BASIC/CLINICAL SCIENCE
Facial Reconstruction Following Mohs Micrographic Surgery: A Report of 622 Cases Eline C. Grosfeld, Jeroen M. Smit, Gertruud A. Krekels, Julien H.A. van Rappard, and Maarten M. Hoogbergen
B a c k g ro u n d : A r o u n d
100
to
200
p a tie n ts
u n d e rg o
s u r g ic a l
r e c o n s tr u c tio n
e v e ry
year
at
our
d e p a rtm e n t
of
p la s t ic
and
r e c o n s t r u c t i v e s u r g e r y a f t e r M o h s m i c r o g r a p h ic s u r g e r y f o r n o n m e la n o m a s k in c a n c e r .
O b je c tiv e : T h e a im o f t h i s r e p o r t is t o p r o v id e a n o v e r v i e w o f t h e t y p e o f f a c ia l r e c o n s t r u c t i o n s p e r f o r m e d a n d in v e s t ig a t e w h e th e r w e
a c h ie v e d
in c r e a s e d , d e f i n i t i v e c lo s u r e r a t e s o f t h e
d e fe c t o n th e
d a y o f th e
e x c is io n a f t e r f u r t h e r im p r o v i n g
th e
c o l l a b o r a t i o n b e t w e e n t h e i n v o lv e d d e p a r t m e n t s .
M e th o d s : A ll p a t i e n t s w h o u n d e r w e n t f a c ia l r e c o n s t r u c t i o n a t t h e D e p a r t m e n t o f P la s tic a n d R e c o n s t r u c t iv e S u r g e r y f o l l o w i n g M o h s m i c r o g r a p h ic s u r g e r y b e t w e e n J a n u a r y 2 0 0 6 a n d J a n u a r y 2 0 1 1 w e r e r e t r o s p e c t i v e l y s y s t e m a t ic a lly r e v ie w e d .
R e su lts: A t o t a l o f 5 6 4 p a t i e n t s w i t h 6 2 2 d e f e c t s w e r e i d e n t if ie d . T h e d if f e r e n t r e c o n s t r u c t i o n s u s e d p e r a e s t h e t ic u n i t a re d e s c r ib e d . T h e n u m b e r o f c a s e s in w h i c h a r e c o n s t r u c t i o n w a s p e r f o r m e d o n t h e s a m e d a y a s t h e r e s e c t io n s i g n i f i c a n t l y in c r e a s e d f r o m 31 t o 8 1 % ( p < .0 0 1 ).
C o n c lu s io n : F a c ia l r e c o n s t r u c t i o n f o l l o w i n g M o h s m ic r o g r a p h ic s u r g e r y is c h a lle n g in g . T h e t y p e o f r e c o n s t r u c t i o n u s e d d e p e n d s o n t h e t y p e o f d e f e c t a n d p a t i e n t c h a r a c t e r is t ic s . A s t r u c t u r e d m u l t i d i s c i p l i n a r y a p p r o a c h im p r o v e s t h e p r o c e s s f r o m
d e fe c t to
r e c o n s t r u c t i o n a n d c a n f a c i l i t a t e r e f e r r a ls .
C o n te x te : C h a q u e a n n e e , d e 1 0 0 a 2 0 0 p a t ie n t s s u b is s e n t u n e r e c o n s t r u c t i o n a u s e r v ic e d e c h i r u r g i e p la s t iq u e e t r e c o n s t r u c t i v e d e I 'e t a b lis s e m e n t a p r e s u n e c h i r u r g i e m i c r o g r a p h iq u e d e M o h s p o u r u n c a n c e r d e la p e a u n o n m e la n iq u e .
O b je c tifs : L e r a p p o r t v i s a i t a d o n n e r u n e v u e d 'e n s e m b le d e s d i f f e r e n t s t y p e s d e r e c o n s t r u c t i o n f a c ia le e t a v e r i f i e r s i le t a u x d e f e r m e t u r e d e f i n i t i v e d e s p e r t e s d e s u b s t a n c e p r a t iq u e e le j o u r m e m e d e I'e x e r e s e a v a it a u g m e n t e a p r e s u n e c o lla b o r a t io n a c c r u e e n t r e le s s e r v ic e s c o n c e r n e s .
M e th o d e : II y a e u u n e c o lle c te m e t h o d iq u e e t r e t r o s p e c tiv e d e d o n n e e s s u r t o u s le s p a t ie n t s q u i a v a ie n t s u b i u n e r e c o n s t r u c tio n d e la fa c e a u s e rv ic e d e c h ir u r g ie p la s t iq u e e t r e c o n s t r u c tiv e a p re s u n e c h ir u r g ie m ic r o g r a p h iq u e d e M o h s , e n tr e ja n v ie r 2 0 0 6 e t ja n v ie r 2 0 1 1 .
R e s u lta ts : A u t o t a l , 5 6 4 p a t i e n t s c o m p t a n t 6 2 2 p e r t e s d e s u b s t a n c e o n t e te r e c e n s e s . L 'a r t ic le f a i t e t a t d e s d i f f e r e n t s t y p e s d e r e c o n s t r u c t i o n e f f e c tu e s p a r z o n e e s t h e t iq u e . L e n o m b r e d e c a s d e r e c o n s t r u c t i o n p r a t iq u e e le j o u r m e m e d e I'e x e r e s e a a u g m e n t e s e n s ib le m e n t ; e n e f f e t , c e lu i- c i e s t p a s s e d e 31 a 8 1 % ( p < .0 0 1 ).
C o n clu s io n s : L a r e c o n s t r u c t i o n d e la fa c e a p r e s u n e c h i r u r g i e m i c r o g r a p h iq u e d e M o h s e s t u n e in t e r v e n t i o n e x ig e a n t e . L e t y p e d e r e c o n s tr u c tio n
depend
du
ty p e
de
p e rte
de
s u b s ta n c e
e t des
c a r a c t e r is t iq u e s
des
p a t ie n t s .
Une
o r g a n is a t io n
s tru c tu re e
et
p l u r i d i s c i p l i n a i r e a m e li o r e le p r o c e s s u s d e p u i s la p e r t e d e s u b s t a n c e j u s q u 'a la r e c o n s t r u c t i o n , e t p e u t f a c i l i t e r le s r e c o m m a n d a t io n s .
