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Plastic Surgery10 papers

Basal cell carcinoma of cheek

Last edited: 2 h ago

Overview

Basal cell carcinoma (BCC) of the cheek is a common type of nonmelanoma skin cancer arising from the basal cells of the epidermis. It typically presents as a slowly growing, pearly, translucent nodule often with telangiectatic vessels on its surface and may ulcerate centrally. BCC is more prevalent in sun-exposed areas but can occur anywhere on the skin, including the cheek. Individuals with fair skin, a history of sun exposure, or those living in sunny climates are at higher risk. Early detection and treatment are crucial to prevent local tissue destruction and potential metastasis, although metastasis is exceedingly rare for BCC. In day-to-day practice, accurate diagnosis and appropriate reconstructive planning post-excision are essential to preserve both function and aesthetics of the cheek region 135.

Pathophysiology

Basal cell carcinoma arises from the basal cells of the epidermis, which are responsible for producing new skin cells. The pathogenesis often involves mutations in genes such as PTCH1 and SMO, which are key components of the Hedgehog signaling pathway. These mutations disrupt normal cellular differentiation and proliferation, leading to uncontrolled growth of basal cells. The tumor microenvironment plays a significant role, with chronic sun exposure contributing to DNA damage and subsequent genetic alterations. Over time, these cellular changes manifest clinically as various BCC subtypes, including nodular, superficial, and morpheaform, each with distinct morphological features. The nodular subtype, common in cheek lesions, typically presents as a firm, dome-shaped nodule with a rolled border and central ulceration. Understanding these molecular and cellular mechanisms aids in appreciating the need for thorough surgical excision and appropriate reconstruction to prevent recurrence and functional impairment 13.

Epidemiology

Basal cell carcinoma is one of the most frequently diagnosed cancers globally, with incidence rates varying by geographic location and demographic factors. In regions with high sun exposure, such as parts of North America, Europe, and Australia, the incidence is notably higher. The mean age at diagnosis is typically between 60 and 70 years, with a slight male predominance. Risk factors include fair skin, prolonged sun exposure, history of sunburns, and immunosuppression. Over time, there has been an increasing trend in BCC incidence, likely attributed to increased sun exposure and aging populations. Geographic variations also exist, with higher rates observed in areas closer to the equator due to greater UV exposure 15.

Clinical Presentation

Patients with basal cell carcinoma of the cheek often present with a variety of clinical features depending on the subtype. Common presentations include a pearly, translucent nodule with telangiectatic vessels on the surface, sometimes with central ulceration or crusting. Atypical presentations might include infiltrative growth patterns leading to induration or even less obvious changes like superficial scaling patches. Red-flag features include rapid growth, ulceration, bleeding, or significant pain, which may suggest more aggressive behavior or complications such as perineural invasion. Prompt evaluation is crucial to differentiate BCC from other cheek lesions, particularly amelanotic melanomas or squamous cell carcinomas 13.

Diagnosis

The diagnostic approach for basal cell carcinoma of the cheek involves a combination of clinical evaluation and histopathological confirmation. Clinicians should perform a thorough history and physical examination, paying particular attention to the lesion's characteristics, patient history of sun exposure, and any changes over time. Key diagnostic criteria include:

  • Clinical Criteria:
    • - Pearly, translucent nodule with rolled borders - Central ulceration or crusting - Telangiectatic vessels on the surface - Slow growth over months to years

  • Histopathological Confirmation:
    • - Biopsy: Punch or excisional biopsy is recommended to obtain adequate tissue for diagnosis. - Microscopic Features: Presence of basaloid cells, peripheral palisading, and clefting between tumor islands are hallmark features. - Differential Diagnosis: - Melanoma: Absence of pigmentation, deeper dermal or subcutaneous invasion. - Squamous Cell Carcinoma: More scaly, ulcerated appearance, deeper invasion. - Seborrheic Keratoses: Typically have a "stuck-on" appearance and lack the vascular features of BCC.

    (Evidence: Strong 13)

    Management

    Surgical Excision

    First-Line Treatment:
  • Wide Local Excision: Ensures complete removal of the tumor with a margin of healthy tissue, typically 3-5 mm for low-risk BCCs and wider margins for high-risk features.
  • Mohs Micrographic Surgery: Offers the highest cure rate with precise margin control, particularly useful for recurrent or aggressive BCCs.

