Facial Reconstruction
Demands Specialized Techniques
after Cancer Removal
September / October 2002
The rising incidence of skin cancer and the utilization
of Mohs' microscopically
controlled surgery demands increasingly
sophisticated techniques in facial reconstruction from Penn
plastic surgeons. Mohs' combines surgery with microscopic examination
of the tissue to remove non-melanoma skin tumors. With a
99 percent
level of confidence of cancer removal, Mohs' has the highest
cure rate of any procedure for certain types of skin cancer.
Although Mohs' is a tissue-sparing technique, the tumor
often extends beyond what is visible. "Whether the wound
is small or large, it is the smallest wound that could possibly
be made given the size of the patient's skin cancer," explains
Leonard M. Dzubow, MD, chief of Dermatologic Surgery at Penn's
Department of Dermatology.
Plastic Surgery for Facial Wounds
"For some patients their physical appearance after Mohs'
can be devastating. What starts as a small blemish on their
face
can become a sizable wound that alters their appearance," says
Scott
P. Bartlett, MD, associate professor, plastic surgery. "The
reconstructive surgeon's job is to repair the wound so it
heals with an optimal aesthetic and functional result."
Skin grafts, flaps or local tissue rearrangements are employed
depending on the size and location of the wound and what
facial tissue is available in the immediate area. The face
has a unique skin-its own sun exposure, the ability to blush
and a vascularity that is different from skin elsewhere on
the body. "It's optimal to use facial skin for reconstruction.
The key is to rearrange the tissue and minimize the scars
by putting them in areas where they are concealed, such as
in a natural crease," explains Dr. Bartlett.
Complex Facial Wounds
"When functional structures like the nose, mouth, eyes
and ears are affected by skin cancer, it's a marriage of
form
and function to repair the wound and still make the patient
look as much like themselves as possible," says Dr.
Bartlett. For example, when skin cancer invades the nose,
the repair may require intricate rebuilding of the lining
of the nose, utilizing cartilage grafts from the ears to
provide support and a flap to optimize coverage all while
maintaining the breathing function. When faced with an irregular
wound on the tip of the nose, the entire tip is removed and
rebuilt as one unit to maintain a geometric appearance.
When patients are left with a deep defect or more complex
wound, additional incisions and a skin flap are used to establish
a normal contour. "It's easier to camouflage a scar
with makeup than it is to hide a hole or indentation," explains
Dr. Bartlett.
Rebuilding the Eyelid
Rebuilding the eyelid and the areas adjacent to the eyelid,
a fairly common location for skin cancer, present a special
challenge. "Reconstruction includes recreating the
eyelid and preserving eyesight and normal eyelid functions,
such as the ability to open and close and provide moisture," says
Roberta
E. Gausas, MD, director of Oculoplastic and Orbital
Surgery in Penn's Department of Ophthalmology. "Because
the eyes are such an integral part of a person's identity
and personality, it is important to make them look as natural
as possible."
Skin grafts or skin flaps taken from the forehead or the
cheek are often used to form a new eyelid. After the blood
vessels grow in, some patients need a second surgery to separate
the eyelids and complete the reconstruction. Mucous membrane
grafts are taken from the inside of the mouth to match the
moist tissue lining the inside of the eyelid.
"The anatomy and function of the eyelid require that
the physician exercise special care in selecting the grafts
utilized to rebuild delicate eyelid tissue," adds Dr.
Gausas, whose subspecialty is ophthalmic plastic and reconstructive
surgery.
Coordinated Care
At Penn, patients benefit from the experienced Mohs' surgeons
and a coordinated effort among skilled plastic surgeons
who specialize in various aspects of facial reconstruction,
including Dr. Bartlett, Dr. Gausas, and Ara
Chalian, MD,
a head and neck surgeon in the Department of Otorhinolaryngology. "Having
a multitude of specialists enables us to refer patients
to the surgeon with the most skill in each area of the
face," adds Dr. Dzubow.
Dr. Dzubow and his colleague Shobana
Sood, MD, are also
researching a new computerized technology to further increase
the accuracy of the Mohs' technique. By taking digital photos
of the microscopic slides, the device can recognize tumor
cells that the naked eye cannot detect under the microscope.
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referral form or by calling
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