Keywords
neoplasms - occupational cancer - skin abnormalities - soft tissue injuries - soft
tissue neoplasms
Introduction
Skin cancer is the most common neoplasm in Brazil[1] and worldwide, representing approximately 30% of all malignant tumors diagnosed
in the country, with emphasis on basal cell and squamous cell carcinomas.[2]
Although non-melanoma skin cancers have a low mortality rate, they can cause significant
morbidity, including disfigurement and functional impairment, especially when located
in exposed areas, such as the face and ears. Therefore, they require monitoring and
treatment by several health specialties.[3] The epidemiological characterization of patients affected by these neoplasms is
essential for the development of preventive, therapeutic, and rehabilitation strategies,
both in public and private healthcare.[4]
Surgical treatment is the gold standard for most non-melanoma skin cancer cases. Establishing
adequate surgical margins is crucial to ensure complete tumor removal and to reduce
recurrence rates. International guidelines recommend margins of 4 to 6 mm for low-risk
lesions and larger ones for high-risk lesions.[5]
In this context, plastic surgeons play a fundamental role not only in tumor excision
but also in the aesthetic and functional reconstruction of the affected areas, aiming
to restore the patients' quality of life.
Moreover, identifying subpopulations and rare cases enables the formulation of specific
protocols, including the need for specialized services, the definition of adequate
surgical margins, and the selection of the most effective procedures.
Given this scenario, the present study aims to analyze the epidemiological profile
of patients undergoing surgical treatment for skin lesions in a tertiary public hospital,
contributing to the improvement of oncological and reconstructive management strategies.
Objective
The objective of the current study was to to analyze the epidemiological profile of
patients with skin lesions referred to a plastic surgery service at a tertiary hospital.
Materials and Methods
This retrospective case series study aimed to establish the epidemiological profile
of patients operated on for skin lesions at the Plastic Surgery Service of Hospital
de Clínicas de Porto Alegre (HCPA), a public tertiary teaching hospital.
The study sequentially included a total of 287 patients who underwent surgical treatment
from January 3, 2022, to July 3, 2023. Resident physicians performed the data collection
under the supervision of attending plastic surgeons, by reviewing electronic medical
and surgical records.
We analyzed the following variables: age, gender, geographic origin (grouped according
to the seven mesoregions of the state of Rio Grande do Sul: Metropolitan, Northwest,
Northeast, Midwest, Mideast, Southeast, and Southwest), histopathological diagnosis,
total number of lesions, anatomical location of the main lesion, tumor recurrence
or persistence, reconstructive technique, and oncological margins of the first excision
(free or compromised, and need for surgical reapproach).
Statistical analysis was performed manually, without the use of specific software.
We expressed quantitative variables as means and standard deviations (SDs), and categorical
variables as absolute and relative frequencies.
The Research Ethics Committee of HCPA approved this study under opinion number 08-058.
Results
Of the 287 cases, 50.5% were female. The mean age of the sample was 62.2 ± 18.9 years.
Most patients (95.5%) had skin phototypes I to III at the Fitzpatrick classification,
corresponding to white skin subjects. [Table 1] shows the distribution of patients per mesoregion in the state of Rio Grande do
Sul. Most patients were from the Metropolitan area, accounting for 93.9% of all visits.
It is noteworthy that this region encompasses several municipalities and has a high
population density, which may explain the greater demand for specialized care.
Table 1
|
Mesoregions of the state of Rio Grande do Sul
|
n
|
%
|
|
Northwest
|
3
|
1.0
|
|
Northeast
|
3
|
1.0
|
|
Midwest
|
2
|
0.7
|
|
Mideast
|
5
|
1.7
|
|
Metropolitan
|
269
|
93.7
|
|
Southwest
|
0
|
0.0
|
|
Southeast
|
5
|
1.7
|
|
Total
|
287
|
100.0
|
Of the 287 lesions referred to the service, 213 (74.2%) were malignant. The most common
diagnosis was basal cell carcinoma (59.6%), followed by spinocellular carcinoma (also
called squamous cell carcinoma; 12.5%). [Table 2] presents the complete distribution of diagnoses identified in the sample. All cases
were confirmed by histopathological examination.