O MEET THE CHALLENGE of radical excision of basal cell carcinoma (BCC) with the smallest possible defect, Mohs microscopic surgery was developed. 1 In Mohs micrographic surgery, complete surgical margins are examined in horizontal sections, whereas after regular From the Departments o f Plastic and Reconstructive Surgery and Dermatology, Catharina Hospital, Eindhoven, the Netherlands. Address reprint requests to: Jeroen M. Smit, MD, PhD, Department o f Plastic and Reconstructive Surgery, Catharina Ziekenhuis, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands; e-mail: [email protected].
DOI 10.2310/7750.2013.13188 © 2014 Canadian Dermatology Association
surgical excision, only a fraction of the surgical margins are examined in a number of vertical slices.2 Nowadays, Mohs micrographic surgery is the recommended treatment for recurrent BCCs in the H area of the face, for large primary facial BCCs, or for facial BCCs with more aggressive growth patterns.3 One of the challenges after Mohs micrographic surgery is the closure of the defect while maintaining an acceptable aesthetic outcome. A variety of techniques have been reported depending on the location and size of the defect.4 The choice of a specific technique may not always be straightforward and depends on, among others, the type of defect, patient characteristics, and surgeon’s preference.
DECKER^ rfry Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
265
Grosfeld et al
At the Catharina Hospital, Eindhoven, the Netherlands, 100 to 200 patients a year are referred to the Department of Plastic and Reconstructive Surgery for facial reconstruction following Mohs microscopic surgery at the Department of Dermatology. In 2006, the collaboration between these departments was intensified for the reconstruction of defects following Mohs micrographic surgery. One of the goals was to increase the number of defects reconstructed on the same day as the excision. The aim of this report is to provide an overview of the types of reconstruction performed during the first 5 years of this extended collaboration and to investigate whether we achieved increased closure rates on the same day as the excision.
Table 1. Units Scored and Subunits Involved
M ethods
Periauricular region
Study Design
Units Nasal region
Periorbital region Cheek region
Forehead region
Perioral region
All patients who underwent facial reconstruction at the Department of Plastic and Reconstructive Surgery follow ing Mohs micrographic surgery between January 2006 and January 2011 were reviewed. Age, comorbidities, nicotine abuse, location of the defect, number of aesthetic subunits involved, size and depth of the defect, number of Mohs excisions, type of reconstruction, amount of reconstructive techniques used to reconstruct the defect, date of surgery, surgeon, anesthetic method, amount of secondary correc tions, complications, and outcome of all patients were collected in a database and were made available for analysis. The approval of the medical ethical commission of the Catharina Hospital was received for this study. Data Assessment All defects were mapped according to the aesthetic subunits of the face.3 The retroauricular region was also included as a subunit. For analysis purposes, the different subunits were merged into units (Table 1). The depth of the defect was rated as follows: subcutis only, muscle involvement, periostal or perichondrial involvement, bone or chondrial involvement, or full-thickness defect (eg, in nasal and ear defects). The type of reconstruction was scored as primary closure, skin graft: (either full thickness or split skin), local flap (eg, rhomboid flap), regional flap (eg, paramedian forehead flap), and free flap. Local flaps were, when possible, further specified. Reconstructions in which the local flap was not specified (eg, a general advancement or extensive undermining) were scored as transposition not further specified (nfs). If a reconstruction consisted of multiple flaps and/or grafts, these were scored individually.
Subunits Nasal sidewalls Dorsum Alae Domes Columella Periorbital subunit Brow Infraorbital subunit Zygomatic subunit Mandibular subunit Forehead Temple Scalp Ear Retroauricular area Upper lip Lower lip
A complication was classified according to the guidelines of the Dutch Association of Plastic Surgery (bleeding, infection, necrosis, wound dehiscence, lesser outcome than expected, or a combination of these).6 The chi-square test was used to statistically compare the percentage of patients reconstructed on the same day as the tum or excision. A multivariate linear regression model was used to investigate a potential association between the year of surgery and the number of days between tum or excision and reconstruction while correct ing for the length, width, and depth of the defect and the number of subunits involved. Significance was set at p < .05. Statistical analysis was performed with the help of SPSS 17 (SPSS Inc, Chicago, IL).
Results Patient Characteristics A total of 564 patients with 622 defects were reviewed; 269 patients were men (47.7%) and 295 patients were women (52.3%). The mean age of the patients was 68.2 years (range 31-99 years). Most tum ors were prim ary tum ors, followed by recurrent tumors and nonradically excised tumors. A minimum of one and a maximum of seven aesthetic subunits were involved in the created defect. The most frequently involved location was the ala nasi (27.5%), followed by the periorbital subunit (18.3%), sidewalls of the nose (18.0%), infraorbital subunit (15.3%), nasal tip
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
Facial Reconstruction Following Mohs Surgery
(14.0%), dorsum nasi (9.8%), forehead (7.9%), upper lip white roll (7.6%), and temple region and ear (6.1%). The mean size of the defect was 58 mm in length (range 5-110 mm) and 46 mm in width (range 2-90 mm). Depth was mostly classified as subcutis only, followed by a full-thickness defect and bone involvement. Patient and tum or characteristics are outlined in Table 2.
periorbital area and nose, 20 the periorbital area and cheek, and 7 the periorbital area and forehead. In these defects, 80 local flaps were used, of which skin transposition nfs (n = 26), tarsoconjunctival flaps (n = 21), and glabella flaps (n = 19) were most frequently used. Thirty-four FTGs and one split-skin graft were used. Eleven defects in this area could be closed primarily.
Reconstruction of Defects Cheek Defects
Nasal Defects O f the 292 nasal defects, 240 affected the nose only, 30 the nose and cheek, 21 the nose and periorbital region, and 1 the nose and perioral region. The ala (n = 171) and the lateral sidewalls (rt = 112) were most frequently affected in nose-only defects. A total of 213 local flaps were used, of which bilobed flaps (n = 74), skin transposition nfs {n = 67), glabella flaps (n = 10), and rotation flaps (n = 9) were most frequently used. Eighty-five paramedian forehead flaps (Figure 1) and 22 full thickness skin grafts (FTGs) were used for reconstruction. When cartilage was missing, a composite graft was used, harvested from the auricular concha (n = 47).
