NEW YORK PLASTIC SURGEON
Plastic Surgery New York, NY
Darrick E. Antell, M.D.
850 Park Avenue, New York, NY 10075
The most important factor in attaining a great result from plastic surgery is the surgeon you choose. Working closely with dermatologists (especially Mohs surgeons) who remove skin cancers, plastic surgeons are often an integral part of the treatment team, ensuring optimal closure of wounds and the best possible cosmetic result. If your dermatologist feels you need reconstructive surgery after cancer removal, odds are he or she will have a short list of preferred plastic surgeons you can choose. Sometimes the best plastic surgery is the one you don't perform. Although surgeons are typically not paid for not operating, earlier this year a patient sent me a full payment check with a lovely thank you note for having advised her not to have surgical reconstruction after her Mohs procedure. This highlights the option of letting wounds heal on their own. If the wound is large enough, this can't always be done, but in this particular case, I had advised the patient that I could see her periodically to observe the natural healing, and we could intervene with a skin graft or another procedure at a later date if needed. Having carefully chosen this approach, we were all delighted with the final outcome, with no reconstruction required.
THE DAY OF SURGERY
In my practice, I often see patients before they have skin cancer surgery to review post-treatment options. Then on the day of their cancer removal, we list the patient on our schedule
Perhaps the biggest advantage of a two-surgeon approach, as in other cancer operations, is that the primary surgeon need not be inhibited from removing as much tissue as needed.
as a "possible" surgical case. After the cancer is out, the dermatologist may choose to repair the wound, or may refer the patient to us. Consider consulting a plastic surgeon with a private, on-site fully accredited operating room, which provides the flexibility to accommodate a surgical case on short notice. This allows better access to care, so the final decision on whether to refer the patient to the plastic surgeon can be delayed until the cancer surgery is completed.
The Value Of Teamwork
Perhaps the biggest advantage of a two-surgeon approach, as in other cancer operations, is that the primary surgeon need not be inhibited from removing as much tissue as needed. The primary surgeon knows that the plastic surgeon is there to back him or her up and take on the repair regardless of the size and location of the wound.
Teamwork is the cornerstone of good medicine; for example, in breast cancer surgery the plastic surgeon takes over after the breast is removed by another surgeon. Similarly, in skin cancer surgery the reconstructive plastic surgeon comes into the picture after removal of the malignant area. I regularly work with the patients of a number of local dermatologists. I also work directly with patients from out of town who have recently had skin cancer surgery; the patient or the surgeon often emails postsurgical photos before the visit so that we may better plan the reconstruction.
The Reconstructive Process
Two common reconstructive options are skin grafts and flaps. A skin graft is the transfer of skin tissue from one part of the body (the "donor site") to another (the wounded area). Skin donor sites are carefully chosen, taking into account the location on the body (the more inconspicuous the better), skin color, thickness and a whole host of other factors. In some instances, the wound may need to settle down prior to reconstruction, since there may not yet be a good "bed" on which to place a skin graft — the skin will likely be inflamed and swollen. In that situation, standard local wound care is initiated and a graft is applied several days later. But if the wound appears to be ready for it, a skin graft can be performed on the same day as the skin cancer removal. Once the graft is placed, a new blood supply should develop naturally to keep the area vital.
When preferable, a skin "flap" may be chosen for the surgery instead. A flap is a piece of tissue that, like a graft, is moved from one area of the body to another. Unlike skin grafts, flaps are typically left attached to one or more sides of their original site to maintain the blood supply. They also usually include the underlying fat or muscle to provide a better blood supply and thicker coverage at the site of the wound. Local flaps (the vast majority of skin flaps for skin cancer reconstruction), which come from the area immediately adjacent to the wound, are ideal if cosmetically feasible.
shows a patient for whom a "bi-lobed" flap was chosen. The left photo shows the original open wound with a Mickey Mouse ears-shaped bi-lobed flap. The flap tissue was transplanted from an area just outside the plane of the photo and then.
It is always better to undergo treatment before the cancer grows larger, thereby destroying more tissue and requiring more difficult surgery and reconstruction.
rotated onto the open wound, being distributed over the greater surface area of both the donor site and the postsurgical cancer wound. When the donor site is closed, the cancer defect site is generally closed as well. The "after" photo shows a well-healed flap; no further treatment was necessary. In some cases as the flap heals there may be a need to dermabrade (sand) the edges, or inject cortisone under the flap to decrease swelling. Careful observation and follow-up appointments will allow the best course of action.
Many people delay seeing their dermatologist for fear of having to undergo a surgical procedure, but it is always better to undergo treatment before the cancer grows larger, thereby destroying more tissue and requiring more difficult surgery and reconstruction.shows an extremely large basal cell carcinoma which involved the cheek, side of the nose, lower eyelid and upper lip. Fortunately, despite the size of this skin cancer, the final surgical result was quite acceptable. Today, many options exist to restore one's appearance after skin cancer surgery — from letting the wound heal on its own to a variety of grafts and flaps. Your dermatologist and plastic surgeon are available to advise you and share their expertise, even if it means no repair is indicated.
DARRICK ANTELL, MD, is a plastic and reconstructive surgeon with an appointment as Assistant Clinical Professor of Surgery at Columbia University. Dr. Antell is a member of The Skin Cancer Foundation's Amonette Circle.
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