Skin Cancer

In our world, this suture job is unacceptable. The sutures are too big. The edges are rolled in. The patient was told to return in ten days at which time the suture tracts will epithelialize resulting in Frankenstein railroad tracts.

SECRET: Insurance companies will pay the exact same amount for a skin cancer to be removed by a highly skilled plastic surgeon, as they will for a dermatologist, nurse, or technician! There is no dermatologist, nurse, or technician on the planet with the skills of a board certified plastic surgeon with five years of surgical training and reconstructive plastic surgery residency. In my humble opinion. 🤔🤫

MOHS PROCEDURE NOSE FROM HELL

Why I became expert in MOHS

A dermatologist in Miami trained by Mohs himself, asked if I would close a patient that lived locally. Sure.

At 3 pm a male arrived with a full thickness loss of his right nose! My first introduction to MOHS procedure before modern H & E stains were used. I was now faced with having to provide an inner lining for the nose, an outer skin, and a cartilage support for the nostril rim! Thinking on your feet is the exciting part of trauma and reconstructive surgery. The problem was defined, now the solution.

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First a nasolabial flap was elevated. Normally these are rotated around to cover the skin side of a defect and are very reliable. But this one had to be rotated on its blood supply, which is risky business. The skin end was sutured to the mucosa of the nose with absorbable sutures, and the flap was flipped over, trimmed and sutured circumferentially inside. The nasolabial donor site was then sutured closed potentially putting more pressure on the twisted blood supply.

Now we needed a composite graft from the ear (skin and cartilage) to mimmic and support the nostril rim. The anterior helix of the ear was perfect. Composite grafts, due to their thickness are risky business even on a well vascularized surface. But on the back of a flap with a twisted blood supply, is really rolling the dice! 🙄🙄

A few days later there was some impending necrosis of the upper graft but then it revascularized and completely healed with a reasonable result. ” It is better to be lucky than to be good”.

I was curious and reviewed the slides. The cancer was only on the outside of the cartilage! The was no reason to cut all the way through the nose for a basal cell. I realized, dermatologists do not understand the principles of reconstructive surgery. If you have a cancer on the forearm, cutting the arm off at the elbow guarantees a cure. But plastic surgeons think, ‘ I can save the arm with a well planned excision of the lesion itself ‘. So I became an expert MOHS surgeon.

BASIC PRINCIPLES AND ENGINEERING

Every injury or lesion is different. There are hundreds of variations that have to be mastered to plan and customize an excision and repair. On the spot improvisation is the name of the game.

LIPOMA MONSTER

My facelift patient came in with a scar down the side of her arm with Frankenstein railroad tracts. I asked if she broke her arm and had surgery. “No”, she said, “I had a lipoma removed by a general surgeon in the next town.” I could not believe the butcher job and I knew the surgeon was married to a plastic surgeon to make matters worse. The incentive for monster scars is that insurance pays by the length of the wound! I called him and said impolite things.

I then decided to find a better way.

CAN YOU SPOT MY FLAP?

This is a very challenging basal cell carcinoma impinging on the medial canthus and tear duct. A lower lid and cheek rotation flap was engineered without distorting or altering the function of the lower lid. Quite a fun adventure. Can you see the flap? Not to worry, neither can I. 🧐 🕵️‍♀️ 🔍