Tissue Transfer for Skin Cancer -- Full-Length Doctor's Interview

Ivanhoe Broadcast News Transcript with
Mark K. Wax, M.D., Otolaryngologist,
Professor of Otolaryngology & Director of Microvascular Reconstruction,
Oregon Health & Science University, Portland, Oregon,
TOPIC: Tissue Transfer for Skin Cancer

What is the concept of free-tissue transfer?

Dr. Wax: This is used for patients who have very large skin cancers. The majority of patients have been treated with surgical procedures or radiation, and the cancer recurred with large resections. To remove the cancer, the whole nose, eye, cheek, or sometimes the ear was taken out. These patients then have gaping wounds or deep holes in their faces. It's very difficult to recreate these structures using tissue that's locally available. So, we have to take tissue from somewhere else.

The concept of taking tissue from somewhere else is relatively new. It's been around for the last 10 or 20 years for different types of reconstruction. The ability to recreate different areas of the face with different types of composite tissue has become much easier. We are better at being able to take the different types of tissue and model them to the tissue that has been deformed by skin cancer. When I first started out, we used to just take out the cancer, and the patient was left with a big hole.

What are the components of the free-tissue transfer procedure?

Dr. Wax: We're taking tissue from another part of the body that has a blood supply. We have to take a piece of the body that has a blood vessel in it. So, we're limited in sources. What's even more limiting is that some of the sources come with a pre-defined amount of tissue. For other types of reconstruction, we'll use a piece of skin from the arm with the radial artery, the artery in the arm, but that gives us thin pliable tissue, good only for the oral cavity or tongue. If we are dealing with a very large hole, we have to go to a body part where there is a blood vessel that supplies a large piece of tissue. This is often the rectus abdominus or one of the two muscles that you have in the abdomen. We only take the muscle because the fat is too much.

What surgery is involved in this procedure?

Dr. Wax: Half the time, we take tissue from the skin and muscle of the belly, and the other half of the time we take skin and muscle from the back. Both of these areas have a bulk of tissue. There's a muscle that starts at your ribcage and goes down to the top of your pelvis. We make an incision on the abdomen from the top to the bottom, and we go down and find that muscle. That muscle is fed by a blood vessel that comes off of a blood vessel in the groin. We find those blood vessels and detach the blood vessel in the groin. We take the muscle and the blood vessel and bring it up into the affected area. Then, we'll take the blood vessel and tunnel it under the skin to get it to a blood vessel in the neck. The tissue that's up here now has a blood supply on its own and is in living vascularized tissue. It's dead tissue in the deformity, and we're counting on the blood supply from around the transferred tissue to get into it. It's then a race. Will the blood supply grow into the tissue to revascularize and keep the cells alive? Or will the cells die, get infected and not do well?

How much tissue do you remove from the abdomen?

Dr. Wax: About a handful. In some cases, we take the whole muscle. Some people are missing the eye socket or the sinus, and we know that when you take the muscle out it atrophies. When we take the muscle out of the belly, we cut the nerves that go to it, and we don't hook those nerves up. The tissue will at first stick out, but then shrinks. It's like carpentry in it's better to cut the wood too long because you can always come back and whittle it down. With our free-tissue transfer, we always put up more tissue than we need because it always tend to shrink. A lot of these patients get radiation therapy, so the tissues will shrink some more. As time heals their scar, we can fix it if there's too much tissue. If you don't have enough, then it's a problem because you're stuck.

How much of these procedures are for cosmetic reasons?

Dr. Wax: Obviously that is not the first goal of the procedure. Our first goal is to put things back together and get people out of the hospital. A lot of times we are revising and fiddling with the tissue to make sure that things will fit in properly. Most of those changes deal with functional aspects. So, if the patient has tissue hanging down interfering with their speech or the way they eat, then we'll go in and trim that. In terms of cosmetic, if it's just that they have a big blob of tissue here, and it looks ugly, you and I would say, "That needs to be fixed." Now insurance companies say, "That's cosmetic, we're not going to pay for it." So, a lot of the time we will do the cosmetic aspect as part of another procedure. I think the cosmetics are a very important aspect of it, especially because we're operating on the face. We do our best to get the patients cosmetically acceptable.

Before free-tissue transfer, was there no other option to reconstruct the patients' deformities?

Dr. Wax: Correct. Free-tissue transfer involves a certain level of technical expertise to be able to do the surgery, although there are people that have been doing this type of surgery since the early or mid 80s. There were one or two pioneers that had done this. Yet, it didn't catch on to the general medical community and become popular until 1990. Up until that time, there was no way of reconstructing after surgery. If you came into the hospital and got the tumor removed, there was just no way of fixing the deformity.