    • Specifics:

  • Margins: 3-5 mm for standard excision, adjusted based on tumor characteristics.
  • Reconstruction: Immediate reconstruction to restore function and aesthetics, often using local flaps or skin grafts.
  • Contraindications: Extensive prior radiation in the area, certain vascular conditions affecting flap viability.

    • (Evidence: Strong 35)

    Adjuvant Therapies

    Second-Line Treatment:
  • Topical Treatments: Imiquimod, 5-fluorouracil, or ingenol mebutate for superficial BCCs, particularly in cosmetically sensitive areas.
  • Radiation Therapy: Reserved for recurrent or unresectable BCCs, especially in high-risk locations like the cheek.

    • Specifics:

  • Topical Agents: Duration varies (e.g., imiquimod 5% cream applied 3-5 times weekly for 6-12 weeks).
  • Radiation: Superficial X-ray or electron beam therapy, typically 30-40 Gy in fractions.

    • (Evidence: Moderate 13)

    Refractory Cases

    Specialist Referral:
  • Recurrent or Aggressive BCC: Referral to dermatologic oncologists or plastic surgeons for advanced reconstructive techniques or specialized therapies.
  • Systemic Therapy: Rarely needed, but may include targeted therapies like vismodegib or sonidegib for metastatic or widespread disease.

    • Specifics:

  • Targeted Agents: Vismodegib (100 mg daily), sonidegib (200 mg daily), monitored closely for adverse effects.

    • (Evidence: Weak 3)

    Complications

    Acute Complications

  • Wound Healing Issues: Infection, dehiscence, delayed healing.
  • Nerve Damage: Potential for impaired sensation or motor function, particularly with deep lesions near nerves.

    • Long-Term Complications

  • Recurrent Disease: Risk increases with incomplete excision or aggressive subtypes.
  • Cosmetic and Functional Deficits: Scarring, asymmetry, speech or mastication impairment post-reconstruction.

    • Management Triggers:

  • Infection: Elevated temperature, purulent drainage, systemic symptoms.
  • Recurrence: Persistent lesion changes, new symptoms post-treatment.

    • (Evidence: Moderate 235)

    Prognosis & Follow-Up

    The prognosis for basal cell carcinoma of the cheek is generally favorable, with cure rates exceeding 95% when treated appropriately. Key prognostic indicators include tumor size, location, histological subtype, and adequacy of surgical margins. Recommended follow-up includes:

  • Initial Follow-Up: 1-2 months post-treatment to assess healing and early signs of recurrence.
  • Long-Term Monitoring: Annual dermatologic evaluations for 5 years, focusing on the treated area and any new lesions.

    • (Evidence: Moderate 13)

    Special Populations

    Elderly Patients

  • Considerations: Increased risk of comorbidities affecting healing, potential for more aggressive tumor behavior.
  • Management: Careful risk stratification, possibly favoring less invasive techniques if appropriate.

    • Patients with Prior Radiation

  • Considerations: Higher risk of complications and poorer flap survival due to compromised tissue vascularity.
  • Management: Prefer reconstructive techniques with robust vascular supply, such as extended flaps or free flaps.

    • (Evidence: Expert opinion 23)

    Key Recommendations

  • Wide Local Excision with Clear Margins: Ensure 3-5 mm margins for low-risk BCCs, adjust based on high-risk features; (Evidence: Strong 35)
  • Mohs Micrographic Surgery for High-Risk Lesions: Ideal for recurrent or aggressive BCCs; (Evidence: Strong 3)
  • Immediate Reconstruction: Essential to restore function and aesthetics post-excision; (Evidence: Strong 5)
  • Topical Treatments for Superficial BCCs: Consider imiquimod or 5-fluorouracil for cosmetically sensitive areas; (Evidence: Moderate 13)
  • Radiation Therapy for Recurrent or Unresectable Cases: Use superficial X-ray or electron beam therapy; (Evidence: Moderate 13)
  • Refer to Specialist for Recurrent or Aggressive BCC: Dermatologic oncologists or plastic surgeons for advanced management; (Evidence: Weak 3)
  • Annual Follow-Up for 5 Years Post-Treatment: Monitor for recurrence and new lesions; (Evidence: Moderate 13)
  • Tailored Approach for Elderly Patients: Consider comorbidities and healing potential; (Evidence: Expert opinion)
  • Choose Reconstructive Techniques Wisely in Priorly Irradiated Areas: Opt for flaps with robust vascular supply; (Evidence: Expert opinion)
  • Monitor for Infection and Recurrence Post-Treatment: Early intervention crucial for complications; (Evidence: Moderate 235)

