VIENNA For skin cancers on the nose, Mohs micrographic surgery is associated with low recurrence rates and spares a maximal amount of healthy tissue, Abel R. González, M.D., reported at the 10th World Congress on Cancers of the Skin.
"Some patients just want a healed wound, but others have a high aesthetic standard," said Dr. González of the Institute of Oncology Angel H. Roffo at the University of Buenos Aires. "They wish a nose restored to normal, no matter how much time or effort it takes" to accomplish the results.
Of the 2,648 Mohs surgeries performed between 1990 and 2004 at the Institute, 780 (29%) tumors were located on the nose. A review of 758 cases shows 322 (42%) of cases were managed with secondary-intention healing, 306 (40%) with flaps, 111 (15%) with grafts, and 19 (2%) with primary closure.
Secondary-intention healing is simple, complications are rare, and it saves time and cost associated with reconstruction, Dr. González said, at the meeting cosponsored by the Skin Cancer Foundation.
For procedures that require nasal reconstruction, skin quality is an important variable.
The upper two-thirds of the nose and the columella are covered by thin, nonsebaceous and slightly mobile skin. Here, local flaps rotate easily and are a good choice for small defects. Grafts blend well into the smooth and shiny surfaces of the dorsum and sidewalls, Dr. González said.
On the tip or ala, the skin is sebaceous and adherent to underlying tissues. Single lobe flaps rotate poorly, but bilobed or nasolabial flaps can overcome these problems. Grafts are a poor choice as they create a patch of shiny skin in the thick, pitted skin of the area, he said.
For superficial defects, a full-thickness skin graft can be performed. When using grafts, the preference is for delayed, full-thickness skin grafts because bleeding or exudation diminishes when a graft is delayed rather than performed immediately. This also results in a well-vascularized bed, which increases graft survival.
When bone or cartilage is exposed, a flap will be necessary.
When nasal support is missing, and a framework needs to be restored, a distant flap will prevent tension that could distort cartilage reconstruction. A distant flap also is needed when repairing defects larger than 1.5 cm.
Incisions placed strategically in the joins that separate the subunits of the nosethe tip, ala, paired sidewalls, dorsum, soft triangles, and columellawill be perceived as a normal fold or contour line.
If more than 50% of a subunit is lost, the guiding principle is that replacing the entire unit usually gives a better result than just patching the defect.
The forehead flap is an excellent option in nasal reconstruction because the forehead skin matches nasal skin almost exactly and has superb perfusion. The forehead flap should always be vertically oriented because of perfusion, and narrow, paramedian flaps allow easier rotation. It should never reconstruct the cheek.
The final defect after five stages of Mohs surgery is shown.
Photos courtesy Dr. Abel R. González