DERMATOLOGIC SURGERY: ROTATION ADVANCEMENT FLAP AS FIRST LINE TREATMENT FOR HIGH-RISK SQUAMOUS CELL CARCINOMAS OF THE PERIOCULAR/PERIORBITAL ZONE- PRESENTATION AND DISCUSSION ABOUT 2 NEW CASES

Abstract

Rotation advancement flaps are a challenge for dermatosurgery
and in particular the severe clinical cases, mainly affecting skin
tumors in the facial area or the so-called ˝high risk areas˝. The
proximity of these areas to important vital structures (such
as nerves and blood vessels) also determines the need for
more precision when performing this type of manipulation.
Teamwork and preoperative planning are crucial and provide
a number of advantages in terms of the timely achievement of
the therapeutic endpoints. We present two cases of patients with
squamous cell carcinomas in the periocular and periorbital areas
treated by rotation advancement flaps. The problems that may
arise within these interventions and the prerequisites for the
latter to be successful are discussed.

Full text

EORGIAN
EDICAL
EWS
ЕЖЕМЕСЯЧНЫЙ НАУЧНЫЙ ЖУРНАЛ
Медицинские новости Грузии
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No 1 (322) Январь 2022
ISSN 1512-0112
ТБИЛИСИ - NEW YORK
NO 9 (354) Декабрь 2024

GMN: Georgian Medical News is peer-reviewed, published monthly journal committed to promoting
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GMN: Georgian Medical News is peer-reviewed, published monthly journal committed to promoting
the science and art of medicine and the betterment of public health, published by the GMN Editorial
Board since 1994. GMN carries original scientic articles on medicine, biology and pharmacy, which
are of experimental, theoretical and practical character; publishes original research, reviews, commen-
taries, editorials, essays, medical news, and correspondence in English and Russian.
GMN is indexed in MEDLINE, SCOPUS, PubMed and VINITI Russian Academy of Sciences. The full
text content is available through EBSCO databases.
GEORGIAN MEDICAL NEWS
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Редакционной коллегией с 1994 года на русском и английском языках в целях поддержки
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avtorTa sayuradRebod!
redaqciaSi statiis warmodgenisas saWiroa davicvaT Semdegi wesebi:
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standartuli furclis 1 gverdze, 3 sm siganis marcxena velisa da striqonebs
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tuli xasiaTis statiebis warmodgenisas avtorebma unda miuTiTon saeqsperimento
cxovelebis saxeoba da raodenoba; gautkivarebisa da daZinebis meTodebi (mwvave
cdebis pirobebSi).
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raTis zeda da qveda nawilebi.
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ar unda aRematebodes 5-s.
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jereba xdeba saavtoro originalis mixedviT.
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aRniSnuli wesebis darRvevis SemTxvevaSi statiebi ar ganixileba.

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DERMATOLOGIC SURGERY: ROTATION ADVANCEMENT FLAP AS FIRST LINE TREATMENT FOR HIGH-RISK SQUAMOUS
CELL CARCINOMAS OF THE PERIOCULAR/PERIORBITAL ZONE- PRESENTATION AND DISCUSSION ABOUT 2 NEW
CASES…………………………………………………………………………......................................................................………………116-121
Osminina M.K, Podchernyaeva N.S, Khachatryan L.G, Shpitonkova O.V, Velikoretskaya M.D, Chebysheva S. N, Polyanskaya A.V, Gugueva E.
A.
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Gocha Chankseliani, Merab Kiladze, Avtandil Girdaladze, Omar Gibradze.
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PREVALENCE OF OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN IRAQI KURDISTAN /DUHOK
GOVERNORATE………………………………………………….............................………………………………………………………143-148
Arustamyan Makich, Guseynova Susanna V, Tyulekbayeva Diana, Tkhakokhova Liana A, Krivosheeva Yana V, Vasilev Semen A, Abbasova
Zeinab I, Ponomareko Nadezhda O, Ismailova Sabina Z, Zakaev Israpil I.
COMPARATIVE ANALYSIS OF HEPATOPROTECTORS IN WISTAR RATS WITH EXPERIMENTALLY INDUCED METABOLICALLY
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Jin Wu, Lan-Xi Wu, Kun Yan, Jun-You Li, Tao-Xiang Niu.
ALOPECIA AREATA PROFILING SHOWS LNCRNAS REGULATE THE SUPPRESSED EXPRESSION OF KERATIN…..…………151-159
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AND TSBP1 POLYMORPHISMS………………........................................................................……………………………………………188-194
Farah Saleh Abdul-Reda, Mohammed AH Jabarah AL-Zobaidy.
EFFECTIVENESS AND TOLERABILITY OF APREMILAST IN TREATMENT OF A SAMPLE OF PATIENTS WITH PSORIASIS…195-198
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STUDY……………………………………………………...............................................................…………………………………………199-204
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MEDICAL STUDENTS………………………….....................................................…………………………………………………………205-212
Tamuna Dundua, Vladimer Margvelashvili, Manana Kalandadze, Sopio Dalalishvili.
THE ORAL HEALTH STATUS AND PREVENTIVE MEASUREMENTS FOR CANCER PATIENTS……..........................................…213-217

