A small portion of the bridge of my nose excised and examined for basal cell carcinoma. Biopsy was positive. Further surgery (Mohs) is suggested. Meanwhile, the site of the bcc excision has healed over and there is only a small pink spot visible on my nose. One has to look closely to see the spot. Question: Is it possible that most of the bcc was removed on original excision? Should I have further surgery even is there appears to be no lesion visible? Can I wait to see what happens?
Is This Surgery Necessary?
Doctor Answers 8
Most likely yes
I am sorry to hear about your skin cancer. Please remember the biopsy was only a tool to obtain a tissue diagnosis and not a treatment. It only took a portion of your lesion and it wasn't intended to remove the entire thing. This is done to find out if a lesion needs further treatment or if it is a benign (not dangerous) lesion. The wound healing process often makes it look like there is not cancer remaining but there is likely cancer left behind underneath the top layer of the skin.
Mohs surgery is the gold standard for removing skin cancers on the face with the highest cure rate. Today Mohs surgery is done by board certified dermatologists who have completed additional surgery training in Mohs and Reconstructive surgery.
The decision to undergo Mohs or other treatment types is up to you. Also, it is up to you whether you want the Mohs surgeon to do the reconstruction following the surgery or if you wish to have another specialist do the reconstruction. I can tell you that a Mohs surgeon that is a member of the American College of Mohs Surgery is an expert at Mohs and Reconstructive surgery. Most of the facial reconstructive procedures for skin cancer are done by American College of Mohs Surgery members. Given the sheer volume and advanced training they have in doing just Mohs surgery and reconstructive surgery, in my opinion, they are the best specialist to treat your skin cancer and reconstruct your hole. Other specialists are also an alternative but you should feel comfortable with whoever it is.
Is Mohs Surgery Necessary?
Thank you for your question. Yes it is possible that most of the BCC was removed with the biopsy, but many skin cancers can appear as small lesions on the surface, and extend more deeply and widely under superficial layers of the skin…much like an iceberg. The recommendation with this sort of a case should you choose to do nothing, is to do so only with close supervision by your surgeon and/or Board Certified Dermatologist. Most Mohs surgeons would agree that this sort of a case, be evaluated and treated with Mohs Micrographic Surgery, so as to preserve as much of the normal non-affected skin as possible, and to provide a closure result with the best cosmetic result. I hope this helps.
BCC excision of the nose
The biopsy of the area simply tested the area to determine a diagnosis. Even if the biopsy did in fact remove the entire lesion, which is unlikely from a routine biopsy, you will still require a procedure to remove the entire skin cancer as well as obtain adequate surgical margins to decrease your chance of recurrence of the BCC at that site.
It sounds as if it were a small area - both surgical excision and Moh's treatment will give you excellent cure rates, The location of the area would determine, for me, which modality I would recommend for you. Often times, surgical excision with adequate margin is adequate treatment, unless recurrent CA, morpheaform BCC, or in an area in which saving as much tissue as possible is warranted.
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Mohs surgery even if biopsy spot nearly imperceptible
You ask a question that comes up over and over again in my practice. The reality is, even though you do not see anything clinically other than the pink spot from the biopsy scar, it is really impossible to tell with the naked eye whether or not all of the tumor has been removed with the biopsy. Mohs surgery is really the gold standard for treating non melanoma skin cancers on the nose because it allows us complete microscopic control of your skin while sparing normal, healthy skin. I would encourage you to follow your doctor's suggestion and undergo mohs surgery.
Is Surgery Necessary??
Skin cancer can grow at a rapid pace. I encourage you to have your mohs surgery as soon as possible.
Mohs Surgery #mohssurgery
I do several hundred Mohs' closures every year. I think you ask such a great question that I often hear from my own patients. Unfortunately you need cleared margins. Yes, often all or most of the skin cancer is removed by biopsy but if your biopsy report states margins are positive you need clear margins. In the head and neck area I feel that Mohs is an excellent way to go. Recurrence rates are lower and cure is greater. I work very closely with Mohs surgeons and I am very glad to have them. I would see a Mohs surgeon for sure. Despite not being able to see it any longer I can assure you there are tumor cells present if the biopsy did not show clear margins.
Basal cell carcinoma on nose
Basal cell carcinoma can grow under the skin, and may not be very visible from the surface. The biopsy showed the presence of basal cell carcinoma cells, there are likely still cells there at the base of the biopsy. The purpose for performing Mohs micrographic surgery, is to take out a small amount of tissue, examine the margins to see if the tumor is still there, and if it is- go back and get more only in that microscpic area. The reconstruction is usually performed after the tumor is removed. This technique gives you the best cure rate for basal cell carcinomas. If you leave the tumor cells there, they will declare themselves to you in the future as a visible spot- but the depth may be much bigger than what can be seen with the naked eye.
Most likely there is residual Basal Cell Carcinoma (BCCA) left as a positive margin. This is why your doctor is recommending more surgery. May I suggest you request a copy of your pathology report to confirm that you still might have the BCCA ( Positive Margin). Further, this report will tell you what type of BCCA you have gotten.
There are basically 3 groups of BCCA commonly referred to by practitioners. Superficial BCCA is often a very superficial process easily managed. Nodular usually presents like a shinny mole and is localized. The last and worst king of BCCA is called sclerosing, moriphorm, infiltrative, etc. BCCA which grows like crab grass. This type is most commonly removed by what is called MOHS Surgery. There si one other type BCCA that can be somewhat aggressive. It presents as an ulcerated lesion usually indicating that the lesion is extensive and is beginning to burrow down or do deeper.
Moh’s Surgery was developed by a General Surgeon named Dr. Moh’s. The technique is most commonly utilized to remove aggressive skin tumors like infiltrative BCCA but, has been expanded to cover other more less aggressive skin tumors by some Moh’s Surgeons. The technique entails removing the cancerous growth with a typical margin/ excision of normal tissue. The defect is mapped out and normal tissue is then removed around and deep to the area of the original tumor excision. This is because as I stated earlier some skin cancers can grow out like crab grass. The pathologist or Dermatopathologist will then look at the specimens to make sure your margins are all free of the BCCA.
Surgery may not be your only option. Certain BCCA’s like nodular & Superficial spreading respond to other forms of treatment with equal effectiveness like Radiation Therapy. Consider returning to your practitioner to discus your options.
The number one goal of your surgery should be to get ride of the skin cancer. The number two goal should be functional reconstruction after surgery so, you do not have issues such as difficulty breathing. And, you last goal should an aesthetically acceptable result. No one likes to end up disfigured. This is why many patients seek out a member of the ASAP/ ASAPS for there reconstruction after Moh’s Surgery. Best,
Gary R Culbertson, MD, FACS