
 basal cell carcinoma ( bcc ) is the most common type of skin cancer in the head and neck region .
the incidence of bcc is on the rise , and it represents approximately 65% of all skin carcinomas [ 13 ] .
bcc is not usually life threatening , unlike malignant melanoma , but it is locally invasive and may lead to considerable morbidity and complications .
bcc is the most frequent tumor type among the us population and also has a strongly rising incidence in europe .
although , the incidence of bcc in turkey is not accurately known , we think that there is a rise in the number of patients who are admitted to medical facilities . with the increase in the incidence of bcc , even though mortality is relatively low , the morbidity and treatment - related costs represent a significant burden to health care systems .
recurrence is more common , especially with positive peripheral margins and certain types of bcc , like morpheaform forms .
positive surgical margins in primary bcc excisions in the head and neck region were reported to be 320% in the literature .
recurrence rates in incompletely excised patients were also reported at 2667% . in our study , we present a case with a series of 320 patients with 331 bccs , involving the head and neck region , and who were treated with complete surgical excision .
the aim of this paper is to describe the clinical , histopathological , and epidemiological features of completely excised bcc and also to evaluate clinical features of the recurrent cases with previous histologically clear margins in the head and neck region .
we performed a retrospective review of the database of our institution , ataturk training and research hospital , which has a wide acceptance of patients from the capital city ankara and surrounding cities .
all patients between january 2008 and january 2013 with head and neck bccs were evaluated . only completely excised primary cases with histopathologically confirmed bccs were included in this study .
all 331 lesions of 320 patients were categorized with regard to age , sex , personal and family history , skin type , tumor location , size , clinical and histopathological subtypes , reconstruction method , and recurrence rates . in order to achieve a systematic analysis of the collected data ,
the head and neck region were divided into the following 8 subunits : scalp , frontotemporal , orbital , nose , cheek , auricula , perioral , and chin - neck area .
the diagnosis of bcc was clinically undertaken first , but , in some cases when the clinical diagnose was not clear , the dermatologist performed a pretreatment biopsy .
excision margins were planned , depending on the clinical features , size , and location of the lesion .
with loupe ( 5 ) magnification , the excision margin was marked in the dermatology department .
while the 3  mm safe margin excision was used in small and well - defined lesions , where up to 10  mm safe margins were chosen for large tumors and unclear borders , deep margins were systematically located in the subcutaneous tissue or were more deeply situated , according to the tissue characteristics of the region .
incomplete excision was defined as a residual tumor at , or within , 1  mm of the lateral or deep incision margins .
all incompletely excised lesions , whether or not they were reexcised , were excluded from the study .
all excision materials underwent routine histopathological examination by the pathology department and were all confirmed as bcc .
methods of reconstruction were primary closure , skin grafts , and local and distant flaps .
routine outpatient controls were planned as postoperative one week , one month , three months , six months , and one year .
statistical analysis was performed using spss 16.0 software ( chicago , il , usa ) .
nonnormally distributed continuous variables were expressed as median , and categorical variables were expressed as numbers and percentages .
mann - whitney u test was used in comparison with the continuous variables , while the chi - square test was used in comparison with the categorical variables .
a sample of 320 patients , presenting 331 histopathologically confirmed bcc of the head and neck , were identified in the retrospective review .
there were 176 ( 55% ) men and 144 ( 45% ) women . in the whole head and neck region , there was no statistically significant difference between the male and female population .
when the subunits were evaluated , scalp , frontotemporal , and auricular regions presented male predominance , while the perioral region presented female predominance ( p < 0.05 ) .
tumors were rare below the age of 20 , with only one case in the present study who revealed no history of an underlying disease such as nevoid bcc syndrome or xeroderma pigmentosum .
higher prevalence of patients ( 34.7% ) was noted in the 6070 age group which was found to be statistically significant ( p < 0.05 ) .
the personal history of chronic sun exposure which is defined by spending every working day in open areas due to occupational reasons was reported in 199 ( 62.2% ) cases .
none of the patients had a predisposing disease such as gorlin 's syndrome or xeroderma pigmentosum .
one hundred and twenty patients ( 37.5% ) were smokers for more than ten years .
the fitzpatrick classifications of the patients were type 1 in 9 ( 2.8% ) patients , type 2 in 129 ( 40.3% ) patients , type 3 in 165 ( 51.6% ) patients , and type 4 in 17 ( 5.3% ) patients , respectively .
