Alternatives to Rhinoplasty for Nose Bulge from Mohs
A doctor said there are 3 options to repair the slight bump as a result of Mohs scar tissue.
1. filler in the bridge of the nose to even it out.
2. take a muscle from the scalp and put in the bridge of the nose to even it out.
3. rhinoplasty, his preferred option. shaving the bone down as he put it. Another doctor only recommended rhinoplasty to shave the bone down for the scar tissue bump to fit into and be less pronounced.
Rhino seems the way to go, yet a bit drastic just to hide this scar bump. Wondering if there are any less drastic options out there that have not been recommended at this point?
Doctor Answers 17
Treatment for nose bulge from Mohs
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.
No rhinoplasty after nasal Mohs surgery
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.
Consider using a Filler
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.
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Best treatment options for Nasal Bulge following Moh's Surgery
Preceived deformities following early rhinoplasty may get worse as the swelling subsides but some will get better. This is the reason all postop rhinoplasty deformities should be treated conservatively and definitive treatment started only after the cause of the deformity has been determined. The "experts" are at a disadvantage in this case as it is unknown how long ago the operation was performed and are not able to feel the bulge to see if it is due to swelling or a bony or soft tissue prominence. My guess is that this is due to a soft tissue (skin) prominence.
When Moh's Surgery is performed it often requires a flap of skin be moved into the defect for closure. This often results in a bulge at the base of the flap. Even when a flap is not neccessary the increased pressure created at the skin closure line can create a bulge at one or both ends of the closure line. These bulges (or bulge) usually improve with time and this can be hastened during the early postop period by applying pressure on the bugles with stretchable tape at night. If a noticable bugle is still there at one year it is probably be necessary to remove it with dermabrasion (sanding) or surgical excision that should leave a small surgical scar which is not be easily seen.
If the bulge is caused by a bony prominence a minor endonasal rhinoplasty with rasping of the bulge to smooth the bulge is all that would be needed. I hope this is helpful
Jack Gunter MD
Correcting Nasal Deformities After Mohs Surgery
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.
Noses bump after Mohs surgery
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.
Nasal Bump After Mohs
The options you have been given are excellent. There are a couple more. I agree with one of the other physicians that I would like to know how long it has been since your excision/repair and I would also like to do exactly what was done. It appears that you had a straight line closure of the wound.
- If it has been a relatively short time since the procedure (less than a year) and it still feels firm, I would suggest waiting with/with out steroid injections into the scar tissue. I have found that several injections help to improve the contour.
- Even with the steroid injections, you may want filler injections to camoflauge the hump until it improves. Obviously the down side to fillers is that the will go away over time and may need to be redone.
- The muscle idea is a great long term option.
- Rhinoplasty is always an option, especially since you had a bump before your surgery. I would caution not to undertake a revision rhinoplasty too soon as you will see settling of the scar over time and can overcorrect your initial hump. Since you already have a scar on the dorsum of you nose, you could use the same incision to perform the rhinoplasty, making the procedure a bit less invasive.
Alternatives for nasal depression.
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.
It does seem as though the options given to you are very reasonable though another would be to rotate a forehead flap down to get the full thickness of the tissue and eliminate the indent. Basically, you either fill in the dent or plane down the bump. It really depends on examining you and what seems to you like it is going to give you the best overall look. Either approach is reasonable.
The scar tissue that's causing the bump on your nose may improve with a dilute triamcinolone injection.
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.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.