Reconstructive Surgery

photo after Mohs surgery before forhead flap reconstruction
photos

The following pages deal with reconstuction for skin cancer. 

Dr. Bentkover’s functional airway reconstruction is discussed on the Rhinoplasty and Revision Rhinoplasty web pages elsewhere on this site. 

In addition to his aesthetic surgical practice, Dr. Bentkover spends a significant amount of time doing reconstructive facial plastic surgery, especially for skin cancer and trauma. Dr. Bentkover feels it is very important to continue using his skills for these patients, especially those who require extensive nasal reconstructions.

To this end, Dr. Bentkover has worked closely with nationally renowned Mohs Micrographic Surgeon, Dr. Donald J. Grande, for over 25 years.  Together, Dr. Grande and Dr. Bentkover continue to take on very difficulty skin cancer cases and strive to deliver the best in skin cancer care.  Our Stoneham location is actually in Dr. Grande’s office, Mystic Valley Dermatology, 92 Montvale Avenue, Stoneham, Massachusetts.  Dr. Grande has trained many Mohs surgeons, and Dr. Bentkover is an active member of his faculty.  

Skin Cancer- an overview
Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year-and the incidence is rising faster than any other type of cancer. While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, or neck, where they can be disfiguring as well as dangerous.

Types of skin cancer
By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it’s also the least dangerous kind-it tends to grow slowly and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage (particularly if it’s located near the eye). Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it’s not treated. A third form of skin cancer, malignant melanoma, is the least common; but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it is not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.

Articles: If you are interested in learning more about skin cancer, at the bottom of this page is the abstract from any article by Dr. Bentkover and some of his colleagues dealing with ways of removing Basal Cell Carcinoma.

Other skin growths you should know about
Two other common types of skin growths are moles and keratoses. Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some-particularly large moles present at birth-or those with mottled colors and poorly defined borders-may develop into skin cancer. Moles are frequently removed for cosmetic reasons, or because they are constantly irritated by clothing, shaving, or jewelry. Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun. Actinic keratoses sometimes develop into squamous cell cancer. Sehorrehic keratoses are raised, rough, pigmented spots which get easily irritated but do not become cancerous.

Recognizing skin cancer
Basal and squamous cell carcinomas can vary widely in appearance. The cancer may begin as small, white or pink nodule or bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that’s rough, dry, or scaly; a firm, red lump that may form a crust; a crusted group of nodules; a sore that bleeds or doesn’t heal after two to four weeks; or a white patch that looks like scar tissue. Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole or brown spot, or as a new growth on normal skin. Watch for the “ABCD” warning signs of melanoma: Asymmetry-a growth with unmatched halves; Border irregularity-ragged or blurred edges; Color-a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and Diameter-a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size.

If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Do not forget your back and your ears.) If you notice any unusual changes on any part of your body, have a doctor check it out.

We have included on this website photos of some extensive nasal reconstruction. These photos are very graphic and may not be appropriate for children or some adults to view.

Abstract of an Original Peer Reviewed Article by Dr. Bentkover and his colleagues

Excision of Head and Neck Basal Cell Carcinoma With a Rapid, Cross-sectional, Frozen-Section Technique
Stuart H. Bentkover, MD; Donald M. Grande, MD; Henry Soto, MD; Beth A. Kozlicak, RN, RNC; Donna Guillaume, RN; Sheila Girouard, RN
Archives of Facial Plast Surg. 2002;4:114-119.

Objectives To compare a rapid, cross-sectional frozen-section technique with Mohs micrographic surgery, using recurrence rate and cost of treatment for excision of basal cell carcinoma as indicators to validate our indications for Mohs surgery.

Design Retrospective study of 557 head and neck basal cell carcinomas excised over 10 years.

Main Outcome Measures Recurrence rates; tumor comparisons by size, location, and subtype; a life table, and a patient satisfaction survey.

Results Recurrence rate for the cross-sectional technique was 2.1% at 5 years. Recurrent tumors had an average diameter of 1.56 cm (vs 1.04 cm for nonrecurrent tumors). Recurrences were in the cheek (30%), nose (20%), temple (20%), forehead/brow (10%), conchal bowl (10%), and postauricular crease (10%). Recurrences were nodular cystic (40%), micronodular (20%), multifocal (10%), and infiltrating (30%). A total of 86.6% of patients surveyed rated the aesthetic outcome of their surgery favorably. The cost compared with the cost of Mohs excision varied depending on the Current Procedural Terminology coding technique.

Conclusions Cross-sectional frozen-section recurrence rates can compare favorably with Mohs micrographic surgery. The cross-sectional frozen-section technique generated a cost savings over Mohs surgery that may not hold true for all practice settings. Margin size did not adversely affect aesthetic results. Loupe magnification x2.5 is important in our technique. We also offer a useful definition for recurrence.


TYPES OF SURGERY

How the cancer is removed

Skin cancer is often diagnosed by removing all or part of the growth and examining its cells under a microscope – a biopsy. It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body. Most skin cancers are removed surgically. If the cancer is small, the procedure can be done quickly and easily in an outpatient facility or our office, using local anesthesia. The procedure may be a simple excision with a relatively small scar.   If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, more major surgery may be required. Other possible treatments for skin cancer include cautery, cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. (Mohs surgery is performed by specially trained physicians and often requires a reconstructive procedure soon thereafter.)

Here is a link to the abstract of an article by Dr. Bentkover and his colleagues comparing two ways of removing Basal Cell Cancer.  Please click the back button on you web browser to return to our website when you are finished.  You may also go back to the previous page to view the abstract. 

http://archfaci.ama-assn.org/cgi/content/abstract/4/2/114

The reconstruction

The different techniques used in for removing skin cancers (like Mohs Micrographic Surgery) are important, but they may leave a patient with a less than pleasing cosmetic or functional deficit. Depending on the location and severity of the cancer, the immediate result may range from a small but unsightly defect to major changes in facial structures such as your nose, ear, or lip. In such cases, Dr. Bentkover’s reconstruction can be very helpful in optimizing the appearance and function of the part of your face affected by the removal of the cancer. Reconstructive techniques ranging from a simple skin graft to a complex transfer of tissue flaps from elsewhere on the body can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.

Some of the techniques include …

  • Simple excisions with straight line closures
  • Skin grafts taken from elsewhere on the body (usually the neck or leg
  • Small adjacent skin flaps – tissue moved from an adjoining area to fill the defect
  • Pedicle flaps – staged reconstructions with flaps taken from more distant areas
  • Tissue expansion – a staged reconstruction involving first enlarging the tissues adjacent to the skin cancer to make more skin for reconstruction

Discussing your options and concerns

A number of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers-and even for malignant melanoma, if it is caught very early.

Dr. Bentkover has well over 25years experience in treating cancers of the face, head, and neck ranging from small early skin cancers to large extensive cancers. He will be happy to discuss various treatment options with you before beginning treatment. The type of treatment recommended depends on the type of cancer, its size and its location.


FAQ

Who gets skin cancer… and why?

The primary cause of skin cancer is ultraviolet radiation-most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and the thinning of the earth’s protective ozone layer are behind the alarming rise we’re now seeing in skin cancers. Anyone can get skin cancer-no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if…

  • Your skin is fair and freckles easily.
  • You have light-colored hair and eyes.
  • You have a large number of moles, or moles of unusual size or shape.
  • You have a family history of skin cancer or a personal history of blistering sunburn.
  • You spend a lot of time working or playing outdoors.
  • You live closer to the equator, at a higher altitude, or in any place that gets intense, year-round sunshine.
  • You received therapeutic radiation treatments for adolescent acne.
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