Of the 110 defects involving the cheek, 43 affected the cheek only, 30 the cheek and nose, 20 the cheek and periorbital area, 15 the cheek and perioral area, 1 the cheek and forehead, and 1 the cheek and periauricular area. In this area, 70 local flaps were used, of which skin transposition nfs (n = 37) and rhomboid flaps (n = 13) were most frequently used. Twenty-one paramedian forehead flaps were used. Eighteen full-thickness skin grafts and two split-skin grafts were used for reconstruc tion. Fourteen defects in this area could be closed primarily.
Defects of the Forehead, Temple, and Scalp Region Defects in the Periorbital Region Of the 113 defects in the periorbital area, including the brow, 65 affected the periorbital area only, 21 the
Table 2. Patient and Tumor Characteristics Characteristic Gender Male Female Type of tumor Basal cell carcinoma Squamous cell carcinoma Lentigo maligna Other Tumor frequency Primary Recurrent Not radically excised Tumor depth Defects of the subcutis Defects involving the muscle Defects involving the periosteum or perichondrium Defects involving the bone Full-thickness defects
n (%)
269 (48) 295 (52) 583 9 2 28
(94) (1) (0.3) (5)
411 (69) 98 (17) 83 (14) 493 (80) 5 (1) 11 (2) 26 (4) 78 (13)
Of the 97 defects involving the forehead, temple, and scalp region, 89 affected this area only, 7 affected this area and the periorbital area, and 1 affected the above-mentioned area and the periauricular area. Forty-one local flaps were used, of which skin transposition nfs (n = 25) and rotation flaps (n = 6) were most frequently used. Seventeen FTGs and 12 splitskin grafts were used. In three cases, a free flap was used. Eighteen defects could be closed primarily; six defects were left to heal by secondary intention.
Defects in the Perioral Region In total, the perioral area, including the chin, was involved in 47 cases. In 31 cases, this affected the perioral area only; in 15 cases, the perioral area and the cheek; and in 1 case, the perioral area and the nose. In this area, 37 local flaps were used, of which skin transposition nfs (n = 21) was most frequent. Fifteen defects could be closed primarily. Four paramedian forehead flaps were used and in one case an FTG. O f the 16 combined defects, most defects were reconstructed by skin transposition (« = 7), paramedian forehead flaps (n = 4), and bilobed flaps (n = 3).
Canadian Dermatology Association I Journal o f Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
267
Grosfeld et al
Figure 1. Example of a nasal reconstruction with a paramedian forehead flap and conchal cartilage grafts. A shows the defect and B and C the result 18 months after the initial reconstruction. In this period, the conchal grafts were placed, the pedicle was divided, and the flap was thinned.
Periauricular Defects Of the 42 defects involving the periauricular area, including the retroauricular area, 41 affected the periauricular area only and 1 affected the periauricular area and the cheek. Twenty-three local flaps were used, of which skin transposition nfs (n = 17) and chondrocutaneous flaps (n = 5) were most frequently used. Fifteen FTGs and three split-skin grafts were used for reconstruction. Two defects were closed primarily.
Mucosal transposition or grafting was used for inner lining defects. Glabellar flaps, tarsoconjunctival flaps, and FTGs were used when the periorbital area was involved. Due to preexisting medical conditions, optimal recon structions could not be performed in two patients. The defects healed by secondary intention to obtain a situation in which prosthetics could be applied. An overview of the type of reconstructions used is presented in Table 3. Time of Closure
Defects Involving Three or More Units Fourteen defects involved three or more units. In most of these cases, two or more flaps were used for closure (Figure 2). Fourteen local flaps were used, including skin transposition (n = 9), glabella flaps (n = 2), tarsoconjunctival flaps (n = 2), and a VY-plasty (n = 1). Seven paramedian forehead flaps were used.
In 50% of cases (n = 314), defects were reconstructed the same day as tum or excision. This significantly increased from 31% (n = 26) in 2006 to 81% (n = 156) in 2010 (p < .001). The time between excision and reconstruction depended on different factors. The time elongated when the defect was more complex, existed of more than one subunit, or was a large or deep
Figure 2. A, Example of a reconstruction of a defect consisting of multiple units. B, The defect was reconstructed with a paramedian forehead flap, a composite graft harvested from the auricular concha, a mucosal transposition, and a local transposition. C, The result 2 years after the initial reconstruction.
268
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July!August), 2014: pp 265-270
Facial Reconstruction Following Mohs Surgery
Table 3. Overview of the Type of Reconstructions Performed per Aesthetic Unit Type o f Reconstruction per Subunit (number of defects)* Nose (292) Local flap Regional flap Skin graft Auricular cartilage graft Periorbital region (113) Local flap Skin graft Primary closure Cheek (110) Local flap Regional flap Skin graft Primary closure Forehead, temple, and scalp region (97) Local flap Free flap Skin graft Primary closure Ideal by secondary intention Perioral region (47) Local flap Regional flap Skin graft Primary closure Periauricular (42) Local flap Skin graft Primary closure Defects involving 3 or more units Local flap Regional flap Heal by secondary intention
n
213 85 22 47 80 35 11 70 21 20 14 41 3 29 18 6 37 4 1 15 23 18 2 14 7 2
*Defects that involved two aesthetic units were scored in both of these individual units. Defects involving three or more units were scored independently.
