Archive for the ‘MOHS | Skin Cancer Reconstruction’ Category
Kalos: The Atlanta Center for Facial Plastic, Reconstructive & Laser Surgery introduces the first comprehensive, office based, Mohs skin cancer reconstructive surgery clinic to Atlanta and the greater metropolitan area. Mohs surgery is performed by specialized dermatologists to remove the skin cancer with a greater than 99% cure rate. After the tumor is removed, there are several options for closure of the defect.
Almost all Mohs surgery is performed under local anesthesia in the comfort of an office setting without the need for an operating room. Insurance will pay for a plastic surgeon to perform the reconstruction no matter how simple or complex the closure is. Benjamin C. Stong MD at Kalos has extensive, highly specialized training in complicated Mohs skin cancer reconstruction, and he provides a complete range of reconstructive options for patients seeking the absolute best outcomes from Mohs skin cancer removal surgery. With a very high volume Mohs reconstructive practice, all closures, no matter how complicated, including: paramedian forehead flap reconstruction, tissue expansion, Gillies fan flap and Karapandzik flap lip reconstructions, eyelid reconstruction, cartilage grafting, melolabial cheek flaps, scalp reconstructions, full thickness nasal reconstructions, and cervical rotation advancement flaps can be performed in the comfort of a beautiful, peaceful office on the same day as the Mohs procedure avoiding the need for a hospital or ambulatory surgery center.
With the use of local anesthesia and oral sedation there is almost no defect in the head and neck that requires a patient to be put to sleep to have the closure performed safely and comfortably. With hundreds of complicated Mohs reconstructive procedures performed in the office setting, Dr. Stong has the experience and techniques to repair complex defects in the face and avoid the need for a cold, impersonal operating room.
Many patients are often unprepared for the overall surgical experience and recovery process. The biggest concern of most Mohs surgery patients is being put to sleep for the reconstruction and the quality of the reconstructive result following tumor removal. Kalos: The Atlanta Center for Facial Plastic, Reconstructive & Laser Surgery and Dr. Stong routinely perform pre-surgical consultations to explain the reconstructive options and prepare the patient for the recovery process prior to undergoing Mohs surgery. Pre-surgical consultation with a plastic surgeon is covered under most insurance plans, and is available to all patients who wish to get the opinion of an experienced Mohs reconstructive plastic surgeon and a better understanding of the healing process following removal of skin cancer. Many Mohs surgery patients also desire consultation for effective skin rejuvenation and facial plastic surgery procedures such as rhinoplasty, facelifts, laser skin resurfacing, and eyelid lifts for facial rejuvenation to improve ones appearance. Kalos offers a comprehensive range of medical grade skin care products, laser surgery, and facial plastic surgery procedures to support our patients’ needs.
Insurance only covers a single reconstructive effort. It is important to find a plastic surgeon with significant experience to perform a Mohs closure to achieve the absolute best outcome. Additionally, Mohs surgery patients wish to avoid the inconvenience of waiting for days for either a hospital or an ambulatory surgery center operating room to become available as well as the lingering after effects of anesthesia. The best outcomes from Mohs surgery involve a team of two separate surgeons: a dermatologist to remove the tumor and a plastic and reconstructive surgeon to perform the closure, with each being highly skilled in their respective portion of the procedure. The ability to offer patients a completely office based Mohs reconstructive surgery center is unique and geared towards exceptional convenience and customer service.
Benjamin C. Stong MD
Atlanta GA
Oculoplastic surgery is a sub discipline of Facial Plastic and Reconstructive Surgery and is performed by Facial Plastic Surgeons as well as Ophthalmologists who sub specialize in eyelid surgery. There are two components to oculoplastic surgery: cosmetic and reconstructive surgery. Blepharoplasty, ptosis repair, and ectropion repair can be performed for both cosmetic and functional, reconstructive reasons. If they are performed for eye dysfunctions such as obstructed vision, excessive tearing, or eye protection, they are considered reconstructive procedures and if they are performed specifically for aesthetic reasons they are considered cosmetic. Repair of the eyelids from cancer removal or trauma is always considered reconstructive surgery.
Blepharoplasty of the upper eyelid always includes removal of excess skin and muscle and usually removal of excess protruding fat from around the eye. The most optimal incision uses an extended incision compared to a more traditional blepharoplasty incision and is carried over the outer orbital rim to correct excessive lateral hooding because the outer eyelid and brow complex age more rapidly than the central eyelid and brow. When the brow is in low position a brow lift procedure is necessary prior to correction of the eyelid to avoid problems. Lower eyelid blepharoplasty is less straight forward with several techniques employed by many surgeons. The most state of the art technique involves a small imperceptible incision just under the lower eyelash line with conservation of the bulging fat to move it into the tear trough in order to create a smooth, youthful, seamless transition between the lower eyelid and cheek with removal of excess muscle and skin. Removal of lower eyelid fat can create a hollowed effect with an abrupt, unnatural transition between the lower eyelid and cheek.
Ptosis repair involves two primary techniques. The first uses an incision in the upper eyelid to tighten the Levator muscle/tendon complex by removing a portion of the tendon, advancing the tendon and reattaching it closer to the eyelid margin, or plicating the redundant tissue. The second method is performed on the inside to the eyelid and involves removing a portion of Mueller’s muscle elevate the eyelid. Sometimes skin may need to be removed during the ptosis repair depending on the amount the eyelid margin needs to be raised and excess skin that is present. Less frequently, a brow lift may need to be added to the procedure if the brow is in a low position.