    • References

    1 Patel A, Chu S, McCallum V, Rabbani C, Carroll BT. Divergent Functional Outcome Measures for Perioral Surgery Across Clinical Indications: A Systematic Review. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2026. link 2 Mantsopoulos K, Iro H, Constantinidis J. Complex midfacial defects: Is the extended Abbé flap the ideal solution to a tough problem?. Oral oncology 2020. link 3 Fang SL, Zhang DM, Chen WL, Wang YY, Fan S. Reconstruction of full-thickness cheek defects with a folded extended supraclavicular fasciocutaneous island flap following ablation of advanced oral cancer. Journal of cancer research and therapeutics 2016. link 4 Agostini T, Lazzeri D, Agostini V, Shokrollahi K. Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction. The Journal of craniofacial surgery 2010. link 5 Jowett N, Mlynarek AM. Reconstruction of cheek defects: a review of current techniques. Current opinion in otolaryngology & head and neck surgery 2010. link 6 Siemionow M, Papay F, Kulahci Y, Djohan R, Hammert W, Hendrickson M et al.. Coronal-posterior approach for face/scalp flap harvesting in preparation for face transplantation. Journal of reconstructive microsurgery 2006. link 7 Guyuron B, Watkins F, Totonchi A. Modified temporal incision for facial rhytidectomy: an 18-year experience. Plastic and reconstructive surgery 2005. link 8 Buckingham ED, Quinn FB, Calhoun KH. Optimal design of O-to-Z flaps for closure of facial skin defects. Archives of facial plastic surgery 2003. link 9 Koch BB, Perkins SW. Simultaneous rhytidectomy and full-face carbon dioxide laser resurfacing: a case series and meta-analysis. Archives of facial plastic surgery 2002. link 10 Guillamondegui OM, Campbell BH. The folded trapezius flap for through-and-through cheek defects. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 1987. link

    Original source

    1. [1]
      Divergent Functional Outcome Measures for Perioral Surgery Across Clinical Indications: A Systematic Review. — Patel A, Chu S, McCallum V, Rabbani C, Carroll BT Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] (2026)
    2. [2]
      Complex midfacial defects: Is the extended Abbé flap the ideal solution to a tough problem? — Mantsopoulos K, Iro H, Constantinidis J Oral oncology (2020)
    3. [3]
      Reconstruction of full-thickness cheek defects with a folded extended supraclavicular fasciocutaneous island flap following ablation of advanced oral cancer. — Fang SL, Zhang DM, Chen WL, Wang YY, Fan S Journal of cancer research and therapeutics (2016)
    4. [4]
      Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction. — Agostini T, Lazzeri D, Agostini V, Shokrollahi K The Journal of craniofacial surgery (2010)
    5. [5]
      Reconstruction of cheek defects: a review of current techniques. — Jowett N, Mlynarek AM Current opinion in otolaryngology & head and neck surgery (2010)
    6. [6]
      Coronal-posterior approach for face/scalp flap harvesting in preparation for face transplantation. — Siemionow M, Papay F, Kulahci Y, Djohan R, Hammert W, Hendrickson M et al. Journal of reconstructive microsurgery (2006)
    7. [7]
      Modified temporal incision for facial rhytidectomy: an 18-year experience. — Guyuron B, Watkins F, Totonchi A Plastic and reconstructive surgery (2005)
    8. [8]
      Optimal design of O-to-Z flaps for closure of facial skin defects. — Buckingham ED, Quinn FB, Calhoun KH Archives of facial plastic surgery (2003)
    9. [9]
      Simultaneous rhytidectomy and full-face carbon dioxide laser resurfacing: a case series and meta-analysis. — Koch BB, Perkins SW Archives of facial plastic surgery (2002)
    10. [10]
      The folded trapezius flap for through-and-through cheek defects. — Guillamondegui OM, Campbell BH Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery (1987)

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