defect requiring general anesthesia. It should be noted, however, that the defects reconstructed in 2006 were significantly larger, wider, and deeper and involved more subunits per defect. When correcting for these variables in a multivariable model, however, the time between tumor excision and reconstruction was still significantly shorter in 2010 {p < .001). Additional Procedures In 163 cases (26%), an additional procedure was required. In 79 cases, one additional procedure was sufficient; in 66
cases, two additional procedures were performed; and in 18 cases, three additional procedures were necessary. The most required additional procedures consisted of flap thinning and dividing the flap pedicle. Complications The overall complication rate was 5.5%. In 28 cases, a complication occurred during the initial reconstruction and in 7 during an additional procedure. In 11 cases, an infection occurred and in 7 bleeding. Five times the wound showed dehiscence. Three times partial flap necrosis occurred. Other complications included a persisting ectropion after reconstruction of the lower eyelid (n = 4), hypertrophic scarring (n = 2), and complications due to general anesthesia (n = 2). Discussion Radical tumor excision is the goal in the treatment of nonmelanoma skin cancer. Studies have shown that Mohs micrographic surgery provides lower recurrence rates than conventional excision for recurrent basal cell carcinomas in the face and for basal cell carcinomas with an aggressive growth pattern.7-10 Furthermore, Mohs micrographic sur gery enables radical tumor excision and reconstruction on the same day, in contrast to conventional excision and pathology, which usually takes 3 to 7 days. The number of cases in which we achieved closure of the defect on the same day as the Mohs micrographic resection significantly increased from 31% in 2006 to 81% in 2010. This was achieved by the following logistic measures: • Mohs micrographic surgery was performed during morning surgical sessions and reconstruction during afternoon sessions under local anesthesia. • On the days Mohs micrographic surgery is performed by the dermatologists, at least one plastic surgeon and one resident are assigned to the reconstructions and have no other activities. • Reconstructions under general anesthesia had to be planned within a week. Special slots in the operating room program were reserved. • Photographs of the tumor and the expected defect were discussed prior to the Mohs micrographic surgery. These agreements made the approach to each patient more standardized and helped us improve our practice. Although not investigated in this article, our more protocolized way of working was well received by patients
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
269
Grosfeld et al
and referring physicians. Patients appreciate that radical tumor excision and the following reconstruction were performed in 1 day and not several days to weeks, as could be the case with regular surgical excision and reconstruc tion. Over the reviewed period, the defects reconstructed became significantly smaller and less deep and involved fewer subunits per defect. This supports the contention that having easy, congenial access to a multidisciplinary surgical team facilitates referrals, increases the number of referrals occurring between specialties, and leads to smaller defects being referred out, all of which can be of potential benefit to patients and physicians. Furthermore, as the flow of patients needing closure became more consistent, this helped us further increase our direct closure rates. In the literature, specific reconstructions are well accepted for certain defects and locations; however, for other defects, the ideal closure is debatable. The use of FTGs in small skin-only defects is one of these. Compared to local skin flaps, higher complication rates but more satisfactory results have been described by Rustemeyer and colleagues.11 Jacobs and colleagues found aesthetically more satisfactory results when local skin flaps were used for reconstruction compared to FTGs.12 Collar and colleagues reviewed nasal defects involving the nasal tip and preferred to close cutaneous nasal defects with the use of FTGs. In our study, FTGs were used less frequently in nasal defects. A possible explanation for this is that our study included all nasal subunits and larger defects, often involving more than one subunit. We prefer a local flap over an FTG as this results in a better cosmetic outcome. Our overall approach to facial reconstruction following Mohs micrographic surgery is that the type of reconstruc tion should depend on the type of defect and the patient’s characteristics and preferences. Prior to the reconstruction, we first inspect the defect (location, depth, and functional properties) to judge what is required of a reconstruction. After close examination of the defect, the patient’s medical condition and motivation to undergo a reconstruction are determined. With this in mind, we make the decision as to what type of reconstruction to use. In elderly patients with a number of comorbidities who want as little done as possible, for example, we tend to use an FTG more often, whereas in young, healthy patients who are motivated, we tend to use more complex reconstructions, provided that they offer a more aesthetic satisfying result.
Conclusion Facial reconstruction following Mohs micrographic surgery is challenging. The type of reconstruction used depends on
the type of defect and patient characteristics. A structured multidisciplinary approach improves the process from defect to reconstruction and can facilitate referrals.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: tissue-sparing outcome. Dermatol Surg 2009;35:1349-54, doi:10,111 l/j.1524-4725.2009. 01240.x. 2. Abide JM. Mohs surgery in the treatment of skin cancer. J Miss State Med Assoc 1986;27:313-6. 3. Thissen MRTM, Neumann MHA, Schouten LJ. A systematic review of treatment modalities for primary basal cell carcinomas. Arch Dermatol 1999;135:1177-83. 4. Jackson IT, editor. Local flaps in head and neck reconstruction. St. Louis (MO): Quality Medical Publishing; 2007. 5. Baker SR. Flap classification and design. In: Baker SR, editor. Local flaps in facial reconstruction. 2nd ed. Philadelphia: Elsevier; 2007. p. 75. 6. Mapping complications in plastic surgery. Masterclassification version 3.0. Available at: http://www.NVPC.nl (accessed December 14, 2007). 7. Smeets NW, Kuijpers DI, Nelemans P, et al. Mohs’ micrographic surgery for treatment of basal cell carcinoma of the face: results of a retrospective study and review of the literature. Br J Dermatol 2004;151:141-7, doi:10.1111/i.l365-2133.2004.06047.x. 8. Smeets NW, Krekels GA, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004;364:1766-72, doi:10. 1016/S0140-6736(04)17399-6. 9. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years’ follow-up. Lancet Oncol 2008;9:1149-56, doi:10. 1016/S1470-2045(08)70260-2. 10. Essers BA, Dirksen CD, Nieman FH, et al. Cost effectiveness of Mohs micrographic surgery vs surgical excision for basal cell carcinoma of the face. Arch Dermatol 2006;142:187-94. 11. Rustemeyer J, Gunther L, Bremerich A. Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment. Oral Maxillofac Surg 2009; 13:15-9, doi:10.1007/sl0006-008-0139-z. 12. Jacobs MA, Christenson LJ, Weaver AL, et al. Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose. Dermatol Surg 2010;36:23-30, doi:10.1111 /j.15244725.2009.01360.x. 13. Collar RM, Ward PD, Baker SR. Reconstructive perspectives of cutaneous defects involving the nasal tip: a retrospective review. Arch Facial Plast Surg 2011;13:91—6, doi:10.1001/archfacial. 2011.13.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Facial Reconstruction Following Mohs Micrographic Surgery: A Report of 622 Cases Eline C. Grosfeld, Jeroen M. Smit, Gertruud A. Krekels, Julien H.A. van Rappard, and Maarten M. Hoogbergen
B a c k g ro u n d : A r o u n d
100
to
200
p a tie n ts
u n d e rg o
s u r g ic a l
r e c o n s tr u c tio n
e v e ry
year
at
our
d e p a rtm e n t
of
p la s t ic
and
r e c o n s t r u c t i v e s u r g e r y a f t e r M o h s m i c r o g r a p h ic s u r g e r y f o r n o n m e la n o m a s k in c a n c e r .
