My Mohs Surgeon does his own reconstruction. Should I request a plastic surgeon? I have Basel Cell Carcinoma between my eye and my nose, and I have yet to have my pre-surgery consultation with the surgeon.
Should I Request a Plastic Surgeon for Mohs Reconstruction?
Doctor Answers (15)
Mohs reconstruction options
Following Mohs surgery nearly all of the reconstructions are performed by your Mohs surgeon assuming that they are fellowship trained and a member of the Amercian College of Mohs Surgery. The key word is College and not Society as there are several gorups out there with similar names. Only members of the Mohs College have been required to spend an additional year after board-certification performing over 500 Mohs cases, becoming experts in complex reconstruction of grafts and flaps, and have experience with the most challenging skin cancer cases. Therefore, finding a fellowship trained Mohs surgeon will provide you with a good starting point. So once you have looked them up in the mohs college directory online, you should ask during your consultation to see examples of their work in reconstruction. Lastly, a great Mohs surgeon will always be open to working with a local plastic, facial plastic, or oculoplastic surgeon should the patient prefer this route. The most important thing for you and your Mohs surgeon is that whatever decision you make, you should be 100% comfortable with your choice beforming the operation begins.
Your Mohs surgeon can help you decide on the optimal reconstruction after Mohs surgery
In the US, the majority of reconstructions done after Mohs removal of a skin cancer in this country are done by the Mohs surgeon, typically immediately after the skin cancer removal. Fellowship-trained Mohs surgeons are usually dermatologists who have done a full year of training after residency devoted primarily and specifically to Mohs surgery and the reconstructive techniques necessary to repair the defects. Mohs surgeons, plastic surgeons and other specialists (facial plastic surgeons and oculoplastic surgeons) share the same techniques in reconstruction, some with special expertise in certain areas (e.g. eyelid). Each Mohs defect and patient is unique but both training and specific experience are the best predictors of a good outcome. In my practice as a Mohs surgeon, I repair the majority of my defects and have literally done thousands of these reconstructions with local flaps, skin grafts, and other repair techniques. I work with colleagues in other specialties when they can provide something additional that will benefit the patient (e.g. general anesthetic for larger cases or more anxious patients or reconstructions that cannot be done well in the Mohs setting under local anesthesia). In your case, you can ask about the experience and training of your Mohs surgeon and might ask to see pictures of their work with similar cases. If you decide to work with a different specialist for repair, you should make sure that that specialist got good training in Mohs reconstruction (not always the case) and that they do enough of these to have a good feel for the reconstructive options. A surgeon doing mostly breast reconstruction, for example may not always be your best choice for reconstruction of your Mohs defect. No matter who does it, you need to be aware that there will be a scar of some sort that will evolve with time and will be dependent not only on the surgeon but on factors like the presence of complications, or the type of defect and repair needed. I like seeing patients in consultation prior to surgery so that I can explain the likely reconstructive options and show photographs so that the patient has the best possible understanding of what's likely to be involved. You should use your consultation to become well-informed as well!
Consider that a plastic surgeon has a minimum of 6 years of surgical training. Now consider that a dermatologist has zero years of formal surgical training.
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MOHS repair options
When choosing a surgeon to perform your Mohs surgery, trust your face to a Board Certified Facial Plastic Surgeon specialist who is uniquely trained and expertly qualified to perform the Mohs Surgery. It is important that the Surgeon you choose understands the importance of removing a cancerous tumor while maintaining both the integrity and cosmetic appearance of the healthy tissue and skin. The most precise method for removal of the cancerous tissue spares the greatest amount of healthy tissue. For this reason, the Mohs surgery may result in a significantly smaller surgical defect and less noticeable scarring, as compared to other methods of skin cancer treatment. Talk to your Facial Plastic Surgeon to assess whether Mohs Surgery is the most appropriate treatment option for your particular diagnosis. Best of Luck! Dr. Clevens
Eyelid Reconstruction after Mohs Surgery for Skin Cancer
Fellowship-trainined MOHS surgeons are dermatologists who have received additional training in treating skin cancers. Most of them are also very well trained in repairing defects in most parts of the face. However, eyelid skin cancers are challenging to repair especially when they involve the lid margin, eyelashes, and the tear duct drainage system. You may want to consult with an Oculoplastic Surgeon to help in the reconstruction of the defect after the MOHS procedure has been performed. I regularly work closely with fellowship-trained MOHS surgeons in coordinating the removal of the eyelid skin cancer (through MOHS) and then having the patient come to my surgery center for the final repair of the defect, which can be performed through various techniques depending on the size and other variables that are discussed in a consulation. Hope this helps and good luck.