GEORGIAN MEDICAL NEWS
No 9 (354) 2024
© GMN 116
DERMATOLOGIC SURGERY: ROTATION ADVANCEMENT FLAP AS FIRST
LINE TREATMENT FOR HIGH-RISK SQUAMOUS CELL CARCINOMAS OF THE
PERIOCULAR/PERIORBITAL ZONE- PRESENTATION AND DISCUSSION ABOUT 2 NEW
CASES
Tchernev G1,2, Pidakev I3, Lozev I3, Warbev M3, Ivanova V3, Broshtilova V4.
1Onkoderma- Clinic for Dermatology, Venereology and Dermatologic Surgery, General Skobelev 26, 1606 Sofia, Bulgaria.
2Department of Dermatology and Venereology, Medical Institute of Ministry of Interior, General Skobelev 79, 1606, Sofia, Bulgaria.
3Department of Common, Abdominal and Vascular Surgery, Medical Institute of Ministry of Interior, General Skobelev 79, 1606, Sofia, Bulgaria.
4Department of Dermatology and Venereology, Medical Military Academy, Sofia, Bulgaria.
Abstract.
Rotation advancement aps are a challenge for dermatosurgery
and in particular the severe clinical cases, mainly aecting skin
tumors in the facial area or the so-called ˝high risk areas˝. The
proximity of these areas to important vital structures (such
as nerves and blood vessels) also determines the need for
more precision when performing this type of manipulation.
Teamwork and preoperative planning are crucial and provide
a number of advantages in terms of the timely achievement of
the therapeutic endpoints. We present two cases of patients with
squamous cell carcinomas in the periocular and periorbital areas
treated by rotation advancement aps. The problems that may
arise within these interventions and the prerequisites for the
latter to be successful are discussed.
Key words. Dermatologic surgery, high risk areas, rotation
advancement ap, skin cancer, cemiplimab, squamous cell
carcinoma.
Introduction.
The surgical treatment of scalp and forehead located cutaneous
tumors remains a major challenge for dermatosurgeons and
plastic reconstructive surgeons [1-3]. This is mainly due to the
limited possibilities of defect closure due to the lack of sucient
skin and skin elasticity, which necessitates the application
of more serious reconstructive aps of rotation, rotation-
advancement or transposition type [4-6].
Complementary or adjuvant options such as radiotherapy [7],
preoperative therapy with cemiplimab/ pembrolizumab and
cetuximab [8,9] or vismodegib [10], and chemotherapy [11]
remain an alternative option that could lead to tumour shrinkage
and facilitate the tasks of dermatosurgeons subsequently.
However, these options are not mandatory but could be
thoroughly discussed with the treating sta and tailored to the
patients' wishes.
We present an interesting case of a patient with an epithelial
skin tumor in the area of the right eyebrow treated surgically by
rotation-advancement ap.
A second case is presented with periorbital/ peri- and palpebral
located keratinocyte cancer, treated surgically again.
Case report 1.
We report a 66-year-old patient presenting for the rst time to
the Dermatosurgery Unit of our Hospital for a skin formation
localized in the area immediately above the right eyebrow
(Figure 1a). Approximately one month ago, the same lesion was
operated on in another clinic, and histopathological results were
suggestive of a squamous, non-keratinizing carcinoma with
a high degree of malignancy: immunohistochemical testing
for cytokeratins, p63 and EMA was positive, G3. Resection
margins laterally and in depth were involved. Clinically, the
tumor formation is endophytic/exophytic in growth and 3 cm
by 1.5 cm in size, soft elastic in consistency, not adherent
to the underlying tissues, but poorly mobile on attempted
displacement in either direction (Figure 1a). Without secretion,
very painful on pressure. The patient was admitted for surgical
treatment due to suspected locoregional recurrence of squamous
cell carcinoma of the skin in the facial area (Figure 1b).
Regarding the anamnestic data there were no comorbidities
and concomitant medication. Laryngeal carcinoma was operated
a year ago and there is additional clinical/ anamnestic/ evidence
of familial lipomatosis involving mainly the upper extremities
and partly the trunk area.
The laryngeal carcinoma was operated by total laryngectomy/
in toto, without lymph node involvement (disectio colli
bilateralis selectiva), and a tracheostomy was available at the
time of hospitalization. Histopathological ndings of laryngeal
carcinoma were suggestive of a well-dierentiated squamous
cell carcinoma with abundant keratin formation, G1, inltrating
the laryngeal cartilage. On this occasion, the patient was under
regular follow-up in an oncology unit.
After disinfection of the surgical eld, an oval excision of 0.6
cm of the tumor formation in depth to the periosteum (Figure
1c) was performed under general anesthesia. After careful
haemostasis, it was decided to undermine initially and after that
rotate the ap, the upper edge of which was 7 cm from the right
eyebrow, and the lower edge running parallel to 1 cm above
the upper left eyebrow, with the incision actually reaching its
lateral margin (Figures 1d & 1e). The arc of the upper edge of
the ap extended to the upper helix of the left auricle. After
thorough undermining of the ap, its transposition forward and
slight rotation followed to cover the defect created within the
tumor excision (Figure 1d). The excess skin tissue was resected
and the edges adapted by single skin sutures (Figure 1f ). An
optimal aesthetic result was achieved (Figure 1g).
Histopathological ndings were conrmatory of the initial
diagnosis, with tumour size determined to be 45mm by 20mm.
Lateral resection lines clear, single tumor cells reaching the
muscle fascia, stage 3 (pT3N0M0).
Case report 2.
We report an 85-year-old female patient with a history of
complaints for about a year, the most recent being the appearance
and relatively rapid growth of a tumor formation around her
right eye (Figure 2a). During the emergency examination, a