O b je c tiv e : T h e a im o f t h i s r e p o r t is t o p r o v id e a n o v e r v i e w o f t h e t y p e o f f a c ia l r e c o n s t r u c t i o n s p e r f o r m e d a n d in v e s t ig a t e w h e th e r w e
a c h ie v e d
in c r e a s e d , d e f i n i t i v e c lo s u r e r a t e s o f t h e
d e fe c t o n th e
d a y o f th e
e x c is io n a f t e r f u r t h e r im p r o v i n g
th e
c o l l a b o r a t i o n b e t w e e n t h e i n v o lv e d d e p a r t m e n t s .
M e th o d s : A ll p a t i e n t s w h o u n d e r w e n t f a c ia l r e c o n s t r u c t i o n a t t h e D e p a r t m e n t o f P la s tic a n d R e c o n s t r u c t iv e S u r g e r y f o l l o w i n g M o h s m i c r o g r a p h ic s u r g e r y b e t w e e n J a n u a r y 2 0 0 6 a n d J a n u a r y 2 0 1 1 w e r e r e t r o s p e c t i v e l y s y s t e m a t ic a lly r e v ie w e d .
R e su lts: A t o t a l o f 5 6 4 p a t i e n t s w i t h 6 2 2 d e f e c t s w e r e i d e n t if ie d . T h e d if f e r e n t r e c o n s t r u c t i o n s u s e d p e r a e s t h e t ic u n i t a re d e s c r ib e d . T h e n u m b e r o f c a s e s in w h i c h a r e c o n s t r u c t i o n w a s p e r f o r m e d o n t h e s a m e d a y a s t h e r e s e c t io n s i g n i f i c a n t l y in c r e a s e d f r o m 31 t o 8 1 % ( p < .0 0 1 ).
C o n c lu s io n : F a c ia l r e c o n s t r u c t i o n f o l l o w i n g M o h s m ic r o g r a p h ic s u r g e r y is c h a lle n g in g . T h e t y p e o f r e c o n s t r u c t i o n u s e d d e p e n d s o n t h e t y p e o f d e f e c t a n d p a t i e n t c h a r a c t e r is t ic s . A s t r u c t u r e d m u l t i d i s c i p l i n a r y a p p r o a c h im p r o v e s t h e p r o c e s s f r o m
d e fe c t to
r e c o n s t r u c t i o n a n d c a n f a c i l i t a t e r e f e r r a ls .
C o n te x te : C h a q u e a n n e e , d e 1 0 0 a 2 0 0 p a t ie n t s s u b is s e n t u n e r e c o n s t r u c t i o n a u s e r v ic e d e c h i r u r g i e p la s t iq u e e t r e c o n s t r u c t i v e d e I 'e t a b lis s e m e n t a p r e s u n e c h i r u r g i e m i c r o g r a p h iq u e d e M o h s p o u r u n c a n c e r d e la p e a u n o n m e la n iq u e .
O b je c tifs : L e r a p p o r t v i s a i t a d o n n e r u n e v u e d 'e n s e m b le d e s d i f f e r e n t s t y p e s d e r e c o n s t r u c t i o n f a c ia le e t a v e r i f i e r s i le t a u x d e f e r m e t u r e d e f i n i t i v e d e s p e r t e s d e s u b s t a n c e p r a t iq u e e le j o u r m e m e d e I'e x e r e s e a v a it a u g m e n t e a p r e s u n e c o lla b o r a t io n a c c r u e e n t r e le s s e r v ic e s c o n c e r n e s .
M e th o d e : II y a e u u n e c o lle c te m e t h o d iq u e e t r e t r o s p e c tiv e d e d o n n e e s s u r t o u s le s p a t ie n t s q u i a v a ie n t s u b i u n e r e c o n s t r u c tio n d e la fa c e a u s e rv ic e d e c h ir u r g ie p la s t iq u e e t r e c o n s t r u c tiv e a p re s u n e c h ir u r g ie m ic r o g r a p h iq u e d e M o h s , e n tr e ja n v ie r 2 0 0 6 e t ja n v ie r 2 0 1 1 .
R e s u lta ts : A u t o t a l , 5 6 4 p a t i e n t s c o m p t a n t 6 2 2 p e r t e s d e s u b s t a n c e o n t e te r e c e n s e s . L 'a r t ic le f a i t e t a t d e s d i f f e r e n t s t y p e s d e r e c o n s t r u c t i o n e f f e c tu e s p a r z o n e e s t h e t iq u e . L e n o m b r e d e c a s d e r e c o n s t r u c t i o n p r a t iq u e e le j o u r m e m e d e I'e x e r e s e a a u g m e n t e s e n s ib le m e n t ; e n e f f e t , c e lu i- c i e s t p a s s e d e 31 a 8 1 % ( p < .0 0 1 ).
C o n clu s io n s : L a r e c o n s t r u c t i o n d e la fa c e a p r e s u n e c h i r u r g i e m i c r o g r a p h iq u e d e M o h s e s t u n e in t e r v e n t i o n e x ig e a n t e . L e t y p e d e r e c o n s tr u c tio n
depend
du
ty p e
de
p e rte
de
s u b s ta n c e
e t des
c a r a c t e r is t iq u e s
des
p a t ie n t s .
Une
o r g a n is a t io n
s tru c tu re e
et
p l u r i d i s c i p l i n a i r e a m e li o r e le p r o c e s s u s d e p u i s la p e r t e d e s u b s t a n c e j u s q u 'a la r e c o n s t r u c t i o n , e t p e u t f a c i l i t e r le s r e c o m m a n d a t io n s .