Table 2
|
Diagnosis
|
n
|
%
|
|
Basal cell carcinoma
|
171
|
59.6
|
|
Squamous cell carcinoma
|
36
|
12.5
|
|
Keloid
|
15
|
5.2
|
|
Actinic keratosis
|
13
|
4.5
|
|
Granulation
|
10
|
3.5
|
|
Cicatricial fibrosis
|
9
|
3.1
|
|
Melanocytic nevus
|
5
|
1.7
|
|
Lentigo maligna
|
4
|
1.4
|
|
Neurofibroma
|
4
|
1.4
|
|
Epidermal cyst
|
3
|
1.0
|
|
Epithelioid sarcoma
|
2
|
0.7
|
|
Hemangioma
|
2
|
0.7
|
|
Bowen's disease
|
2
|
0.7
|
|
Cutaneous polypoid
|
2
|
0.7
|
|
Lipoma
|
1
|
0.3
|
|
Lipogranuloma
|
1
|
0.3
|
|
Viral wart
|
1
|
0.3
|
|
Pilomatricoma
|
1
|
0.3
|
|
Keratoacanthoma
|
1
|
0.3
|
|
Juvenile xanthogranuloma
|
1
|
0.3
|
|
Epithelioma
|
1
|
0.3
|
|
Actinic poikiloderma
|
1
|
0.3
|
|
Trichoepithelioma
|
1
|
0.3
|
|
Total
|
287
|
100.0
|
Among the basal cell carcinomas, the distribution of histological subtypes was as
follows: nodular (49.7%), infiltrative (38.6%), superficial (11.1%), and metatypical
(0.6%). In 10.1% of cases, patients were referred for secondary surgical interventions.
Excisions and reconstructions in the anatomical regions of the head and neck accounted
for 92.3% of referrals. The nasal subregion was the most affected (39.0%), followed
by the auricular subregion (13.2%). [Table 3] presents the distribution of lesions by anatomical subregion.
Table 3
|
Subregion of the skin lesion
|
n
|
%
|
|
Scalp
|
6
|
2.1
|
|
Frontal
|
23
|
8.
|
|
Temporal
|
14
|
4.9
|
|
Auricular
|
38
|
13.2
|
|
Upper eyelid
|
2
|
0.7
|
|
Lower eyelid
|
10
|
3.5
|
|
Nasal
|
112
|
39.0
|
|
Upper labial
|
14
|
4.9
|
|
Lower labial
|
5
|
1.7
|
|
Infraorbital
|
13
|
4.5
|
|
Zygomatic
|
12
|
4.2
|
|
Buccinator
|
4
|
1.4
|
|
Mental
|
3
|
1.0
|
|
Mandibular
|
6
|
2.1
|
|
Cervical
|
3
|
1.0
|
|
Upper limb
|
10
|
3.5
|
|
Trunk
|
6
|
2.1
|
|
Lower limb
|
6
|
2.1
|
|
Total
|
287
|
100.0
|
In 89.2% of surgeries, histopathological examination revealed clear margins after
the first excision. The procedures adopted varied according to the extent of the lesion,
anatomical location, and possibility of immediate reconstruction. They were classified
as follows: 1) lack of immediate reconstruction, waiting for the histopathological
report, provided there was no significant functional risk, such as ocular exposure;
2) primary closure of the surgical wound; 3) reconstruction with a skin graft; 4)
reconstruction with a local or distant flap. [Table 4] presents the distribution of tissue synthesis techniques employed.
Table 4
|
Technique
|
n
|
%
|
|
Primary closure
|
148
|
51.6
|
|
Healing by secondary intention
|
15
|
5.
|
|
Skin graft
|
51
|
17.8
|
|
Skin flap
|
73
|
25.4
|
|
Total
|
287
|
100.0
|
Intraoperative frozen section examination was used whenever possible. However, the
technique was not available in all cases, particularly outside office hours (8–21h)
or due to the unavailability of a pathologist. Whenever available, this examination
assessed the presence of compromised margins, especially in tumors with infiltrative
behavior. However, in some cases, the team decided against immediate reconstruction
before a definitive histopathological examination report.
We adopted this approach especially in cases of residual or recurrent tumors, referred
from other services, or previously treated. Although delayed reconstruction may require
additional procedures, it can prevent unnecessary flaps or grafts in cases with compromised
margins, since these structures require partial or complete removal with the surgical
specimen in patients with residual neoplasms.
