When performing IMRT treatment planning for head and neck cancer, how do you instruct your dosimetrists to manage the optimization process for targets that are very close to the skin surface (or with PTVs that extend into air), yet the skin itself is not at risk?

We use method #2 described - creating a faux bolus in the planning system without changing the 3mm PTV expansion on CTV. If in the re-calculation process the dose is not adequate to gross disease under the skin or at the anterior commisure, physical bolus may be applied. In reality, we rarely use ph...