Ectropion repair is performed for excessive laxity in the lower eyelid and is performed in two ways: a canthopexy and canthoplasty. A canthopexy is simply repositioning or tightening the eyelid tendon and a canthoplasty involves making a skin incision and removing excess skin and shortening the horizontal distance of the eye. The need for a canthoplasty over a canthopexy is based on the distance the eyelid moves from the eyeball or globe and is commonly performed for excess laxity associated with facial paralysis and age related involutional ectropion otherwise canthopexy procedures are desirable for less severe laxity issues because they don’t shorten the horizontal length of the eye resulting in a more unnatural appearance.
Eyelid reconstruction from Mohs skin cancer surgery or trauma involves evaluating the amount of remaining functional eyelid remaining for full thickness defects. If less than a third of the eyelid is missing then a primary wedge resection repair is indicated because there is enough built in redundancy to the eyelid and relaxation following surgery to achieve an excellent outcome. If there is approximately fifty percent to two thirds of the eyelid missing a tenzel rotation advancement flap is used with a release of the eyelid tendon to gain enough tissue and movement on the remaining eyelid to advance the two edges together and achieve a cosmetically excellent outcome. For near total eyelid defects, pedicled Hughes flaps can be used to replace the entire lower eyelid with transposition flaps to repair subtotal defects of the upper eyelid.
Oculoplastic cosmetic and reconstructive surgery is performed by all Facial Plastic Surgeons as well as Ophthalmologists with specific training. It requires a detailed knowledge of eyelid anatomy and function as well as plastic surgery reconstructive principles to achieve excellent outcomes. Understanding the type of training and knowledge base of your surgeon is critical to avoiding bad outcomes and achieving desirable results.
Post provided by Benjamin C. Stong, MD
Skin cancer is the most common malignancy in humans, with the order of frequency in descending order: basal cell carcinoma, squamous cell carcinoma, and melanoma. Mohs micrographic surgery is used to remove basal and squamous cell carcinoma with frozen section tumor control and a subsequent closure of the defect that should follow essential reconstructive principles. The majority of the Mohs surgeries are performed by either fellowship trained or non fellowship trained dermatologists. Most simple closures are performed by the Mohs surgeon, often with good outcomes. Some patients request a referral to a facial plastic surgeon with significant experience if the lesion is on the face.
The options for reconstruction include: secondary intention, elliptical primary closure, local flap closure, regional flap closure and skin grafts. Uncommonly tissue expanders or free tissue transfer may be necessay with very large defects and is beyond the scope of this article and will be addressed in later posts. Cartilage grafts from the ear or rib can be used to strengthen nasal repairs preventing nasal obstruction or recontour ear defects, and infrequently, bone grafts from the skull may be needed to help rebuild total or near total nasal defects.
With primary closures, the defect should be converted into an ellipse with elevation of surrounding tissue and proper closure technique. Tissue eversion turns out the edges of the skin, puckering the incision to compensate for wound contraction, and is critical to create an imperceptible closure. Placing the incision parallel to relaxed skin tension lines is of primary importance in order to camouflage the incision, orienting it to the naturally occurring wrinkles that develop in the face. The incisions can be revised with either surgical removal and closure or skin resurfacing procedures, after healing for a minimum of 9 months to a year.
Local flap closures are used to repair larger defects that exceed the ability to perform an elliptical primary closure. Geometric patterns are created in the adjacent tissue of the face and flaps of muscle and skin or skin only are rotated into the defect. Consideration of blood supply is essential when designing these flaps of tissue to insure their survival and optimal wound healing. When transposing tissue from the surrounding area it is very important to understand how the direction of pull these flaps generate will affect important surrounding structures such as the eyelid, brow, lip, and hairline. If the flap is placed in the wrong orientation, there can be significant distortion of these structures resulting in patient dissatisfaction.
Regional flaps use tissue from other areas of the face and move it into the defect area. The workhorse regional flaps in Mohs reconstruction are the paramedian forehead flap and cheek interpolation flap. The donor areas come from the central forehead and cheek skin respectively. There is a pedicle with an arterial supply to the end of the flap that is preserved crossing over an intervening area of normal skin while the flap develops a native circulation. The blood supply to the tissue is conducted through the bridge of tissue that is left attached to its origin and arterial supply for at least three weeks. Because the survival of the flap is dependent on leaving it attached, a second stage is required to remove the bridge of tissue and finish the reconstruction of the defect area as well as restoring the donor site. These types of flaps are usually reserved for larger defects of the eyelid, nose, and ear.
Skin grafts are usually reserved for patients who cannot undergo local and regional flaps for either medical of personal reasons. The skin is usually donated from around the ear or the neck and placed into the defect. Because there is no direct blood supply to the tissue, it usually takes longer to heal. Typically, there are more unsatisfactory results due to the longer healing process and the mismatch of skin, but they are convenient for both patient and physician because the procedure is a single stage.
Mohs reconstruction is challenging and requires an experienced surgeon who understands the decision process that goes into closing a defect. Most of the reconstructions can be performed in the office on the same day as the removal. Steroid injections and massage are used to hasten the healing process and improve outcomes if needed. When considering having a Mohs reconstructive procedure it is important to find an experienced surgeon, who understands the challenges and pitfalls of the surgeries and has experience with all the types of reconstructive techniques to achieve optimal outcomes.
Post provided by: MOHS Micrograpic Surgery Atlanta GA | Benjamin C. Stong MD