117
Figure 1a. Tumor recurrence of histologically proven SCC in the area above the right eyebrow.
Figure 1b. Preoperative preparation- marking of resection lines.
Figure 1c. Defect in the forehead area occurring after oval excision of the tumor.
Figure 1d. Upper arc of the surgical incision when performing advancement rotation ap.
Figure 1e. Staged undermining of the scalp and stoppage of bleeding.
Figure 1f. Postoperative nding after placement of the advancement rotation ap and 2 drains.
Figure 1g. Postoperative day 4 after drain removal.
periorbital/peripalpebral localized tumor formation measuring
5.8 by 6 cm, circumscribing the orbicularis oculi as a belt, as
well as the upper eyelid area beyond the orbit (Figure 2a) was
found. There was also a centrally localized area with a small
ulceration and a mild necrotic area with dried bloody discharge
present as a tract from the center of the tumor at 15:00 (Figure
2a). Clinical ndings were suggestive of an epithelial cutaneous
tumor with periorbital/periocular localization (Figure 2a). As
comorbidities, non-insulin-dependent diabetes mellitus, arterial
hypertension, aortic aneurysm (from previous epicrises) and
permanent dyspnea were known.
Paraclinical data war mostly in reference values, CT scan
(performed on an emergency basis) with evidence of a soft tissue
tumour measuring approximately 55 by 65mm, with an uneven
surface, patchy structure and small gas collections ventrally
consistent with tissue degradation. After contrast enhancement,
the formation increases inhomogeneously in density. The right
eyebulb was normal in shape and size and preserved in structure.
In conclusion, it is a tumour formation with evidence of upper
eyelid tissue disintegration, without evidence of inltration of
the eye bulbus and orbital structures as well as of the cranial
bones. A normal CT image of the brain corresponding to age.
Surgical intervention under intravenous anaesthesia was
undertaken. The tumor lesion was removed as an oval excision,
and bleeding was stopped with an electrocautery and single
subcutaneous resorbable sutures (Figure 2b). The entire right
eyebrow and upper eyelid were resected, and the eyebulbus and
cartilage were carefully prepared (Figure 2b). Similarly to the case
presented above (case 1), an arc-shaped incision was made starting
from the right temporal area and directed towards the scalp, with a 6
cm turn reaching the preauricular area on the left (Figures 2c & 2d).
The second incision was made starting at the medial orbital
angle, across the back of the nose (transversal) and just above
the right eyebrow, with its end reaching 1 cm below the lateral
orbital angle on the left (Figure 2e). The skin ap between
these 2 arches was carefully apped in a stepwise fashion,
and bleeding (from the peripheral areas, but also from the ap
itself) was stopped with an electrocautery knife. The ap was
gently rotated and transposed anteriorly (Figure 2e), with the
left portion xed with single skin sutures to the skin of the
right temporal area (Figures 2f & 2g). This was followed by a
stepwise adaptation of the skin with single skin sutures along
each of the two arches (resection arches of the ap: superior and
inferior) (Figures 2f & 2g).

