A man in his late 60’s with a lentigo maligna melanoma of his right lower eyelid and a recurrent squamous cell carcinoma of his left cheek. He was pretreated with Aldara, an immune sensitizer to decrease the size of his lentigo maligna melanoma. He is shown 14 months after Full thickness skin graft to his right lower eyelid after modified Mohs excision, using his upper eyelid skin as a donor site. Enough skin could be harvested from his upper eyelids, improving their appearance and giving the perfect thickness and color of skin to match his lower eyelid. Two months later he had his recurrent SCCA excised with Mohs surgery.
He is also shown 1 year after Mohs excision of his left temple SCCA, with the defect being repaired with an extended Mustarde’ Cervical- facial flap. A large flap is developed from the left cheek, like a facelift flap, and the incision is continued in front of and then below the left ear, advancing the neck and cheek skin into the defect. The skin matches in color and texture, and continues to grow his normal beard.
A retired man in his later 60’s with a lentigo maligna melanoma of his lower lip. He is shown just after modified Mohs excision and again, 4 months after excision of the remaining sun exposed vermillion of the lower lip and vermillion advancement. The modified Mohs allowed us to clear the margins of his tumor with the smallest possible defect. Excision of the remaining sun exposed vermillion of the lower lip decreases his chance of developing another sun related malignancy there. The vermillion advancement takes non sun exposed vermillion from inside the lip and moves it forward. The scar will thicken for 6 weeks and then softens over the next 2 years. At 4 months his lip is soft and mobile and the scar is difficult to see from even a close distance.
A woman in her early 80’s with a defect of her nose after Mohs excision. She is shown just after Mohs surgery but before reconstruction with a Rieger type flap. She is shown again, 4 months after repair. Scar has faded nicely and the skin matches in color and texture.
A woman in her mid 70’s with a large defect of her nose after Mohs excision of a basal cell carcinoma. She is shown just after Mohs and again, 1 year after a v-y Rieger flap of her nose performed under local with iv sedation as an outpatient.
An interesting case of a man in his early 80s with a squamous cell carcinoma of his chest. I sent him to our local Moh’s surgeon for excision and then planned his repair. The key was to design the rhomboid flap so that it would not distort the location of his nipple and leave him with significant asymmetry. He is shown after Mohs and again, 2 1/2 months after flap repair under local with IV sedation at the hospital. The scar will typically now fade over the next 2 years. He can take his shirt off at the pool without feeling deformed.
A woman in her mid 70’s with squamous cell carcinoma of her lower lip. She had a large defect after Mohs excision which I was able to repair with an advancement of the non-sun exposed mucosa from inside the lip. She is shown before and again, 9 months after surgery. Her lip motion is normal after surgery.
A man in his later 60’s with a lentigo maligna melanoma of the lower lip. A lentigo maligna melanoma can sometimes be much larger than expected. He was treated in combination with the Mohs surgeon who performed modified Mohs, sometimes called “slow mohs”. In normal Mohs surgery the dermatologist maps the lesion and performs a frozen section of the edges. Frozen section cannot be done on pigmented lesions because it distorts the view- the same mapping technique can be done but the sections are sent out for permanent path with a rapid turn around. The techniques takes days rather than hours and is typically done over the 5 days before planned reconstruction. In this way, the reconstruction is able to proceed with clear margins. In this man’s case the defect was limited to the central vermillion ( pink part) of the lip. Because this is thought to be caused by chronic sun exposure of the lower lip, it is good, if possible, to excise the remaining sun exposed vermillion and roll the non sun exposed vermillion from inside the mouth to reconstruct the lip. This is sometimes called a “vermilionectomy / lip shave with mucosal advancement procedure”
This was done here, and he is seen after the modified Mohs and again, 6 weeks after surgery. Scars are typically at their thickest and reddest at 6 weeks, but he already has a “normal” appearance. The lip feels a little stiff to him at 6 weeks but he can whistle, and the scar will now continue to soften and improve over the next 6 months or more. A good solution to a sometimes difficult problem.