Nasal Reconstruction After Mohs Surgery

Techniques and Considerations to Optimize Aesthetic and Functional Outcomes

The nose occupies a central position in the face and plays a pivotal role in defining one's appearance, identity, and self-image. When skin cancers arise on the thin and delicate nasal skin, Mohs micrographic surgery offers the most precise removal technique.

Yet nasal Mohs surgery often leaves tissue defects requiring complex reconstruction to restore natural contour, function, and aesthetics. From primary closure to sophisticated flap repairs, reconstructive approaches after nasal Mohs excision have evolved considerably.

Optimizing this reconstruction poses challenges amidst the complexities of nasal anatomy, the multifaceted goals of repair, and the confluence of expertise needed across dermatologic and reconstructive specialties. However, when performed skillfully using the most suitable technique, patients' original nasal form and function can be regained.

Background and History of Mohs Surgery

Dr. Frederic Mohs pioneered Mohs micrographic surgery in the 1930s when he performed the procedure on his own face for basal cell carcinoma. By applying fixative and agar to excised tissue, he could precisely map tumor margins and check slide microscopy for residual cancer cells, allowing incremental removal of cancerous tissue while sparing the surrounding skin.

In the following decades, as Dr. Mohs refined his techniques and published data demonstrating significantly higher cure rates for facial skin cancers with his targeted approach, other dermatologists and surgeons adopted Mohs surgery. The technique's superior cosmetic outcomes and maximum tissue preservation made it especially valuable for complex reconstructions like the nose.

Today, with cure rates over 99% for some lesions, Mohs surgery remains the gold standard for the removal of nasal skin cancers. The technique's tissue-sparing benefits are balanced against reconstructive goals like restoring natural contours, minimizing scarring, and maximizing nasal functions. As technology refines Mohs excision, the focus also remains on optimizing reconstructive techniques after nasal Mohs surgery.

Anatomy of the Nose

The nose has a complex anatomical structure consisting of bone, cartilage, skin, mucosa, and various glands.

The bony skeleton of the nose includes the nasal bones and nasal septum. The nasal bones form the bridge of the nose and provide support. The nasal septum divides the nasal cavity into left and right sides and attaches to the maxilla bones.

Nasal cartilage includes the lateral and alar cartilage. The lateral cartilages are C-shaped and form the external nares. The alar cartilages join the lateral cartilages and help define the nostrils.

The nasal skin covers the bony and cartilaginous framework. The skin is thin and tightly attached, making it prone to cancerous lesions. The mucosa lines the nasal cavity and contains glands that produce mucus and trap particles.

The nose contains sensory nerve fibers for the sense of smell. Blood vessels supply oxygenated blood for heating and moisturizing inhaled air.

The nose can be divided into 3 subunits:

1. The dorsum (bony bridge)
2. The sidewalls (form the sides)
3. The tip (alar and lateral cartilages)

Reconstruction after nasal Mohs surgery aims to repair defects in these subunits while restoring normal nasal contours, functions, and aesthetics. Reconstructive approaches must account for the complex interplay between bone, cartilage, skin, and other nasal tissues.

Mohs Surgery for Removal of Skin Cancers

Mohs micrographic surgery is a precise surgical technique for removing skin cancers, especially on the face. During the procedure, thin layers of skin containing cancerous cells are progressively removed while being mapped under the microscope. This allows for maximum removal of tumor tissue with minimal excision of healthy tissue.

Need for Nasal Reconstruction After Mohs Surgery

When nasal Mohs surgery is performed to remove skin cancers, defects in the skin and tissue of the nose often remain that require reconstruction. Reparative procedures are needed to repair tissue and restore the normal appearance and function of the nose.

Reconstructive Options

A variety of surgical options exist for nasal reconstruction following Mohs surgery, ranging from simple primary closure to complex flap reconstruction. Each reconstructive procedure has its own benefits, drawbacks, and resource requirements. 

Reconstructive Technique	Description
1. Direct closure	The skin edges are sutured directly together. The best option for small defects.
2. Skin grafts	Skin is harvested from another part of the body and grafted onto the nasal defect. Can be used for medium-sized defects.
3. Local flap reconstruction
3.1 Bilobed flap	Rotating adjacent skin and tissue to close the defect.
3.2 Transposition flap	Moving skin and tissue from nearby to fill the defect.
4. Regional flap reconstruction
4.1 Nasolabial flap	Rotating skin and tissue from the nasolabial fold to repair the nose.
4.2 Paramedian forehead flap	Rotating tissue from the forehead to the nose.

Factors Influencing the Reconstructive Approach

Several considerations influence the choice of reconstructive technique after nasal Mohs surgery. These include:

1. Size and location of the resulting nasal defect

More extensive lesions requiring larger skin and soft tissue repairs typically warrant flap reconstruction, while smaller defects are often amenable to primary closure or skin grafting. Defects in certain areas, like nasal sidewalls, often favor flap reconstruction to achieve optimal aesthetic and functional outcomes.

2. Available resources and expertise

Reconstructive options vary in complexity, with flap repairs generally requiring more specialized skills, operating time, and postoperative care. The experience level and subspecialty training of the surgical team play a determining role in the range of techniques that may be feasibly employed.

3. Patient characteristics and goals

Patient's general health, tissue availability, comorbidities, desires regarding postoperative appearance and function, and willingness to undergo more involved reconstructive procedures inform the approach chosen. A technique that balances patients' priorities with the technical demands of repairing the defect is pursued whenever possible.

