated approach often yields better outcomes than aggressive excision alone [10, 14].

Institutional experience and clinical perspective

In our institutional practice at the Bundeswehrkrankenhaus Hamburg, a tertiary referral center for complex facial reconstruction, basal cell carcinoma cases account for a significant portion of head and neck oncologic surgeries. Based on our experience, flap selection is often driven not only by defect size and location but also by patient-specific factors such as comorbidities, anticoagulation status, and the anticipated compliance with postoperative care. For elderly patients with perinasal or medial cheek defects, we routinely favor the nasolabial flap due to its low donor-site morbidity and superior aesthetic integration. In contrast, the forehead flap remains our technique of choice for midline nasal defects requiring robust vascular supply and subunit restoration. Notably, in the past two years we have increasingly incorporated virtual planning for flap dimensioning and symmetry control, particularly in patients with prior surgeries or scarred facial tissue. We have also observed a growing subset of patients with locally advanced or previously neglected BCC, often due to delayed access or underestimation of the lesion’s extent. In these cases, a combined approach involving neoadjuvant systemic therapy followed by staged resection and reconstruction has shown promise in reducing surgical morbidity while maintaining oncologic safety.

This evolving experience underscores the need for individualized strategies that go beyond textbook algorithms and highlights the value of interdisciplinary collaboration, especially with dermatology and oncology teams, to optimize both function and form in facial reconstruction.