Advances in flap surgical techniques and regenerative approaches for reconstruction of extensive defects in cutaneous squamous cell carcinoma: a systematic review of functional and aesthetic outcomes

Diego Román Zapata Ospina; Shanice Osmara Carrasco Ruiz; Andres Santodomingo Galindo; Alvarez Arroyo José Javier; Elizabeth Arellano Pacheco; María Fernanda Rojas García; Juan Gabriel Torres Bernal

doi:10.18203/2320-6012.ijrms20243778

Authors

Diego Román Zapata Ospina Medical Department, Fundación, Universitaria San Martín, Colombia
Shanice Osmara Carrasco Ruiz Department of Internal Medicine, ISSSTE, Hospital General de La Paz, México
Andres Santodomingo Galindo Department of Epidemology, Independent Investigator, Chile
Alvarez Arroyo José Javier Department General Surgery, Independent Investigator, México
Elizabeth Arellano Pacheco Department of Internal Medicine, Hospital General de Zona 50 Instituto Mexicano del Seguro Social, Mexico
María Fernanda Rojas García Medicine Department, Universidad Nacional Autónoma De México, México
Juan Gabriel Torres Bernal Medical Department, Universidad Nacional de Colombia, Colombia

DOI:

https://doi.org/10.18203/2320-6012.ijrms20243778

Keywords:

Cutaneous squamous cell carcinoma, Flap surgery, Reconstruction techniques, Functional outcomes, Aesthetic outcomes, Regenerative therapies

Abstract

About 20–30% of non-melanoma skin malignancies globally are cutaneous squamous cell carcinomas (cSCCs). Achieving the best functional and cosmetic results in complex and Long-term instances that need rebuilding is extremely difficult. Though they lack a thorough assessment of their efficacy but recent developments in flap surgery and regenerative medicines present encouraging alternatives. We only included papers which are published between 2000-2024 were included in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) -guided systematic review. Data were taken from 45 studies with 3,560 individuals (9 RCTs, 20 cohort studies, and 11 case series). Functional recovery, cosmetic satisfaction, and the rates of complications for both regenerative (such as platelet-rich plasma [PRP] and bioengineered scaffolds) and advanced flap techniques like perforator and free tissue flaps were evaluated. The Newcastle-Ottawa scale and the ROB 2 tool were used to evaluate the risk of bias. Compared to pedicled flaps (7.2/10, p<0.01), perforator flaps showed a 96.5% success rate and better functional recovery (mean mobility score: 8.5/10). Although free tissue transfers had a greater rate of complications (18%) but they produced the greatest aesthetic satisfaction scores (85%). Regenerative techniques enhanced wound healing by 25% and decreased infection rates by 15% (p=0.04). Graft survival was increased to 90% with bioengineered scaffolds as opposed to 75% without them. Complication rates were 20% overall but in high-risk instances, regenerative treatments reduced them to 10%. After all research, we can conclude that for cSCC reconstruction, the combination of regenerative procedures and sophisticated flap techniques minimizes problems while optimizing functional and aesthetic results. Free tissue transfers are favored for cosmetic reasons however perforator flaps are excellent for functional recovery. Regenerative methods like PRP and scaffolds can enhance surgical outcomes and durability.

Metrics

Metrics Loading ...

References

Papadopoulos O, Karantonis FF, Papadopulos NA. Non-Melanoma Skin Cancer and Cutaneous Melanoma for the Plastic and Reconstructive Surgeon. Non-Melanoma Skin Cancer and Cutaneous Melanoma: Surgical Treatment and Reconstruction. 2020;153-239.

Shaari AL, Xing MH, Mundi N, Khorsandi AS, Geronemus R, Urken ML. Reconstruction of the external auditory canal: The tragal flap revisited and review of contemporary reconstructive techniques. Am J Otolaryngol. 2021;42(6):103094.

Umesha KV. Role of Adjacent Flaps in Reconstruction of Skin and Soft Tissue Defect After Excision of Skin Tumours. Master's thesis, Rajiv Gandhi University of Health Sciences (India).

Sittitrai P, Ruenmarkkaew D, Klibngern H. Pedicled flaps versus free flaps for oral cavity cancer reconstruction: a comparison of complications, hospital costs, and functional outcomes. Int Arch Otorhinolaryngol. 2023;27:32-42.

Colella G, Rauso R, De Cicco D, Boschetti CE, Iorio B, Spuntarelli C, et al. Clinical management of squamous cell carcinoma of the tongue: Patients not eligible for free flaps, a systematic review of the literature. Exp Rev Anticancer Ther. 2021;21(1):9-22.

Forner D, Phillips T, Rigby M, Hart R, Taylor M, Trites J. Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis. J Otolaryngol Head Neck Surg. 2016;45(1):11.

