Introduction

Skin cancer is the most common neoplasm in Brazil¹ 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.³The 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 nonmelanoma 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 - Geographical distribution of patients referred to the Plastic Surgery Service of Hospital de Clínicas de Porto Alegre with skin lesions

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 - Diagnoses of patients with skin lesions referred to the Plastic Surgery Service of Hospital de Clínicas de Porto Alegre

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. 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 3 - Distribution of skin lesions by anatomical subregion

Table 4 - Distribution of surgical procedures performed at the Plastic Surgery Service of Hospital de Clínicas de Porto Alegre from January 3, 2022 to July 3, 2023

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 secondarylevel 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.