Repair of MOHS around the eyelid
Reconstruction of the eyelid after MOHs require techniques that reduce the possibility of lid malpositions such as ectropions or eyelid asymmetry. If the lesion is small and there is excess skin, closure of the wound without adjacent tension will likely not result in lid malposition. However, if there is exisiting laxityof the lower eyelid and if the closure imparts tension such that the lid moves away from the eye, reconstruction using free skin grafts or myocutaneous flaps might be recommended. It is important to discuss these issues with your MOHS specialist and he or she will provide excellent advice and direction for the reconstruction.
Reconstruction After Mohs Surgery
In general, an individual fellowship trained in Mohs surgery is more than capable of treating your tumor and reconstructing the defect. I work with a number of fellowship trained Mohs Surgeons in my area who are excellent what they do, but sometimes feel it is appropriate to refer patients to me for a variety of reasons. These reasons include complex nasal, lip, ear, or scalp defects which are very large in size or in which important structural elements such as cartilage or nasal lining are missing. The second reason is patient preference: some patients request to see a Facial Plastic Surgeon for their reconstruction. From a Facial Plastic Surgeon's perspective, a Mohs Surgeon provides a very valuable service, because excision of well differentiated skin cancers (if performed by me), requires frozen sections, which is a less than efficient way to spend my professional time. Lastly, the Mohs technique is the most accurate way of removing well differentiated skin cancers (SCCA or Bcca).
Should I request a Plastic Surgeon do the repair after Mohs surgery
The correct answer is you should pick the person who you think is going to give you the best result. As mentioned by many others a well-trained and experienced member of the American College of Mohs Surgery should be able to perform just about any necessary reconstruction, but if you think that a plastic surgeon is going to give you a better result, pick a plastic surgeon. That's not to say the plastic surgeon will provide the smallest scar or the best cosmetic result. Both Mohs surgeons and plastic surgeons are going to leave a scar. You can't repair a wound without leaving a scar. It may be the most beautiful scar in the world. But if somewhere deep in your brain you think another specialty or another particular doctor would have given you a better result, you might not be satisfied with the most beautiful scar in the world. So be true to yourself and pick who you think is the best to do the repair. The vast majority of my patients are repaired by myself and are extremely satisfied with the results. But if a patient ever "wonders" whether they should see a plastic surgeon, I encourage them because in five years I want them to be satisfied with their results.
Reconstruction following MOHS surgery
Reconstruction following MOHS surgery can be adequately repaired by well trained MOHS dermatologic surgeon. However, in the particular area that your skin cancer is located in - between the eye and nose, the skin cancer may involve the tear drainage system or other periocular structures. In this case, you may want to consider an oculoplastic surgeon who is well versed in the tear drainage system and periocular structures to repair your defect. Appropriate reconstruction is necessary in this specialized area to obtain a good functional and cosmetic result.
Reconstructions by a fellowship-trained Mohs surgeon
The answer lies with the training in reconstructive techniques that your Mohs surgeon received during fellowship and experience acquired while in practice. As a Mohs surgeon, I routinely perform complex reconstructions such as flaps and grafts on patients undergoing Mohs micrographic surgery. I often find that my annual volume of highly complex reconstructions such as forehead flaps exceeds those performed by quiet a few of my colleagues in other surgical specialties. While plastic surgeons may boast of the number of years spent in surgical training, keep in mind that little of that time was devoted to reconstruction of post-Mohs defects. Fellowship-trained Mohs surgeons spent the entire fellowship learning techniques specific to such reconstructions. In your particular case, question your Mohs surgeon on his or her experience and comfort level with reconstructive techniques; find out if s/he is fellowship trained. You may also request to see photos of the previous outcomes from similar reconstructions. If you are not satisfied with what you hear or see, you can seek a second opinion from ENT, plastic, or oculoplastic surgeon, depending on the location of the tumor.