Cvrtak S. Reconstructive Microsurgery. Doctoral dissertation, University of Rijeka. Faculty of Medicine. Department of Surgery.

Mohan AT, Sur YJ, Zhu L, Morsy M, Wu PS, Moran SL, et al. The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstruct Surg. 2016;138(4):710-29.

Marchi F, Wei FC. Microsurgical Procedures in Plastic Surgery. Textbook of Plastic and Reconstructive Surgery: Basic Principles and New Perspectives. 2022;125-39.

Qiao Z, Wang X, Deng Y, Li Q, Zan T, Sun Y, et al. Clinical application of pre-expanded perforator flaps. Facial Plast Surg Aesthet Med. 2023;25(1):68-73.

Daikuara LY, Chen X, Yue Z, Skropeta D, Wood FM, Fear MW, et al. 3D bioprinting constructs to facilitate skin regeneration. Adv Funct Mater. 2022;32(3):2105080.

Wu S, Sun S, Fu W, Yang Z, Yao H, Zhang Z. The role and prospects of mesenchymal stem cells in skin repair and regeneration. Biomedicines. 2024;12(4):743.

Elbarbary AH, Hassan HA, Elbendak EA. Autologous platelet‐rich plasma injection enhances healing of chronic venous leg ulcer: a prospective randomised study. Int Wound J. 2020;17(4):992-1001.

Arabpour Z, Abedi F, Salehi M, Baharnoori SM, Soleimani M, Djalilian AR. Hydrogel-Based Skin Regeneration. Int J Mol Sci. 2024;25(4):1982.

Eming SA, Krieg T, Davidson JM. RETRACTED: Gene therapy and wound healing. Clin Dermatol. 2007;25(1):79-92.

Petrie K, Cox CT, Becker BC, MacKay BJ. Clinical applications of acellular dermal matrices: a review. Scars Burns Heal. 2022;8:20595131211038313.

Burke B, Eden C, Perez C, Belshoff A, Hart S, Plaza-Rojas L, et al. Inhibition of Histone Deacetylase (HDAC) Enhances Checkpoint Blockade Efficacy by Rendering Bladder Cancer Cells Visible for T Cell-Mediated Destruction. Front Oncol. 2020;10:699.

Hu YY, Jin Q, Wang J, Wu SF, He Y, Jin PH. Integrated therapeutic strategies for various cutaneous malignancies: Advances and challenges of multifunctional microneedle patches toward clinical translation. Chem Engineer J. 2024;494:153033.

Parekh V, Seykora JT. Cutaneous squamous cell carcinoma. Clin Lab Med. 2017;37(3):503-25.

Cui L, Jiang WQ, Zhang DK, Wang GF, Han YD, Pu WW, et al. A three-dimensional visualization of the full-field surgical region based on thin-slice MRI: A helpful approach for simultaneously guiding tumor resection and perforator flap elevation. Front Surg. 2022;9:984892.

Lupon E, Lellouch AG, Deilhes F, Chaput B, Berthier C. Reconstruction of a dorsal thoracic wall defect with a dorsal intercostal artery perforator flap after removal of a bulky cutaneous squamous cell carcinoma: a case report. J Med Case Rep. 2019;13:1-6.

Neamonitou F, Kotrotsiou M, Stavrianos S. Microvascular reconstruction of the anterior skull base tumors; our experience. J Plast Reconstruct Aesthet Surg. 2021;74(6):1355-401.

Awad MM, Wahsh MA, Hussien MH, Adel Saqr M. Assessment of Local Freestyle Perforator Flaps for Face Defects Reconstruction. Egypt J Hosp Med. 2023;91(1):4011-8.

Zheng L, Lv XM, Shi Y, Huang MW, Zhang J, Liu SM. Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region. Int J Oral Maxillofac Surg. 2023;52(4):423-9.

Jeong HH, Choi DH, Hong JP, Suh HS. Use of a helical composite free flap for alar defect reconstruction with a supermicrosurgical technique. Arch Plast Surg. 2018;45(05):466-9.

Qassemyar Q, Gianfermi M, Sarfati B, Leymarie N, Kolb F. Super‐microdissected local flaps for the coverage of temporal defects. Microsurgery. 2014;34(7):554-7.

Marchi F, Wei FC. Microsurgical Procedures in Plastic Surgery. Textbook of Plastic and Reconstructive Surgery: Basic Principles and New Perspectives. 2022;125-39.

Fernandes RP, Pirgousis P. Local/Regional Flaps in Oral/Head and Neck Reconstruction. Contemporary Oral Oncology: Oral and Maxillofacial Reconstructive Surgery. 2017;235-59.

Guo L, Pribaz JJ. Clinical flap prefabrication. Plast Reconstruct Surg. 2009;124(6S):e340-50.