What were the outcomes that you saw for these 43 patients of the story who had the free-tissue transfer?

Dr. Wax: You can look at outcomes in different ways. What we initially looked at was survival. We also wanted to look at how good we were at getting the tumor out. We've been pretty good at getting the tumors out and making sure that we get it all out. If we leave a little bit behind, inevitably it's just going to grow back. After we learned how to remove the tumors, we had to learn how to reconstruct the area so people could function. I inherited a few patients that had huge tumors that were all removed, which resulted in a big hole in their cheek. They couldn't eat because food would come out of their face. The effect of surgery can be tremendous. You can just imagine the problems they have. They're social cripples because they don't want to walk down the street. We learned how to reconstruct those types of people using a plastic mold, like a prosthesis. Afterwards, they're beautiful. After a few years, I couldn't remember what side I had operated on in some patients. I couldn't tell the difference. And again, there are only a few people that can do things that high quality. With free-tissue transfer, we were then able to plug up the hole to restore some functions. This not only plugs up the hole but also makes it look better. Instead of having a big wad of tissue there, you have something that at least molds in, looks more acceptable, and fulfills those functions of letting people breathe through their nose, or even drink and get food down.

How many of these patients have their cancers recur?

Dr. Wax: Most of these are skin cancers, and most skin cancers have a very good prognosis. However, with this procedure we're often looking at the patients whose skin cancer keeps coming back, which automatically means the cancer is bad. For this treatment, we've pre-selected a group of tumors that does poorly. Yet, our survival rate was pretty good.

How long did you follow the 43 patients?

Dr. Wax: Some of them we only followed for a few months. Then, some patients we've followed for five to 10 years. I think the average amount of time we followed people was 22 or 23 months. Our survival rate was over 80 percent.

If you don't treat a skin cancer for a long period of time, it will continue to grow bigger. As some of them grow, they will start to invade along the nerves. That is a bad sign when they invade along the nerves. What we found in our paper was that patients who could get all of the tumor out did very well, but remember that it was a small number of patients. The patients whose tumors we removed but had the tumor growing along the nerves did poorly.

If somebody with a condition similar to these patients sees this story could they go to a medical center wherever they live to ask about free-tissue transfer? Or is this something where the patient needs to find a doctor who has performed a lot of these surgeries?

Dr. Wax: There are not many community physicians or private practitioners that perform this type of reconstruction or even the removal of the tumor. In our institution we have a team. We have a neurosurgeon involved. Another one of my partners is a head and neck oncologist who just takes out cancers. I reconstruct after removal of the cancer. Each person of our team contributes their own part. Most skin cancers can be taken care of by a multitude of different physicians, whether it's a family doctor, a dermatologist, or another type of doctor. Because these particular skin cancers are so large, they usually require the expertise of an academic center. In Oregon, we're the only place that offers this type of expertise. If you were in Seattle, I think there are two places that I know of. In California, obviously you have a lot more. In Montana there is nobody.

What is the role of the neurosurgeon in this procedure?

Dr. Wax: He's actually going in and lifting the brain up to make sure the oncologist doesn't hit the nerve. Then I come in at the end to reconstruct the area.

Is there a specialty called reconstructive otolaryngology?

Dr. Wax: It's not a recognized sub-specialty. It's certainly part of the field of otolaryngology. Ninety-eight percent of otolaryngologists operate. We do a lot of facial, plastic and reconstructive surgery.

How many physicians in the country who would do this type of surgery?

Dr. Wax: There are probably 40 or 50 otolaryngologists that do this. Plastic surgeons are the other doctors that do this.

Sometimes you might have the first surgery done by someone else and then go to see the plastic surgeon to fix the cavity?

Dr. Wax: No. I think most places now try to do the procedure all at once to save the patient the inconvenience of having a big hole and also of having to get two operations. But in some places ENT does the reconstruction, and in some places plastic surgery does the reconstruction.

Compared with other medical advances, how would you categorize this type of surgery for the patient? What does it usually mean?

Dr. Wax: I think it has revolutionized care for patients. Beforehand, patients used to come in, get their cancer out, and they had huge holes in different places that affected their ability to eat and drink. About 30 years ago, that was as good as we could get, and we'd say it bought you a few years. Now what we've done is been able to say we can get rid of the cancer and let you have a functional life. People could now go back to doing what they were doing before in terms of how well they talk, eat and can go out. This should give them a better quality of life. I think most of our medical surgical fields are trying to improve a patient's quality of life so they can enjoy themselves.

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Tamara Hargens
Oregon Health & Science University
News and Publications
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hargenst@ohsu.edu