118
An area in the shape of a triangle was cut in the lateral part of
the ap for better adaptation, rotation/transposition of the skin
and decrease in tension during xation/adaptation of the skin
over the right eyelid/right ocular bulbus (Figure 2e). Scalpel
reduction of the tissue / thickness of the ap / was carried out
for better t over the upper eyelid / periocular area (Figure 2f).
Two drains were installed and xed.
A good postoperative result was achieved (Figures 2f & 2g).
The histopathological result showed: Skin, subcutaneous and
soft tissue involved by keratinizing highly dierentiated (G1)
squamous cell carcinoma inltrating deep to the adnexae and
fascia, stage 2 (T3N0M0R1). An oncology committee discussion
was planned regarding the subsequent discussion about the
additional diagnostic and therapeutic options. А systemic
therapy with Cemiplimab/ pembrolizumab was planned.
Discussion.
Defects in the forehead and periorbital area are extremely dicult
to correct, adapt and obtain a satisfactory nal aesthetic result.
Facial asymmetry, proximity of the resection lines to the angular
veins, necrosis of a particular transposed area/ap or postoperative
permanent paralysis, infection or even mortality occurring within
the surgical interventions are some of the main factors that make
the dermatosurgeon as cautious as possible [12,13].
Figure 2a. Tumor recurrence of histologically proven SCC in the area above the right eyebrow.
Figure 2b. Preoperative preparation- marking of resection lines.
Figure 2c. Defect in the forehead area occurring after oval excision of the tumor.
Figure 2d. Upper arc of the surgical incision when performing advancement rotation ap.
Figure 2e. Staged undermining of the scalp and stoppage of bleeding.
Figure 2f. Postoperative nding after placement of the advancement rotation ap and 2 drains.
Figure 2g. Postoperative day 4 after drain removal.