there was no significant difference in the lesions that was related to a patient 's skin type , in regard to subunits ( table 1 ) .
tumors most commonly occurred on the nose , with 107 ( 32.3% ) , followed by the orbital at 63 ( 19.1% ) , cheek 60 ( 18.1% ) , frontotemporal 42 ( 12.7% ) , auricular 23 ( 6.9% ) , scalp 21 ( 6.4% ) , perioral 9 ( 2.7% ) , and the chin - neck 6 ( 1.8% ) regions .
the size of the tumors was analyzed in 3 groups ; 185 ( 55.9% ) tumors were smaller than 10  mm in diameter , 143 ( 43.2% ) were between 10  mm and 30  mm , and 3 ( 0.9% ) were larger than 30  mm . in the nose and cheek regions the lesions were under 10  mm and in scalp region lesions between 10 and 30  mm were higher in number ( p < 0.05 ) .
reports of clinical evaluation showed that all of the examined primary bccs were of the nodular type and were either ulcerated or pigmented . with confirmation to histopathological analyses , 46 ( 13.8% ) were of the mixed type ( nodular + micronodular ) ; 39 ( 11.7% ) were of the micronodular type ; 37 ( 11.2% ) were of the superficial type ; 31 ( 9.3% ) were of the basosquamous type ; 23 ( 6.9% ) were of the adenoid type ; 14 ( 4.2% ) were of the sclerotic type of bcc .
the rest of the lesions 141 ( 42.6% ) were reported as being of the nodular type . regarding the distribution of histopathologic patterns , no statistically significant difference was found in the entire head and neck region . in the scalp , frontotemporal , nose , and cheek regions ,
two hundred and ninety - four excisions ( 88.9% ) were undertaken under local anesthesia ; 37 ( 11.1% ) were done under general anesthesia .
the reconstruction method regarding the size of the defect was comprised of primary closure 84 ( 25.4% ) , full thickness skin grafting 54 ( 16.3% ) , and local flaps 192 ( 58% ) .
one defect ( 0.3% ) was reconstructed with the radial forearm free flap procedure ( table 2 ) .
recurrent lesions were in the scalp ( n = 3 ) , orbital ( n = 2 ) , and nose ( n = 4 ) regions .
the histopathological subtypes of these tumors were sclerotic ( n = 4 ) , micronodular ( n = 3 ) , mixed ( n = 1 ) , and nodular ( n = 1 ) .
bcc is the most common type of skin cancer in caucasians , which predominantly occurs on the exposed parts of the body , with 7585% of the lesions found in the head and neck regions [ 1 , 2 , 69 ] . according to our findings
, more than half of the lesions are found in the nose ( 32.3% ) , orbital ( 19.1% ) , and cheek ( 18.1% ) areas which are the most central and prominent parts of the entire head and neck region .
these regions are also more prone to chronic sunlight exposure [ 2 , 5 , 10 , 11 ] .
most of the bcc lesions are reported in the 4079 age group , with the mean age of 62 . in tropical regions and in patients with family history ,
we have had a statistically significant increase in the 6070 age group ( 34.7% ) , in all the head and neck regions .
but in other mediterranean countries , the predominance is in the 7080 age bracket [ 8 , 1315 ] . regarding the patient 's age and the location of the lesions , no significant difference was found .
this can be explained with the siesta culture in these countries , which prevents their population from rush - hour sun exposure .
men generally have up to 2 times higher rate of bcc [ 9 , 10 , 16 ] . in our study ,
when the whole head and neck region is encountered , there was no statistically significant difference between men ( 55% ) and women ( 45% ) that was consistent with other studies [ 10 , 13 , 17 ] .
most of our patients are from central anatolia , where the population is generally comprised of men and women who both work during the daytime as farmers .
when the subunits were evaluated , scalp , frontotemporal , and auricular lesions are more common in men , which can be explained by androgenic alopecia or short hair on men , when compared to the long hair or kerchief worn by women .
perioral lesions are found less in men , especially on the upper lip , which can be contributed to moustache on men .
phenotypic characteristics , such as fair skin type , red hair , and freckling are risk factors for bcc [ 9 , 19 ] .
most of our patients were of type 2 ( 39.4% ) and type 3 ( 51.6% ) , regarding the fitzpatrick classification .
when the subunits were encountered , there was no significant difference in the lesions based on the patients ' skin type .
