Currently, I'm on my general surgery rotation. We had a great skin cancer case come into the resident surgery clinic last week. This lady has been very unfortunate and had multiple skin cancers on her face which have pretty much eaten her nose away. Now, she had a new one similar to the picture below. Her skin cancers, including her new one, were clinically keratoacanthomas. This new one above her lip grew to this size in about 2 weeks. The natural course of these lesions is controversial. Basically, they can be cancerous (squamous cell carcinoma) or they can be benign and go away on their own, only time will tell. Well, most people don't want to wait to figure it out since they continue to grow, etc. (I wouldn't!) So our lady already has a disfigured nose, and now has this new skin cancer which is almost identical to the one pictured below only located directly above the lip, not on it.
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| Lesion similar to my patient's. (Picture from here) |
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We decided to proceed with surgery to remove the lesion and hoped we could find a plastic surgeon to help us with this case. I am by no means even remotely familiar with the administrative/reimbursement side of things, but from my vague understanding, patients come to our resident clinic with little or no fee and are able to have surgery for a much reduced price or free or something of that nature. Therefore, if we need a specialist, we must find someone who will participate in this charity care. Luckily, we found a plastic surgeon who agreed to supervise the chief resident and me on the case!
The next week, we went to the operating room. We cut out the visible tumor and sent it to pathology. While we waited for the results, we determined that that we could very easily close the defect (hole) we had created. Unfortunately, the margins were positive, meaning there was still tumor around what we cut out. Then we had to cut out more, send it to pathology, and wait again. The margins were positive again! The pathologist confirmed that it was squamous cell carcinoma (skin cancer) and said that it was a pretty aggressive tumor because it invaded around the nerves (perineural invasion) in the skin we had cut out. We cut more out and sent it to pathology again. No longer would this be a simple closure. We had created a pretty large defect, similar to the one in the picture below (ignore the grey & black, that was already in the picture). At this point, we were extremely glad to have asked a plastic surgeon to supervise us. He was essential to helping guide us in repairing this hole we had created in our patient's face. The 3rd time we sent tissue to the pathologists, the margins were clear = no more tumor, whew.
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| This is about the size and location of the defect we created. (Picture from here) |
Typically, you can do a rotational flap by taking skin from up near the nose and rotating it down above the lip. So take a look at the picture below with my attempt (the gray & black figures) to demonstrate the technique. Sorry, its blurry. We would cut along the lines, as they did in the picture, then take that flap and swing it over to above the lip to fill the hole we had created by cutting out the skin cancer.
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An example of the rotational flap. (Picture from here)
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However, remember I told you our patient had had multiple prior surgeries on her nose, so we were unable to use the skin near the nose because it was already scarred. We elected to perform this same rotational flap, but in reverse. We cut the flap from down the side of her face by her mouth, rotated it up into the defect, sutured it in place, and sutured the area we had cut the flap from together in a line. When we finished, it looked similar to the picture below. (The black lines show how we cut our flap, although ours were curved).
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| Similar to our finished product. (Picture from here) |
In the end, I think it looked great!
I have actual pictures from all stages of our case, but due to HIPAA, I'm not 100% sure I'm allowed to post them even though she allowed us to take them, so we'll just make do with these pics from all over the internet. I couldn't find any that showed exactly what we did, but I hope I adequately explained the technique.
I love this case, because its relevant to my career and interests. My attending has asked me to do a presentation to all the surgery residents about keratoacanthomas and squamous cell carcinomas at morning conference. (Eek!) I'll be sure to report how it goes...
Disclaimer: I am an intern. I am not a trained dermatologist or surgeon, so this information represents my opinion and not necessarily medical fact.
