Alternatives to Rhinoplasty for Nose Bulge from Mohs

Mohs surgery is  procedure named for Dr. Frederick Mohs, who developed this skin cancer removal technique while he was a medical student. Mohs surgery involves removal of a skin cancer by checking microscopic margins to assure complete removal of the tumor while limiting the amount of normal tissue removed. It is commonly used for skin cancers of the nose, eyelid, lip, ear......places where you want to remove the smallest amount of tissue possible and still remove the whole tumor. Once Mohs surgery is performed, the resultant defect (hole) is repaired, usually with a skin graft, skin flap, or sometimes it heals the best without any repair at all.

Your photos show that the surgeon used a skin flap to repair the defect left in your nose after the skin cancer removal. This flap has caused elevation of the tissue in one area causing a bump, and a depression above the bump where there is scar.

It doesn't make any sense to me for you to have a rhinoplasty, since there has been no nasal bone or cartilaginous change to your nose, you just have a soft tissue problem. It also seems overly aggressive to have a "muscle from your scalp" placed. With the large defect you have, I think it would not be advisable to use filler as a first option.

Although it is hard to tell for sure without examining you, my inclination would be to work on the soft tissue scar, since you were happy with your nose before the Mohs surgery. The flap could be thinned surgically under local anesthesia, possibly steroid injected, and if there was still a deformity superiorly, maybe a little filler could even things out. I agree with your feelings that something "less drastic" should be done.

I read your concern and reviewed your photos. If the bump on your nose is comprised of mostly scar tissue, consider asking your dermatologist if you might benefit from a dilute triamcinolone (Kenalog) injection. A steroid injection may soften the scar tissue and improve the appearance of your nasal profile.

I hope this is helpful for you.

Many defects that result following facial skin cancer removal using Moh's technique require local flap reconstruction. Although many of these flaps can be one stage procedures, it is extremely common for some to require some type of secondary revisional procedure. Small areas of excess tissue, as you are experiencing, are common following local rotation flaps. Many of these will smooth out over time, however a significant number will require a small revision procedure to help refine the contour.

With out the benefit of touching your nose I will make either one of two assumptions. If the bump is hard and you had it before your surgery you would need a rhinoplasty to remove it. If the bump is made up of soft tissue and you did not have it before the surgery a simple injection of steroid  to diminish the scar and swelling would probably work very well.

Good luck.

There are several options here for this type of post MOH's nasal deformity which I have seen a lot over the years. The best option is to do a filler above the bulge to give the appearance of a natural dorsum using Restylane which is the best HA filler for the nasal dorsum. It will last almost 2 years and by that time the rest of the MOH's deformity will have settled down in most instances so no further surgery is needed.

Dear rhinoplasty patient,
I reviewed your post Mohs surgery’s photo. It appears that the scar formation after your Mohs surgery has created the bump on your nose. All options that were given to you by your PS are great alternatives to treat your nose. I would go with a conservative option. First, I would inject the area with small amount of Kenalog, and then in three months, I would inject Radiesse to the bridge of your nose. Good Luck
 

If you are happy with rest of the nose I would use a combination of soft tissue over cartilage to fill in the dent. Though fillers can improve this, they would fall short of correction, be expensive and need to be redone every year or two. Make sure you see an experienced rhinoplasty surgeon for this problem for the best result.

There are several alternatives to correct contour deformities of the nose that arise after Mohs surgery.  These include a formal rhinoplasty to reshape the nose, fillers to fill slight depressions or camoflauge irregularities, local flaps to rearrange the soft tissue (skin) envelope, or soft tissue augmentation (building up) -- a thin layer of scalp tissue, called fascia, is frequently used.

The extent of the deformity will dictate which technique will provide the best result.  Sometimes, a combination of techiques is required.  Your surgeon has offered three good alternatives to fix your problem.  Based on the pictures you provided, it appears as though a rhinoplasty to remove the underlying boney hump AND slight soft tissue augmentation with temporalis (scalp) fascia will restore an aesthetically-pleasing profile.

Good luck. 

The external surgery on the nose from Mohs micrographic surgery will definitely leave a scar, that will be permanent. Building up the bridge of the nose can be performed during the rhinoplasty procedure with cartilage taken from the internal portion of the nose. In addition, rasping of the hump should also be performed to give a better aesthetic profile. The only way this would be done is through a rhinoplasty procedure.  

I would wait for 6 months to see if the scar has flattened. Steroid injection is a good option while waiting. If the soft tissue bump from the Moh's scar is still unacceptable I would try scar revision first followed by laser resurfacing. With your skin type this should be satisfactory if you were happy with the shape of your nose prior to the Moh's. Otherwise a rhinoplasty will be in order. However I will not alter the bone to fix the soft tissue deformity.