4. Surgeon experience

The reconstructive surgeons' training, specialty, and degree of experience with different reconstructive options strongly influence the choice of technique. More novel and complex techniques are usually reserved for surgeons with specialized expertise in these advanced reconstructive maneuvers.

Preoperative Planning and Consultation

Preoperative planning and discussion between the patient and surgeon are essential for optimal outcomes in reconstruction after nasal Mohs surgery. The consultation aims to ensure patients understand the procedure, align expectations and make an informed decision about proceeding.

Key Elements of the Preoperative Evaluation

Reviewing biopsy results to confirm the extent and location of the skin cancer within the nose

Assessing diagnostic imaging like CT or MRI scans to evaluate underlying bone and cartilage involvement

Discussing the size and complexity of the resulting nasal defect based on the planned Mohs excision

Explaining potential reconstructive options in detail, including benefits, drawbacks, and the likelihood of achieving desired functional and aesthetic goals with each approach

Identifying and addressing any patient-specific comorbidities or anatomical factors that may impact wound healing or the reconstructive procedure

Outlining the risks associated with each reconstructive option, including potential complications and the possibility of revision surgery

Providing realistic expectations for postsurgical appearance, function, and lifestyle limitations based on the reconstructive technique chosen

Allowing time for patients to ask questions to ensure they understand all aspects of the proposed reconstruction procedure

Obtaining written informed consent is also essential to confirm patients comprehend the risks and benefits, are aware of alternatives to the proposed reconstructive approach, and consent to undergoing the procedure. The consent process ensures patients make an autonomous, educated decision regarding their reconstruction after nasal Mohs surgery.

Techniques for Optimal Nasal Reconstruction

The goal of reconstruction after nasal Mohs surgery is to restore both the aesthetic appearance and functional integrity of the nose. Several considerations guide surgical techniques to achieve optimal outcomes:

Achieving natural contours of the nose

Reconstructive procedures aim to repair nasal defects while preserving the creases, convexities, and concavities that define the normal shape of the nose. Nasal subunits are respected to optimize aesthetic results and minimize the appearance of scars. Local flap reconstructions like bilobed flaps often best reproduce natural contours.

Minimizing scarring

Surgical techniques that minimize tension on wound edges and close defects in layers help reduce the prominence and visibility of postoperative scars. Scar revision procedures may also be used to refine and camouflage nasal scars that do impact appearance.

Maximizing functional outcomes

In addition to cosmetic goals, reconstructions seek to restore normal nasal functions like breathing, protection of the nasal passage, and sense of smell. Regional flaps like paramedian forehead flaps, with similar tissue characteristics, often optimize functional outcomes.

Postoperative care

Measures like moist wound healing, meticulous personal hygiene, and sun protection help for optimal healing and the final reconstructive result. Additional procedures like splinting, steroid injections, or tissue expansion are sometimes employed for optimal outcomes.

Potential Complications and Revision Surgery

As with any surgical procedure, complications may arise following nasal reconstruction. Both the reconstructive technique used and patient-specific factors impact the risks involved. Potential complications include:

• Wound healing issues: Delayed healing, infection, and dehiscence can occur, particularly with flap reconstructions and in patients with comorbid conditions impacting wound repair.
• Necrosis of reconstructive tissue: Ischemia leading to tissue necrosis is a concern, especially with more complex flaps that have a delicate blood supply.
• Distortion of nasal contours: Inadequate replacement of nasal subunits and failure to reproduce normal anatomic creases can result in an unnatural appearance.
• Synechia: Abnormal adhesion of nasal tissues that restricts movement and worsens breathing.
• Loss of nasal function: Impaired nasal breathing, protection, and sense of smell may occur due to failure to properly reconstruct key nasal structures.

Revision surgery may be needed to address complications, optimize aesthetic or functional outcomes, or treat discontentment with the initial reconstructive result. The complexity, risks, and resource requirements of revision vary based on the original procedure, complication being treated and reconstructive approach utilized. Patient factors like comorbidities, tissue availability, and expectations also influence revision surgery considerations.

Conclusion

Reconstruction after nasal Mohs surgery for skin cancer aims to restore both the appearance and function of the nose. The choice of reconstructive technique depends on factors like the size and location of the nasal defect, patient characteristics and goals, available resources and expertise, and the surgeon's experience.

While primary closure and skin grafting remain useful options for smaller defects, flap reconstruction often provides superior outcomes for more extensive losses of nasal tissues and subunits. Regardless of the approach utilized, attention to details like achieving natural contours, minimizing scarring, and maximizing functional outcomes can help optimize the reconstructive result.

Proper postoperative care and management of potential complications also influence reconstructive outcomes. Overall, a collaborative approach involving communication between the patient, dermatologic and reconstructive surgeons allows the selection of the technique best suited to address each individual's specific nasal needs after Mohs surgery. 

Contact Dermatology and Skin Health Today!

For the best chance at reconstructing your nose with minimal scarring and maximum restoration of function, consult with the experts at Dermatology and Skin Health for your Mohs surgery. Our certified Mohs surgeons utilize the most precise techniques available to excise nasal skin cancers with the smallest possible defects, setting the stage for optimal reconstructive outcomes. Contact us today to schedule your consultation and learn how we can help completely remove your nasal skin cancer while maximizing the chances of full recovery through skillful reconstruction.