O MEET THE CHALLENGE of radical excision of basal cell carcinoma (BCC) with the smallest possible defect, Mohs microscopic surgery was developed. 1 In Mohs micrographic surgery, complete surgical margins are examined in horizontal sections, whereas after regular From the Departments o f Plastic and Reconstructive Surgery and Dermatology, Catharina Hospital, Eindhoven, the Netherlands. Address reprint requests to: Jeroen M. Smit, MD, PhD, Department o f Plastic and Reconstructive Surgery, Catharina Ziekenhuis, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands; e-mail: [email protected].
DOI 10.2310/7750.2013.13188 © 2014 Canadian Dermatology Association
surgical excision, only a fraction of the surgical margins are examined in a number of vertical slices.2 Nowadays, Mohs micrographic surgery is the recommended treatment for recurrent BCCs in the H area of the face, for large primary facial BCCs, or for facial BCCs with more aggressive growth patterns.3 One of the challenges after Mohs micrographic surgery is the closure of the defect while maintaining an acceptable aesthetic outcome. A variety of techniques have been reported depending on the location and size of the defect.4 The choice of a specific technique may not always be straightforward and depends on, among others, the type of defect, patient characteristics, and surgeon’s preference.
DECKER^ rfry Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
265
Grosfeld et al
At the Catharina Hospital, Eindhoven, the Netherlands, 100 to 200 patients a year are referred to the Department of Plastic and Reconstructive Surgery for facial reconstruction following Mohs microscopic surgery at the Department of Dermatology. In 2006, the collaboration between these departments was intensified for the reconstruction of defects following Mohs micrographic surgery. One of the goals was to increase the number of defects reconstructed on the same day as the excision. The aim of this report is to provide an overview of the types of reconstruction performed during the first 5 years of this extended collaboration and to investigate whether we achieved increased closure rates on the same day as the excision.
Table 1. Units Scored and Subunits Involved
M ethods
Periauricular region
Study Design
Units Nasal region
Periorbital region Cheek region
Forehead region
Perioral region
All patients who underwent facial reconstruction at the Department of Plastic and Reconstructive Surgery follow ing Mohs micrographic surgery between January 2006 and January 2011 were reviewed. Age, comorbidities, nicotine abuse, location of the defect, number of aesthetic subunits involved, size and depth of the defect, number of Mohs excisions, type of reconstruction, amount of reconstructive techniques used to reconstruct the defect, date of surgery, surgeon, anesthetic method, amount of secondary correc tions, complications, and outcome of all patients were collected in a database and were made available for analysis. The approval of the medical ethical commission of the Catharina Hospital was received for this study. Data Assessment All defects were mapped according to the aesthetic subunits of the face.3 The retroauricular region was also included as a subunit. For analysis purposes, the different subunits were merged into units (Table 1). The depth of the defect was rated as follows: subcutis only, muscle involvement, periostal or perichondrial involvement, bone or chondrial involvement, or full-thickness defect (eg, in nasal and ear defects). The type of reconstruction was scored as primary closure, skin graft: (either full thickness or split skin), local flap (eg, rhomboid flap), regional flap (eg, paramedian forehead flap), and free flap. Local flaps were, when possible, further specified. Reconstructions in which the local flap was not specified (eg, a general advancement or extensive undermining) were scored as transposition not further specified (nfs). If a reconstruction consisted of multiple flaps and/or grafts, these were scored individually.
Subunits Nasal sidewalls Dorsum Alae Domes Columella Periorbital subunit Brow Infraorbital subunit Zygomatic subunit Mandibular subunit Forehead Temple Scalp Ear Retroauricular area Upper lip Lower lip
A complication was classified according to the guidelines of the Dutch Association of Plastic Surgery (bleeding, infection, necrosis, wound dehiscence, lesser outcome than expected, or a combination of these).6 The chi-square test was used to statistically compare the percentage of patients reconstructed on the same day as the tum or excision. A multivariate linear regression model was used to investigate a potential association between the year of surgery and the number of days between tum or excision and reconstruction while correct ing for the length, width, and depth of the defect and the number of subunits involved. Significance was set at p < .05. Statistical analysis was performed with the help of SPSS 17 (SPSS Inc, Chicago, IL).
Results Patient Characteristics A total of 564 patients with 622 defects were reviewed; 269 patients were men (47.7%) and 295 patients were women (52.3%). The mean age of the patients was 68.2 years (range 31-99 years). Most tum ors were prim ary tum ors, followed by recurrent tumors and nonradically excised tumors. A minimum of one and a maximum of seven aesthetic subunits were involved in the created defect. The most frequently involved location was the ala nasi (27.5%), followed by the periorbital subunit (18.3%), sidewalls of the nose (18.0%), infraorbital subunit (15.3%), nasal tip
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
Facial Reconstruction Following Mohs Surgery
(14.0%), dorsum nasi (9.8%), forehead (7.9%), upper lip white roll (7.6%), and temple region and ear (6.1%). The mean size of the defect was 58 mm in length (range 5-110 mm) and 46 mm in width (range 2-90 mm). Depth was mostly classified as subcutis only, followed by a full-thickness defect and bone involvement. Patient and tum or characteristics are outlined in Table 2.
periorbital area and nose, 20 the periorbital area and cheek, and 7 the periorbital area and forehead. In these defects, 80 local flaps were used, of which skin transposition nfs (n = 26), tarsoconjunctival flaps (n = 21), and glabella flaps (n = 19) were most frequently used. Thirty-four FTGs and one split-skin graft were used. Eleven defects in this area could be closed primarily.
Reconstruction of Defects Cheek Defects
Nasal Defects O f the 292 nasal defects, 240 affected the nose only, 30 the nose and cheek, 21 the nose and periorbital region, and 1 the nose and perioral region. The ala (n = 171) and the lateral sidewalls (rt = 112) were most frequently affected in nose-only defects. A total of 213 local flaps were used, of which bilobed flaps (n = 74), skin transposition nfs {n = 67), glabella flaps (n = 10), and rotation flaps (n = 9) were most frequently used. Eighty-five paramedian forehead flaps (Figure 1) and 22 full thickness skin grafts (FTGs) were used for reconstruction. When cartilage was missing, a composite graft was used, harvested from the auricular concha (n = 47).
