Small Basal Cell CA on bridge of nose. How small is too small for Mohs instead of punch excision? (photos)

Question

I was dx'd with a small basal cell on my nose. I am 36 & don't have other medical problems . My MD said the Mohs is unnecessary, i.e. it's too small and if he referred me for Mohs they might laugh at us. I don't want to have a deforming scar in a prominent place. How small is too small for Mohs? He recommends we do a punch excision . My derm is HMO and I am concerned they are trying to save $ rather than provide the best removal method.

Barbara Jemec, MD, FRCS(Plast) · Answer

As the other doctors who have answered your question say it depends on the subtype of BCC. If it is micro-nodular/infiltrative/morpheic then Mohs' is recommended.In the first instance have a biopsy taken so the correct subtype is diagnosed.Scars on the nose will settle well, please don't worry.

Daniel Berg, MD · Answer

Depending on the subtype of basal cell carcinoma there may be roots that are invisible and are best discovered with Mohs surgery.  IN the US, medicare has considered patient age <40 to be an additional indication for Mohs surgery.  Finally, though basal cell grows slowly, you are young and in this location a case could be made for using the treatment with the highest cure rate (98-99%).All of this means that you should not be laughed at for consulting regarding Mohs surgery.  There are other treatments and this decision is ultimately yours after informed discussion between you and your doctor.

Andrew Kaufman, MD · Answer

There are a lot of variables or factors that determine whether Mohs is appropriate. Size of the lesion is one of them. Another is pathology? ... Is it an aggressive subtype of basal cell carcinoma (e.g. infiltrative, morpheaform, metatypical)? Another is location?... Is it in an area where you would want to preserve the greatest amount of tissue or an area at higher risk of recurrence (e.g. nose, ears, eyes, lips)? While not all basal cell carcinomas on the nose need to be removed without Mohs, the recommended surgical margin without Mohs is about 3 mm. That means that an additional 1/8th of an inch needs to be removed around the tumor to give at least a 90% chance that it will not recur. If you try to cheat the margin, there is a higher chance that the skin cancer will recur. Whereas with Mohs generally, we start with a 1 mm margin (i.e. 1/25th of an inch) and then trace out the roots (i.e. higher cure rate and preservation of healthy tissue). I can't imagine a doctor "laughing at" you for referring a basal cell carcinoma on the nose for Mohs. Best option is to discuss with your doctor again about your concerns and see what is right for you. Good luck.

Small Basal Cell CA on bridge of nose. How small is too small for Mohs instead of punch excision? (photos)

Answers (3)