most of the lesions were found to be less than 10  mm in size ( 55.9% ) , when the whole head and neck region was evaluated .
this might be related to the recent increase in the public cognition of health issues and admission numbers at health facilities in turkey .
the ratio of tumors less than 10  mm was found to be higher in cosmetically more recognized regions , such as the nose and cheek ( 65.4% and 68.3% , resp . ) .
although a universally accepted classification scheme is lacking , commonly accepted clinical types are nodular , superficial , fibroepitelial , and morpheaform [ 9 , 12 ] .
there are also histopathologic patterns , such as nodular , micronodular , adenoid , superficial , and sclerotic , which are referred to as subtypes of clinical type of nodular bcc [ 9 , 20 ] .
all of our patients were clinically evaluated as the nodular type bcc ; histopathologically most of the lesions were nodular ( 42.2% ) . in the scalp , frontotemporal , nose , and cheek regions ,
the main goal of the bcc treatment is to eradicate the tumor with the safest and most cost - effective method available and to provide an aesthetically and functionally pleasant outcome .
even though different treatment modalities for bcc have been described , surgical excision is the most commonly preferred method for tumor removal . in the literature , the 3 
mm peripheral surgical margin is adequate for the clearance of 85% of small and well - defined bccs , and the 4 - 5  mm margin will raise this to 95% .
it has been shown that loupe magnification can assist in reducing incomplete excision rates [ 2022 ] . in our practice , with loupe magnification ,
the 3 to 10  mm excision margin was used , depending on the clinical features , size , and location of the lesion .
it has been shown that the recurrence rate for primary bccs after surgical excision varies between 5% and 14% [ 1 , 5 ] .
lesions in the head and neck region are at more risk for recurrence , when compared to lesions in trunk and extremities [ 1 , 5 , 7 , 23 ] .
even though some factors , like anatomical localization , histopathological characteristics , and initial treatment strategy , have been proposed , there is lack of accepted understanding in the recurrence of the lesions .
incomplete excision was reported as one of the risk factors for recurrence [ 6 , 10 , 20 , 24 ] .
the main difference of our study when compared with the previous studies is the precise evaluation of the factors effective on recurrence in completely excised bccs . in our series ,
recurrent lesions were in the scalp ( n = 3 ) , orbital ( n = 2 ) , and nose ( n = 4 ) regions .
interestingly , all recurrences were in the median parts of head and neck region ; this may be attributed to high recurrence rates in embryonic fusion planes [ 9 , 2527 ] .
histopathological subtype of recurrent tumors was mainly micronodular and sclerotic , which is more difficult to eradicate and has high risk of recurrence .
our study revealed that recurrence is related to the localization and histopathologic subtype , whereas they were not related to age , sex , and size of the lesion .
the low recurrence rates in our series might be due to the relatively low rates of histopathologically aggressive subtypes , excision with appropriate margin , and no positive surgical margins after surgery .
in conclusion , this study presents a relatively large number of series of surgically treated bccs in the head and neck region .
we would like to emphasize the importance of the preoperative evaluation of the patient keeping the epidemiology in mind , defining the surgical margins in order to get lower recurrence rates , and by motivating the patient for follow - up visits , in order to evaluate outcomes and diagnose recurrences .
 the aim of the study is to analyze all completely excised bccs in the head and neck region with regard to age , sex , personal and familial history , skin type , tumor localization and size , histopathological subtype of tumor , reconstruction method , and recurrence rates . 
 incompletely excised bccs were not included in this study since incomplete excision is the most important preventable risk factor for recurrence . in 320 patients , 
 331 lesions were retrospectively evaluated by dividing into the following 8 subunits : scalp , frontotemporal , orbital , nose , cheek , auricula , perioral , and chin - neck area . 
 most of the patients were in 6070 age group ( 34.7% ) . 
 the nose ( 32.3% ) was the most common site of presentation . 
 clinically , all lesions and , histopathologically , most of the lesions ( 42.2% ) presented were of the nodular type . 
 all cases of recurrence after complete excision ( n = 9 , 2.7% ) were located in the median parts of the head and neck region and were mainly diagnosed histopathologically as sclerotic and micronodular . 
 even though completely excised , head and neck region bccs , especially which are more prone to recurrence due to anatomical and histopathological properties , should be more closely monitored in order to decrease morbidity and health care costs . 
1. Introduction 
2. Material and Methods
3. Results
4. Discussion
5. Conclusion