Of the 110 defects involving the cheek, 43 affected the cheek only, 30 the cheek and nose, 20 the cheek and periorbital area, 15 the cheek and perioral area, 1 the cheek and forehead, and 1 the cheek and periauricular area. In this area, 70 local flaps were used, of which skin transposition nfs (n = 37) and rhomboid flaps (n = 13) were most frequently used. Twenty-one paramedian forehead flaps were used. Eighteen full-thickness skin grafts and two split-skin grafts were used for reconstruc tion. Fourteen defects in this area could be closed primarily.
Defects of the Forehead, Temple, and Scalp Region Defects in the Periorbital Region Of the 113 defects in the periorbital area, including the brow, 65 affected the periorbital area only, 21 the
Table 2. Patient and Tumor Characteristics Characteristic Gender Male Female Type of tumor Basal cell carcinoma Squamous cell carcinoma Lentigo maligna Other Tumor frequency Primary Recurrent Not radically excised Tumor depth Defects of the subcutis Defects involving the muscle Defects involving the periosteum or perichondrium Defects involving the bone Full-thickness defects
n (%)
269 (48) 295 (52) 583 9 2 28
(94) (1) (0.3) (5)
411 (69) 98 (17) 83 (14) 493 (80) 5 (1) 11 (2) 26 (4) 78 (13)
Of the 97 defects involving the forehead, temple, and scalp region, 89 affected this area only, 7 affected this area and the periorbital area, and 1 affected the above-mentioned area and the periauricular area. Forty-one local flaps were used, of which skin transposition nfs (n = 25) and rotation flaps (n = 6) were most frequently used. Seventeen FTGs and 12 splitskin grafts were used. In three cases, a free flap was used. Eighteen defects could be closed primarily; six defects were left to heal by secondary intention.
Defects in the Perioral Region In total, the perioral area, including the chin, was involved in 47 cases. In 31 cases, this affected the perioral area only; in 15 cases, the perioral area and the cheek; and in 1 case, the perioral area and the nose. In this area, 37 local flaps were used, of which skin transposition nfs (n = 21) was most frequent. Fifteen defects could be closed primarily. Four paramedian forehead flaps were used and in one case an FTG. O f the 16 combined defects, most defects were reconstructed by skin transposition (« = 7), paramedian forehead flaps (n = 4), and bilobed flaps (n = 3).
Canadian Dermatology Association I Journal o f Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
267
Grosfeld et al
Figure 1. Example of a nasal reconstruction with a paramedian forehead flap and conchal cartilage grafts. A shows the defect and B and C the result 18 months after the initial reconstruction. In this period, the conchal grafts were placed, the pedicle was divided, and the flap was thinned.
Periauricular Defects Of the 42 defects involving the periauricular area, including the retroauricular area, 41 affected the periauricular area only and 1 affected the periauricular area and the cheek. Twenty-three local flaps were used, of which skin transposition nfs (n = 17) and chondrocutaneous flaps (n = 5) were most frequently used. Fifteen FTGs and three split-skin grafts were used for reconstruction. Two defects were closed primarily.
Mucosal transposition or grafting was used for inner lining defects. Glabellar flaps, tarsoconjunctival flaps, and FTGs were used when the periorbital area was involved. Due to preexisting medical conditions, optimal recon structions could not be performed in two patients. The defects healed by secondary intention to obtain a situation in which prosthetics could be applied. An overview of the type of reconstructions used is presented in Table 3. Time of Closure
Defects Involving Three or More Units Fourteen defects involved three or more units. In most of these cases, two or more flaps were used for closure (Figure 2). Fourteen local flaps were used, including skin transposition (n = 9), glabella flaps (n = 2), tarsoconjunctival flaps (n = 2), and a VY-plasty (n = 1). Seven paramedian forehead flaps were used.
In 50% of cases (n = 314), defects were reconstructed the same day as tum or excision. This significantly increased from 31% (n = 26) in 2006 to 81% (n = 156) in 2010 (p < .001). The time between excision and reconstruction depended on different factors. The time elongated when the defect was more complex, existed of more than one subunit, or was a large or deep
Figure 2. A, Example of a reconstruction of a defect consisting of multiple units. B, The defect was reconstructed with a paramedian forehead flap, a composite graft harvested from the auricular concha, a mucosal transposition, and a local transposition. C, The result 2 years after the initial reconstruction.
268
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July!August), 2014: pp 265-270
Facial Reconstruction Following Mohs Surgery
Table 3. Overview of the Type of Reconstructions Performed per Aesthetic Unit Type o f Reconstruction per Subunit (number of defects)* Nose (292) Local flap Regional flap Skin graft Auricular cartilage graft Periorbital region (113) Local flap Skin graft Primary closure Cheek (110) Local flap Regional flap Skin graft Primary closure Forehead, temple, and scalp region (97) Local flap Free flap Skin graft Primary closure Ideal by secondary intention Perioral region (47) Local flap Regional flap Skin graft Primary closure Periauricular (42) Local flap Skin graft Primary closure Defects involving 3 or more units Local flap Regional flap Heal by secondary intention
n
213 85 22 47 80 35 11 70 21 20 14 41 3 29 18 6 37 4 1 15 23 18 2 14 7 2
*Defects that involved two aesthetic units were scored in both of these individual units. Defects involving three or more units were scored independently.
