Basal Cell Carcinoma Mohs Case Study
Mohs surgery allows for the patient to have their cancer excised, the pathology completed and reconstruction of the surgical defect completed in one visit.
W. Elliot Love, DO, Director, Cutaneous Surgery and Oncology
Mary is a 73-year-old woman with a past history of basal cell carcinoma on the left nasal tip two years ago and unrelated ovarian cancer.
- She presented to her plastic surgeon with two months of crusting on the right nasal tip.
- She had a long history of sun exposure, including significant exposure in her second and third decades of life as well as one or two bad sun burns.
- A biopsy done at that time revealed another basal cell carcinoma, infiltrative type.
- She was subsequently referred to the MetroHealth Department of Dermatology for Mohs micrographic surgery.
Mary arrived for Mohs surgery six weeks later. Upon arrival, she had a 1.1-cm crusted nodule on her right nasal tip with an ill-defined anterior border.
- The great majority of the visible tumor involved only the right nasal tip cosmetic unit at this point.
- She had advantageous skin laxity superior and lateral to the tumor.
- The remainder of her physical exam and review of systems was negative for anything precluding her from Mohs surgery.
Named for its originator Dr. Frederick Mohs, Mohs micrographic surgery is the most effective treatment for skin cancer, particularly non-melanoma skin cancer. A fellowship-trained Mohs surgeon receives extended training in cutaneous histopathology and reconstructive surgery.
This allows for the patient to have their cancer excised, the pathology completed and reconstruction of the surgical defect completed in one visit:
The excised tissue is mapped and if there is tumor visible microscopically on a peripheral and/or deep margin, the Mohs surgeon only excises tissue from that location (referred to as a layer). Therefore, functional and aesthetic outcomes are maximized because minimal normal tissue is excised due to direct microscopic examination of 100 percent of the surgical margins.
For these reasons Mohs surgery has the highest long-term clearance rates for treating non melanoma skin cancers, approaching 99 percent.
Mohs surgery is performed under local anesthesia and Mary was anesthetized with 1 percent lidocaine with epinephrine:
- Two total layers were required to clear her basal cell carcinoma.
- Her final defect involved the right nasal supratip, tip and a small portion of the infratip and anterior alar cosmetic subunits (figure 1).
- At this point, all reconstructive options were discussed with the patient, including following up with her plastic surgeon for reconstruction.
- Mary decided to have immediate reconstruction of her surgical defect.
- Because of the superior and lateral laxity, it was repaired using a bilobed transposition flap (figure 2).
Mary followed up six months later and was delighted with her results (figure 3). Not only was she cancer free, she achieved a great aesthetic result without loss of external nasal valve function.
She states “you can’t even see where the surgery was done!”
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