Mohs and Plastic Surgery for Squamous Cell Carcinoma in Situ on Nasal Tip*

This patient had a squamous cell carcinoma in situ (Bowen's disease) on her nasal tip. Mohs surgery was performed to remove the lesion. Although the clinical (visible) size was only 0.5 cm x 0.4 cm the cancer was larger than it appeared, requiring 3 stages of Mohs surgery, with a final wound size of 1.6 cm x 1.5 cm. Reconstruction involved plastic surgery with use of a trilobe flap to close the defect without distorting the shape of the nose. To improve the quality of her scar, both dermabrasion and injection of steroid were performed to further smooth her scar. She has an excellent result. Her nose appear appears pink compared to her preoperative photo. This is due to preexisting rosacea (an increase in blood vessels under the skin, causing a pink/red complexion). Rosacea is a progressive condition that increases as we age, but the intensity of rosacea may increase after surgery. With time the rosacea often fades after surgery, but on occasion it persists. Thankfully, there are some common treatments for rosacea, such as photofacial (BBL/IPL) treatments, topical gel, and oral treatments. More

There are many options that could have been used to fill this defect (hole). It could have been allowed to heal on its own. However, the result would often be an indented and shiny white scar. A skin graft could have been used, taking skin from another part of the body in order to patch the hole. Unfortunately, skin grafts heal less predictably, often appearing as a patch...sometimes a different color, texture, or thickness than the surrounding skin. Instead, we utilized a skin flap (aka adjacent tissue transfer) to close this hole. Skin flaps typically shift skin from areas with extra/redundant skin to the area of skin shortage. While a skin graft completely disconnects the skin from the body, a skin flap maintains an established connection in order to maintain healthy blood flow and promote quicker and more predictable healing. There are many different types of flaps with varying complexity. There are several different options that could have been used in this case. This particular flap is called a trilobe flap, because the design utilizes three lobes to transpose redundant skin (from the loose upper nose) down to the nasal tip (where skin is very thick and inflexible). The downside of a flap is that it usually requires additional cutting and stitching in the area. However, a flap often yield superior results because you are filling the hole with similar skin. Proper design is very important to avoid a distorted shape. More