Lembo F, Cecchino LR, Parisi D, Portincasa A. Utility of a new artificial dermis as a successful tool in face and scalp reconstruction for skin cancer: analysis of the efficacy, safety, and aesthetic outcomes. Dermatol Res Pract. 2020;2020(1):4874035.

Abbase EH, Shenaq SM, Spira M, El-Falaky MH. Prefabricated flaps: experimental and clinical review. Plast Reconstruct Surg. 1995;96(5):1218-25.

Chen L, Xing Q, Zhai Q, Tahtinen M, Zhou F, Chen L, et al. Pre-vascularization enhances therapeutic effects of human mesenchymal stem cell sheets in full thickness skin wound repair. Theranostics. 2017;7(1):117.

Zhou F, Zhang L, Chen L, Xu Y, Chen Y, Li Z, et al. Prevascularized mesenchymal stem cell-sheets increase survival of random skin flaps in a nude mouse model. Am J Transl Res. 2019;11(3):1403.

Uysal CA, Ogawa R, Lu F, Hyakusoku H, Mizuno H. Effect of mesenchymal stem cells on skin graft to flap prefabrication: an experimental study. Ann Plast Surg. 2010;65(2):237-44.

Zhang Q, Chiu Y, Chen Y, Wu Y, Dunne LW, Largo RD, et al. Harnessing the synergy of perfusable muscle flap matrix and adipose-derived stem cells for prevascularization and macrophage polarization to reconstruct volumetric muscle loss. Bioact Mater. 2022;22:588-614.

Conese M, Annacontini L, Carbone A, Beccia E, Cecchino LR, Parisi D, et al. The Role of Adipose‐Derived Stem Cells, Dermal Regenerative Templates, and Platelet‐Rich Plasma in Tissue Engineering‐Based Treatments of Chronic Skin Wounds. Stem Cell Int. 2020;2020(1):7056261.

Zhu Y, Peng N, Wang J, Jin Z, Zhu L, Wang Y, et al. Peripheral nerve defects repaired with autogenous vein grafts filled with platelet-rich plasma and active nerve microtissues and evaluated by novel multimodal ultrasound techniques. Biomat Res. 2022;26(1):24.

Gentile P, Garcovich S. Systematic Review: Adipose-Derived Mesenchymal Stem Cells, Platelet-Rich Plasma and Biomaterials as New Regenerative Strategies in Chronic Skin Wounds and Soft Tissue Defects. Int J Mol Sci. 2021;22(4):1538.

Supp DM, Supp AP, Boyce ST, Bell SM. Enhanced vascularization of cultured skin substitutes genetically modified to overexpress vascular endothelial growth factor. J Investig Dermatol. 2000;114(1):5-13.

Winge MC, Kellman LN, Guo K, Tang JY, Swetter SM, Aasi SZ, et al. Advances in cutaneous squamous cell carcinoma. Nat Rev Cancer. 2023;23(7):430-49.

Habban Akhter M, Amin S. An investigative approach to treatment modalities for squamous cell carcinoma of skin. Curr Drug Delivery. 2017;14(5):597-612.

Amini S, Viera MH, Valins W, Berman B. Nonsurgical innovations in the treatment of nonmelanoma skin cancer. J Clin Aesthet Dermatol. 2010;3(6):20.

Lee TY, Lee S, Eun S. The Free Flap Reconstruction of Facial Defects after Squamous Cell Carcinoma Excision. Medicina. 2024;60(9):1432.

Rodio M, Tettamanzi M, Trignano E, Rampazzo S, Serra PL, Grieco F, et al. Multidisciplinary Management of Cutaneous Squamous Cell Carcinoma of the Scalp: An Algorithm for Reconstruction and Treatment. J Clin Med. 2024;13(6):1581.

Malahias M, Ackling E, Zubair O, Harper N, Al-Rawi H, Khalil H. Extended Scalp Flaps for Extensive Soft Tissue Scalp Defects as a Day Surgery Procedure Under Local Anesthetic: A Single Centre Experience. J Neurol Surg B Skull Base. 2021;82(6):689-94.

Bota O, Meier F, Garzarolli M, Schaser KD, Dragu A, Taqatqeh F, et al. Lower leg reconstruction after resection of a squamous cell carcinoma on necrobiosis lipoidica with a pedicled fibula and an extended anterolateral thigh flap-a case report. World J Surg Oncol. 2023;21(1):38.

Faenza M, Molle M, Mazzarella V, Antonetti AM, Filosa FG, Pelella T, et al. Functional and Aesthetic Comparison between Grafts and Local Flaps in Non-Melanoma Skin Cancer Surgery of the Face: A Cohort Study. JPRAS Open. 2024;42:97-112.