Extraocular sebaceous carcinoma (SC) is a rare malignant tumor occurring in mostly head and neck region [1,2]. Though it is less frequent than ocular SC, extraoccular SC is likely to be locally aggressive and go through distal metastasis, and once metastasis occurs, the progress is fast , so diagnosis and proper treatment are necessary by all means. Therefore, the authors performed flap operation considering facial aesthetic unit after wide excision, and the results of 2 years of regular follow-up visit which showed no evidence of recurrence indicated as follows.
Case reports:Case 1 A woman age 61 visited dermatology clinic with no symptomatic yellowish lesion in left alar region, and as a result of punch biopsy, the lesion was diagnosed as SC. As no distant metastasis was observed in pre-operation test, the case was referred to plastic surgeon for surgical treatment. With about 1 cm border, wide excision was done, and as 1.8×2 cm sized defect occurred, angular artery-based retroangular flap considering aesthetic unit was designed and reconstructed. As a result of biopsy after the surgery, the symptom was diagnosed as SC. During the 2 years of follow-up observation after the surgery, no recurrence or metastasis was observed, and aesthetic conditions were also satisfactory.
Case 2 To a woman age 54, yellowish brown lesion occurred in right temporal area several months before walking into the clinic. As a result of biopsy in local clinic, the symptom was diagnosed as SC, and Moh's operation was done. Two months after surgery, lesion occurred again in the surgery area, and the patient visited plastic surgery clinic. The size of the lesion was 0.6×1.0 cm, and in the center, erythermatous nodule was observed. In pre-operation test, no lesion or distal metastasis was found on area other than pre-operation area. With 1 cm of safe margin, wide excision was done, and after the excision, defect size was 2.5×3.0 cm. By considering aesthetic unit, defect was covered by executing superior auricular artery island flap, and the results were aesthetically satisfactory with no recurrence or distal metastasis after the surgery.
Discussion Extracocular SC, as it has less local recurrence and metastatic tendency than ocular SC, is thought to have somewhat better prognosis. However, since the primary lesion tends to be locally aggressive, and with about 21% of patients, lymph node and distant metastasis are observed, caution should be taken. In addition, as the number of cases reported and clinical follow-ups is limited, there are no reports on the true measure of the nature of this neoplasm, extraocular SC .
Therefore, for treatment, early aggressive surgical therapy after adequate evaluation of distal metastasis remains the only option. And the lesion has a tendency to be locally aggressive, so in traditional excision, 5–6 mm safety margin is recommended .
As such, in case only palliative excision is done, local metastasis also occurs much, and once metastasis occurs, it spreads fast, so minimum 10 mm border was given for excision considering aesthetic unit, and though radiological therapy and anti-cancer therapy effects also are given, the degree of significance still remains an argument. When it comes to sufficiently wide range of excision, Tan et al said that the size of the resultant defect and its aesthetic outcomes should not be considered as a rule of tumor surgery .
However, the large defect area left behind remains both a difficult for doctor to properly cover and a disaster to patient. Therefore, the authors devised proper flap operation that considered aesthetic unit after sufficient excision, and covered it successfully.
The angular artery based retroangular artery flap the authors introduced before can be used for one-stage operation. Local anesthesia can be administered and has color, texture and thickness analogous to the original skin. Moreover, it has the advantage of concealing the donor scar in the nasolabial fold, and yet is proper for the reconstruction of lower half of the nose and lower eyelid . Furthermore, superior auricular artery island flap also could properly cover the upper region of auricle and its surrounding with post-auricular flap which has similar color and touch to facial skin through reliable pedicle with local anesthesia alone . Through this process, the authors were able to properly cover the defect area after sufficient excision, gaining satisfactory aesthetic results with no recurrence during follow-up observation period, and now are reporting it.
In summary, extraocular SC is locally aggressive and has potential of distal metastasis, and once metastasis occurs, it spreads fast, so extraocular SC requires sufficient pre-operation test, proper surgery and long time follow-up observation. To reduce defect area after surgery, Moh's micrographic surgery is done as well, but as it involves high risk, it requires cautious long term follow-up observation and larger series study. Therefore, it is judged that proper flap operation that considers sufficiently wide range of excision and aesthetic unit would be proper method of treating extraocular SC.
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