Discussion
In our study, patients undergoing surgical procedures for excision of non-melanoma
skin cancers were older, with a mean age of 62.2 ± 18.9 years. This age range is consistent
with the epidemiological profile of these lesions in the state of Rio Grande do Sul,
where the incidence of skin cancer is higher in subjects over 60-years-old. The sample
had a similar distribution regarding gender, reflecting this population proportion.[6] Rio Grande do Sul has the highest percentage of white subjects in Brazil, according
to the 2022 Brazilian Demographic Census, with 78.4% of the state's population presenting
Fitzpatrick phototypes I to III.[7] Areas with this combination of ethnic characteristics and high sun exposure, such
as Brazil and Australia, have a higher incidence of skin cancer.[8]
As agriculture is the state's main economic activity, prolonged and cumulative sun
exposure affects a significant portion of the population. This chronic exposure, combined
with a predominant phototype, contributes to the increased incidence of skin cancer
in this population.[9] This aspect was evident in the present sample, which consisted of more than 95%
patients with fair skin.
The anatomical regions most affected by skin lesions were at the head and neck, with
a predominance of the nasal and auricular regions. Patients with tumors in these areas
frequently receive referrals to specialized plastic surgery centers, such as HCPA,
due to the complexity of the required reconstructions and the higher risk of scarring.[10] Lesions in the central face (“T” region: eyelids, nose, and lips) have a high potential
for functional and aesthetic impairment. This higher impairment occurs because small
tissue losses in these structures can have a significant impact on the patients' quality
of life.[11] The Mohs micrographic surgery has a wide indication for treating the T region.[12] However, it was not addressed in this study because it was not performed during
the period analyzed.
Regarding reconstructive techniques, the most frequent approach was primary closure.
We used more skin flaps (25.4%) than grafts (17.8%), mainly because they provide better
functional and aesthetic outcomes in the head and neck region.[13] However, this choice requires even greater rigor in obtaining free surgical margins
due to the lower availability of donor areas. Additionally, the need for reoperations
may compromise future reconstructive options.
Most cases referred to the Plastic Surgery Service at HCPA were suspected or confirmed
skin neoplasms, accounting for approximately 75% of the cases analyzed. The remaining
sample consisted of miscellaneous etiologies, including those with benign or undetermined
origin or uncertain surgical requirements. Referral often resulted from diagnostic
doubts or concerns about potential functional and aesthetic complications resulting
from excision and scarring. The HCPA's Plastic Surgery Service also manages other
conditions, such as congenital malformations, trauma, and acquired deformities.
However, it is crucial to treat injuries of lower complexity at the primary and secondary
levels of healthcare, preserving HCPA's role as a tertiary referral center. The shortage
of specialized professionals in smaller institutions, exacerbated by economic and
political crises, contributes to the overload of tertiary centers.
As a strategy to mitigate this demand, a partnership between the head of the Plastic
Surgery Service at HCPA and the Municipal Government of Porto Alegre enables the treatment
of injuries of lower complexity in a secondary-level outpatient surgical center, at
the Health Center of Instituto de Aposentadorias e Pensões dos Industriários (IAPI).
Healthcare systems operate across prevention, treatment, and rehabilitation. The priority
at HCPA's Plastic Surgery Service is the treatment and rehabilitation of patients
with neoplasms, requiring surgeons trained in several types of reconstruction. The
department employs professionals skilled in craniomaxillofacial surgery and reconstructive
microsurgery. Furthermore, the service is multidisciplinary, including dental professionals
with expertise in anaplastology, as well as speech therapists, nutritionists, nurses
specializing in wound care, physical therapists, and psychologists specializing in
rehabilitation.
Conclusion
Most patients with skin lesions treated by HCPA's Plastic Surgery Service , a tertiary
and specialized center, were elderly subjects, predominantly over 60-years-old, from
the Porto Alegre Metropolitan mesoregion. Most lesions were on the face, predominantly
in the nasal and auricular regions.
In this reference service, a significant portion of the cases presented compromised
margins, requiring surgical reinterventions with enlarged resections, often involving
bone and cartilaginous structures.
Such cases often require a multidisciplinary approach with other surgical specialties,
such as Head and Neck Surgery, Ophthalmology, and Neurosurgery, highlighting the complexity
of management in a specialized tertiary service.
Bibliographical Record
Ciro Paz Portinho, Gabriel Pereira Bernd, Rodrigo Vieira Pereira, Leonardo Priesnitz
Friedrich, Alice Fischer-Morello, Daniele Walter Duarte, Antônio Carlos Pinto Oliveira,
Marcus Vinicius Martins Collares. Epidemiologia dos pacientes com lesões cutâneas
tratados em um hospital público terciário. Revista Brasileira de Cirurgia Plástica
(RBCP) – Brazilian Journal of Plastic Surgery 2025; 40: s00451812472.
DOI: 10.1055/s-0045-1812472