119
Mohs surgery is one of the options for adequate treatment of
skin cancer in facial areas [14]. This type of surgery requires
certain preparation [15]. The rst step in this type of surgery is
to remove the tumor and ensure tumor cell-free resection areas
[14,15]. The second step involves reconstruction of the face
to achieve an optimal aesthetic result [16]. Most often, these
steps are performed by plastic reconstructive surgeons and/or
experienced dermatosurgeons [14-16].
The correction of defects by a certain type of plastic surgery
largely overlaps with cosmetic surgery as a technique, the
dierences being mainly due to the fact that in the direct
performance of skin ap, the rapid intraoperative evaluation of
the resection lines is lacking [17,18].
The volume of the surgery, the total duration and the type of
anaesthesia are all determining factors for the number of people
involved. Attention should also be paid to the fact that a major
surgical intervention in the facial area could change the very
appearance of the patient in one direction or another, his visual
identity [19]. The eorts after such rotation, transposition,
advancement or combination aps should be directed to a large
extent to the preservation of the patient's individual vision
[20,21]. The nal result after this kind of surgery requires
sometimes up to a year to obtain a real nal evaluation of
the vision postoperatively. Within this period, it is possible
to carry out a variety of additional corrections: from minor
surgical manipulations in the form of adaptation of the edges, to
intralesional application of corticosteroids or laser resurfacing
for keloids for example [21-23]. This depends on the individual
patient's wishes, general clinical condition, age and general
prognosis according to the stage of the disease (with or without
evidence of dissemination).
Corrections of postoperative defects are corrected depending
on the localization and volume and range from: primary
repair, healing by secondary intention, skin grafting, to - ap
reconstruction for a specic area [24,25].
The periocular, periorbital and orbito-palpebral areas are
dangerous due to the high risk of complications [26-29].
Locoregionally advanced or not advanced cutaneous tumors in
high-risk facial areas, such as the periocular and oculopalpebral
zones, for example, require a rapid therapeutic/ surgical response
[30-32] because tumor progression occurs unexpectedly rapidly
[33,34] or similarly to the patients we presented.
The good news in the patients we have presented is that 1) there
is no involvement of the cartilage that makes up the eyelids,
as well as the nerves in the immediate vicinity (permanent
neurological decits/need for an eye surgeon) (Figure 2a) and 2)
there is no involvement of the frontal bone below the tumor, in
the forehead area (need for a neurosurgeon on the team) (Figure
1a). These facts largely give freedom to the surgical team in
choosing one or another technique and reduce the degree of
complexity of the intervention.
Relapses in squamous cell carcinomas of the skin could
be multifactorial. Perineural and lymphovascular invasion,
poor tumor cell dierentiation, tumor size greater than 2 cm,
tumor invasion beyond the dermis, and immunosuppression
could be reported as determinants of local recurrence and
metastasis [35-38]. Locally advanced or locoregionally
advanced inoperable squamous cell carcinomas of the skin
raise again the question: would postoperative therapy with
pembrolizumab and cemiplimab [39] not be a good solution?
In PD-L1-positive tumors, there was an objective response
rate (ORR) of 55% to pembrolizumab, while PD-L1- staining
tumors had an ORR of only 17% to pembrolizumab [40,41].
This makes immunohistochemical evaluation of inltrates
extremely important, especially when dealing with patients
whose resection lines are not clear of tumor cells.
Rotation aps remain a major challenge for dermatosurgeons
and dermatologists in general. Preservation of ap circulation
along the course of the artery temporalis supercialis, frontal
branch, is and remains crucial. It is because of this factor
that it is important that the superior arc of the incision is well
situated (Figures 1f,1g & 2f,2g), so as not to disrupt the integrity
of the artery. The latter should supply blood to the ap or,
preferably, the surgical incision should pass over the artery. The
advancement ap should contain the artery within itself, and
this is ensured by the wider arc of the upper surgical incision.
The ramus frontalis of the arteria temporalis supercialis should
be preserved.
The non-involvement of this branch within the operation
ensures the good postoperative results seen in patient 1 (1g,1g).
A similar result was achieved in patient 2 (2f,2g), but follow-
up of the nal aesthetic result was not possible.
Immunohistochemical testing for the marker (PD-L1) was
recommended at another institution with a view to possibly
starting systemic therapy with pembrolizumab or cemiplimab.
Expression of this marker (PD-L1) 1) on the one hand correlates
with disease progression/risk of developing local metastases,
nodal recurrence, tumor diameter, histological grade and tumor
thickness [42-44].
On the other hand, 2) the identication of similar histologic
markers in the tissue could have tremendous prognostic value
regarding future targeted therapy [45,46].
Cemiplimab and pembrolizumab are in fact a new such
advanced option in locally advanced squamous cell carcinomas
of the skin, including periocularly localized ones [46- 48]. With
good PD-L1 expression in the patient we described in number 2,
the drugs (cemiplimab/ pembrolizumab) could also be considered
as a good therapeutic alternative to avoid reoperation.
The rotation advancement aps remain a priority option for
scalp reconstruction after removal of heterogeneous skin tumors
even in cases where Mohs surgery is used [49].
Although rare, this type of ap repair could be applied
repeatedly and simultaneously, in dierent combinations, in
order to correct defects in the scalp area in a single surgical
session [50].
Rotational advancement aps remain one of the most reliable
treatment options for defects in the forehead, brow and around
the periorbital area.
The rapid and adequate performance of this type of
manipulation requires the presence of several dermatologists/
surgeons, with or without the presence of a plastic surgeon as
well, in order to 1) minimize profuse blood loss, 2) reduce the
duration of general anesthesia, and 3) demonstrate an acrybic
knowledge of the anatomy of the region.

120
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