Mohs and Plastic Surgery for Basal Cell Carcinoma on the Right Tip of Nose*

Procedure Details

This 59 year old female was referred to our office by her dermatologist. The patient states that she had the lesion for 9 months and during that time she had failed other treatments including cryotherapy (freezing with liquid nitrogen) twice and had also failed treatment with Aldara (imiquimod). Biopsy by her dermatologist revealed basal cell carcinoma. Mohs surgery and Plastic Reconstructive Surgery were performed. A forehead flap was recommended for reconstruction. This recommendation was discussed with the patient and family as it requires intensive bandaging over the next several weeks and a follow up surgery to divide and inset the flap. This D & I was performed six weeks after the initial reconstruction. A revision was also performed to perfect her scars and with time, the redness from the surgeries subsided and the patient is happy with her results.
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Forehead Flaps

There are many different options for reconstruction of the nose.  Plastic Surgery is a unique specialty becuase there are a multitude of ways different problems might be addressed, whether cosmetic or cancer related. Training as a plastic surgeon is heavily focused on:

#1 Comprehensive Analysis - whether cancer or cosmetic

#2 Preoperative Planning - selection of optimal procedures

#3 Surgical Precision - exercising technical excellence

Plastic surgeons have many reconstructive options at their disposal, but should strive to perform the simplest and saftest procedure that will give the best results.  Unfortunately, in this patient a simple procedure, such as simply pulling the hole together, would yield a terrible result.  With such a large hole, it is necessary to bring in extra skin from another area.  The forehead flap remains the gold standard for repair of large nasal defects becase of the reliable healing and excellent skin match.  The long-term results are usually excellent when performed and revised appropriately.  Unfortunately, the forehead flap is a difficult process for patients to undergo because they require significant aftercare by the patient during the healing process.  Also, the temporary results are unsightly becuase a bridge of skin connects the forehead to the nose and remains that way for 3 to 6 weeks.  Additionally, the forehead flap requires at least two or three procedures to achieve the final result.  For these reasons, many other options are considered such as "skin grafts" and other local "skin flaps" such as bilobe flaps, nasolabial flaps, and dorsal nasal flaps.  Skin grafts are able to cover large areas, but often provide a poor skin match when they are a different color, texture and thickness.  Skin grafts also heal slower, are less reliable, and are problematic for holes over exposed nose cartilage.  Despite these drawbacks, there are times when skin grafts are the best choice.  Local "skin flaps" provide a much better skin match, but are limited by the size of the defect.  The work extremely well for appropriately sized holes, but an undersized flap attempting to fill an oversized defect can cause significant distortion of the shape of the nose.  In this case, the forehead flap provided ample skin, an excellent skin match, and reliable healing which made it the optimal choice for repair.

 

To read and learn more about the forehead flap procedure, go to the following:

Correa, B. J., Weathers, W. M., Wolfswinkel, E. M., & Thornton, J. F. (2013). The Forehead Flap: The Gold Standard of Nasal Soft Tissue Reconstruction. Seminars in Plastic Surgery27(2), 96–103. http://doi.org/10.1055/s-0033-1351231

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743909/

Location

Skin Cancer Consultants

*All information subject to change. Images may contain models. Individual results are not guaranteed and may vary.