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Cancer on the Face Poses Many Challenges

People seek out of Dr. Cynthia Gregg, one of the Triangle’s premier facial plastic surgeons, for a variety of reasons: they are considering a face lift, a brow lift, rhinoplasty, or other options to alter and improve how they present themselves to the world. This translates into a special concern: how they feel about how they look.

Mary: Before and after reconstruction surgery.

Reconstruction or repair following a facial trauma, such as the surgical removal of cancer, ranks high on the list of emotionally charged alterations of facial appearance.

“Basal cell carcinomas are cancers that can show up on the face,” Dr. Gregg explains. “Their occurrence and location on the face is important because there are anatomical planes—embryonic points of formation—where the carcinoma can grow or skate along these planes. This is particularly true around the middle of the face—on the nose and around the eyes.

“So,” she continues, “you can get a basal cell that on the surface of the skin looks very small, but underneath it’s grown down deep into the tissue following those anatomical planes.”

This was precisely the case for Mary, a 72-year-old patient who had a basal cell carcinoma in the middle of her chin. “It was just a very small spot on my chin,” Mary recalls. “It was minute, really. Then, when the dermatologist did the Mohs procedure to remove it, it was kind of like an onion growing underneath. When the dermatologist finished the procedure, there was a very large hole, about the size of a cigar butt burned into my chin. It was scary to look at to say the least.” (see photos, above).

Mary left the dermatologist’s office where the procedure was performed and went straight to Dr. Gregg the same day. “I’d had the same procedure done for a spot of cancer on my forehead a few years before,” Mary explained, “so I knew to go right to Dr. Gregg.”

Once in the office, Dr. Gregg was able to examine the wound, and together they formed a treatment plan.

Mohs, the procedure to which Mary referred, is a technique used to remove skin cancers from sensitive areas such as the face. “The defect on Mary’s chin measured 14 mm x 13 mm in size and was a full thickness defect, meaning that it went down to the muscle layer,” Dr. Gregg explains. “The really nice thing about the Mohs procedure, a technique performed by a specially trained dermatologist, is that it is ‘tissue-sparing,’ meaning it takes as little of the healthy tissue surrounding the lesion as possible while maintaining a cure rate as high as 99 percent. So while Mary’s lesion was quite deep, it was as small as it could have been and there is little risk of it returning. From a reconstruction standpoint, Mohs is great because it leaves the healthy tissue and, as I proceed with reconstructive surgery, I know my margins are clear.”

Considering Options

Still, when Mary arrived to be evaluated for reconstructive surgery by Dr. Gregg, there were multiple options to be considered on how best to help her surgical wound heal.

“The first option we consider is doing nothing at all,” says Dr. Gregg. “Letting the surgical wound heal on its own, believe it or not, is not an unreasonable option in certain places on the face. A second option would be to do a full thickness skin graft—where we take some skin from another area of the body to graft onto the surgical site. The disadvantage of this is that sometimes the outcome turns out looking like a patch, and also you’re now going to have a scar where we take the skin—usually behind the ear, the lower neck, or above the clavicle area. A third option, if there’s enough skin—for example, on the cheek—is to close it primarily. This is easier on older patients with looser skin, and a bit harder on say, an 18-year-old with less skin laxity.”

A final repair option to be considered, notes Dr. Gregg, was the use of a flap, which was ultimately the option chosen to repair Mary’s chin.

Multiple Flaps

“There are a number of flaps,” Dr. Gregg explains. “Flaps are classified as transposition, rotation or interpolated flaps—each basically consisting of taking skin from one place and moving it over to another location, but leaving it attached to its blood supply. Interpolated flaps are best used for very large defects—for example, on the bottom third of the nose. In this example we could come up to the forehead just below the hair line and swing a flap of skin down, then leave it there for a few weeks, letting the blood supply grow and develop. Then we go in for a second procedure to take down or detach the flap pedicle and put everything back together. This method comes with a little more down time, but the result is often better.”

Facial Procedures

Relying on her extensive training, the latest technology, and years of experience, Dr. Gregg performs the full range of facial plastic surgery procedures, including forehead and brow-lift surgery, facial scar treatment, otoplasty (to correct protruding ears), rhinoplasty nasal surgery, blepharoplasty eyelid surgery, rhytidectomy facelift surgery, and mid-face lift.

She and her staff—which includes a surgical nurse, nurse injectors, and an aesthetician—also offer a comprehensive range of skin care procedures and products, including treatment of sun damage and photo-aging, Botox cosmetic injections, laser hair removal, and use of natural cosmetic dermal fillers such as Restylane, Juvéderm, and Sculptra.

Considering the size and location of the defect in Mary’s chin, another type of flap, called an advancement flap, was chosen for her repair. She was scheduled for reconstructive surgery with Dr. Gregg; and, under IV anesthesia, Dr. Gregg used an O-to-T-flap design to close the defect on Mary’s chin. The results were nothing less than stunning, as the accompanying photographs reveal.

“It was scary to have that much tissue removed,” notes the patient, “so to have it look so good after Dr. Gregg’s repair was a relief.” Then Mary adds with a smile, “and it probably gave me a little bit of a chin lift, too.”

Patients and Process

Dr. Gregg says her goal is always to fix a surgical defect in the best possible way, and it is essential for the patient to be the centerpiece of the process—since they know, for their own wishes, the best of all possible outcomes. “It’s essential for the patient to actively engage in the process, understanding the nature and potential of different options and approaches. No one knows better what the best possible outcomes can be—and each option we consider involves a different process and a potentially different outcome.”

Dr. Gregg

Options also exist for correcting previous repairs that didn’t turn out as well as hoped, notes Dr. Gregg. “There are things we can do to improve a scar,” she says. “We can offer laser resurfacing, micro-needling, silicon gels, silicon sheets, steroid injections—there’s a great deal we can do to improve a facial scar. This is important because what I’ve learned over the years, most particularly when it comes to the face, is that these surgical procedures are a very emotional experience. First comes the diagnosis of the cancer, and then, following surgery, there’s the ever-present reminder. My job is to help minimize that reminder, and in doing so perhaps help to minimize the pain of the trauma of cancer as well.”