defect requiring general anesthesia. It should be noted, however, that the defects reconstructed in 2006 were significantly larger, wider, and deeper and involved more subunits per defect. When correcting for these variables in a multivariable model, however, the time between tumor excision and reconstruction was still significantly shorter in 2010 {p < .001). Additional Procedures In 163 cases (26%), an additional procedure was required. In 79 cases, one additional procedure was sufficient; in 66
cases, two additional procedures were performed; and in 18 cases, three additional procedures were necessary. The most required additional procedures consisted of flap thinning and dividing the flap pedicle. Complications The overall complication rate was 5.5%. In 28 cases, a complication occurred during the initial reconstruction and in 7 during an additional procedure. In 11 cases, an infection occurred and in 7 bleeding. Five times the wound showed dehiscence. Three times partial flap necrosis occurred. Other complications included a persisting ectropion after reconstruction of the lower eyelid (n = 4), hypertrophic scarring (n = 2), and complications due to general anesthesia (n = 2). Discussion Radical tumor excision is the goal in the treatment of nonmelanoma skin cancer. Studies have shown that Mohs micrographic surgery provides lower recurrence rates than conventional excision for recurrent basal cell carcinomas in the face and for basal cell carcinomas with an aggressive growth pattern.7-10 Furthermore, Mohs micrographic sur gery enables radical tumor excision and reconstruction on the same day, in contrast to conventional excision and pathology, which usually takes 3 to 7 days. The number of cases in which we achieved closure of the defect on the same day as the Mohs micrographic resection significantly increased from 31% in 2006 to 81% in 2010. This was achieved by the following logistic measures: • Mohs micrographic surgery was performed during morning surgical sessions and reconstruction during afternoon sessions under local anesthesia. • On the days Mohs micrographic surgery is performed by the dermatologists, at least one plastic surgeon and one resident are assigned to the reconstructions and have no other activities. • Reconstructions under general anesthesia had to be planned within a week. Special slots in the operating room program were reserved. • Photographs of the tumor and the expected defect were discussed prior to the Mohs micrographic surgery. These agreements made the approach to each patient more standardized and helped us improve our practice. Although not investigated in this article, our more protocolized way of working was well received by patients
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
269
Grosfeld et al
and referring physicians. Patients appreciate that radical tumor excision and the following reconstruction were performed in 1 day and not several days to weeks, as could be the case with regular surgical excision and reconstruc tion. Over the reviewed period, the defects reconstructed became significantly smaller and less deep and involved fewer subunits per defect. This supports the contention that having easy, congenial access to a multidisciplinary surgical team facilitates referrals, increases the number of referrals occurring between specialties, and leads to smaller defects being referred out, all of which can be of potential benefit to patients and physicians. Furthermore, as the flow of patients needing closure became more consistent, this helped us further increase our direct closure rates. In the literature, specific reconstructions are well accepted for certain defects and locations; however, for other defects, the ideal closure is debatable. The use of FTGs in small skin-only defects is one of these. Compared to local skin flaps, higher complication rates but more satisfactory results have been described by Rustemeyer and colleagues.11 Jacobs and colleagues found aesthetically more satisfactory results when local skin flaps were used for reconstruction compared to FTGs.12 Collar and colleagues reviewed nasal defects involving the nasal tip and preferred to close cutaneous nasal defects with the use of FTGs. In our study, FTGs were used less frequently in nasal defects. A possible explanation for this is that our study included all nasal subunits and larger defects, often involving more than one subunit. We prefer a local flap over an FTG as this results in a better cosmetic outcome. Our overall approach to facial reconstruction following Mohs micrographic surgery is that the type of reconstruc tion should depend on the type of defect and the patient’s characteristics and preferences. Prior to the reconstruction, we first inspect the defect (location, depth, and functional properties) to judge what is required of a reconstruction. After close examination of the defect, the patient’s medical condition and motivation to undergo a reconstruction are determined. With this in mind, we make the decision as to what type of reconstruction to use. In elderly patients with a number of comorbidities who want as little done as possible, for example, we tend to use an FTG more often, whereas in young, healthy patients who are motivated, we tend to use more complex reconstructions, provided that they offer a more aesthetic satisfying result.
Conclusion Facial reconstruction following Mohs micrographic surgery is challenging. The type of reconstruction used depends on
the type of defect and patient characteristics. A structured multidisciplinary approach improves the process from defect to reconstruction and can facilitate referrals.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: tissue-sparing outcome. Dermatol Surg 2009;35:1349-54, doi:10,111 l/j.1524-4725.2009. 01240.x. 2. Abide JM. Mohs surgery in the treatment of skin cancer. J Miss State Med Assoc 1986;27:313-6. 3. Thissen MRTM, Neumann MHA, Schouten LJ. A systematic review of treatment modalities for primary basal cell carcinomas. Arch Dermatol 1999;135:1177-83. 4. Jackson IT, editor. Local flaps in head and neck reconstruction. St. Louis (MO): Quality Medical Publishing; 2007. 5. Baker SR. Flap classification and design. In: Baker SR, editor. Local flaps in facial reconstruction. 2nd ed. Philadelphia: Elsevier; 2007. p. 75. 6. Mapping complications in plastic surgery. Masterclassification version 3.0. Available at: http://www.NVPC.nl (accessed December 14, 2007). 7. Smeets NW, Kuijpers DI, Nelemans P, et al. Mohs’ micrographic surgery for treatment of basal cell carcinoma of the face: results of a retrospective study and review of the literature. Br J Dermatol 2004;151:141-7, doi:10.1111/i.l365-2133.2004.06047.x. 8. Smeets NW, Krekels GA, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004;364:1766-72, doi:10. 1016/S0140-6736(04)17399-6. 9. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years’ follow-up. Lancet Oncol 2008;9:1149-56, doi:10. 1016/S1470-2045(08)70260-2. 10. Essers BA, Dirksen CD, Nieman FH, et al. Cost effectiveness of Mohs micrographic surgery vs surgical excision for basal cell carcinoma of the face. Arch Dermatol 2006;142:187-94. 11. Rustemeyer J, Gunther L, Bremerich A. Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment. Oral Maxillofac Surg 2009; 13:15-9, doi:10.1007/sl0006-008-0139-z. 12. Jacobs MA, Christenson LJ, Weaver AL, et al. Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose. Dermatol Surg 2010;36:23-30, doi:10.1111 /j.15244725.2009.01360.x. 13. Collar RM, Ward PD, Baker SR. Reconstructive perspectives of cutaneous defects involving the nasal tip: a retrospective review. Arch Facial Plast Surg 2011;13:91—6, doi:10.1001/archfacial. 2011.13.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 4 (July/August), 2014: pp 265-270
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
