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Leading dermatologists tap their cosmetic skills to achieve optimal skin cancer surgery outcomes

The goals of skin cancer surgery go beyond curing the cancer and filling the defect. Dermatologists who stress good cosmetic outcomes are integral to optimal patient satisfaction. While some dermatologists prefer to refer their patients to others for needed cosmetic work, many are using their own cosmetic skills to restore and even enhance patients’ physical appearance post surgery. Expert dermatologists shared their professional pearls exclusively for this Dermatology World supplement.

Recapturing a sense of normal ... and more

“Anybody who is doing any work on the face — whether it’s truly cosmetic surgery or purely reconstructive surgery — has to understand that the goal of both is really the same. It’s to try to make people’s appearance normal,” said Christopher Miller, MD, assistant professor of dermatology and director of dermatologic surgery at the Hospital of the University of Pennsylvania. “Every skin cancer removal creates a wound that alters a patient’s sense of what his or her normal face is.” 

Dr. Miller turns to cosmetic-driven literature to inform his approaches to reconstruction.

“The cosmetic literature is where you’ll find explanations for what is considered the aesthetic ideal. For example: the angle of the nose from the lip; position of the eyelids relative to the iris; volume of the cheeks; the volume and position of the vermilion lip,” Dr. Miller said.

Reconstruction often leads to opportunities for other cosmetic improvements, according to Dr. Miller. Thus, dermatologists are not only in the position to restore, but also enhance appearance once the skin cancer has been removed.

“If the patient requires a skin graft around the lower eyelid, you can borrow that graft from many places. But if you take the skin graft from the upper eyelid, you’re effectively giving the patient a blepharoplasty and still achieving the outcome you want. You’re still fixing the wound,” Dr. Miller said.[pagebreak]

Cosmetic approach natural for some

For many dermatologists, performing cosmetic procedures is a part of their everyday practice. Susan H. Weinkle, MD, assistant clinical professor of dermatology at the University of South Florida, incorporates what she does cosmetically into skin cancer reconstruction. She offered tips on some of the common cosmetic procedures she has done in her treatment of skin cancer patients.

“Wounds heal with contraction, and sometimes, a skin cancer doesn’t grow in the right direction [of relaxed skin tension lines].” In order to soften [and relax] that contracture, she injects it with botulinum toxin at the time of surgery. For especially deep cancers, she’ll inject fillers for tissue augmentation, including hyaluronic acid or calcium hydroxyl appetite, after the wound heals. Dr. Weinkle uses a chemical peel to address hyperpigmented scarring. The chemical peel lightens the pigment, and she follows up with hydroquinone. For raised or prominent suture lines, Dr. Weinkle recommends a fractionated laser or dermabrasion to soften the scar.

Good technique key to optimal outcome

Ali Hendi, MD, a Mohs surgeon and attending physician at Georgetown University Hospital in Washington, D.C., believes in the lost art’ of good surgical technique.

“There are a lot of basic [but often forgotten] surgical techniques that give you such fine scars, which, in time, should be almost, if not completely, invisible,” Dr. Hendi said.

When removing skin cancers from the face, the first cosmetic goal is to maintain symmetry. There are several ways to obtain symmetry after excisional surgery and Mohs closure, he said. The first, according to Dr. Hendi, is minimizing standing cones, or dog ears, in the course of a reconstruction.

“Traditional surgical dogma tells you that the length of the closure has to be three times the width, to avoid standing cones. That works on the back or on the arms, but on the face especially on the lower part of the face, along the jawline you need to have a ratio that’s much greater, like five or six to one,” Dr. Hendi said. “That means having angles that are 10 to 20 degrees, as opposed to the standard 30 degrees. It also means having a longer closure. But you’d rather have a longer closure which disappears versus a short closure that leaves you with a standing cone deformity.”

The next consideration is proper eversion. Wounds contract after surgery in every direction, in vertical and horizontal planes.

“When there is contraction in the vertical plane, if there is no eversion or the suture line is flat, what happens is that suture line becomes depressed. You avoid that by suturing in a fashion where you have eversion, which allows you to have a scar line that becomes flat,” Dr. Hendi said.

He explained that on convex surfaces, dermatologists should use a lazy S closure, as opposed to a straight-line closure. This addresses contraction in the horizontal plane.[pagebreak]

Referrals sometimes warranted

Skin cancer patients’ cosmetic needs range from simple solutions, such as fillers, to the placement of prosthetic noses or ears after Mohs micrographic surgery. For some dermatologists, cosmetic management of skin cancer patients necessitates making patient referrals to achieve the best results for the patients.

“Patients are devastated when they have surgery that is potentially mutilating. Cosmetic surgery really transforms those people’s lives,” said Clay J. Cockerell, MD, past president of the American Academy of Dermatology and clinical professor of dermatology and pathology at the University of Texas Southwestern Medical Center.

“I’m not a cosmetic surgeon,” Dr. Cockerell said, “so I’ve referred patients many times to get them the best cosmetic results.”

Dermatologists are on the front lines, however, treating patients before the cosmetic work begins. Dermatologists are the specialists most skilled at taking the least amount of tissue and creating the smallest scar possible during basal cell carcinoma removal, according to Dr. Cockerell.

“We’ll curette the area first to find the extent of the cancer and take the narrowest margin we can,” Dr. Cockerell said. “Sometimes, when plastic surgeons or others who don’t have dermatology background are treating these patients, they just take a one cm margin as a first step.”[pagebreak]

Enhancing the specialty

While dermatologists must ultimately choose whether a referral is warranted, Ronald L. Moy, MD, reminded dermatologists that they have cosmetic training at their disposal, and that taking on that task can enhance the specialty.

“Dermatologists have all the same skills. We suture precisely; we have all the latest laser and resurfacing techniques. You use the same skill set, whether you’re doing a facelift or a flap or graft to close a skin cancer hole.”

Dr. Moy uses laser resurfacing after and, in some cases, during skin cancer surgery.

“We offer laser resurfacing to every patient, even if they have just a straight-line scar or any type of flap or graft,” said Dr. Moy, president of the American Academy of Dermatology and a professor in the division of dermatology at the David Geffin School of Medicine at UCLA. Dr. Moy uses a fractional C02 laser to achieve best results. “We often prevent scars by using fractional lasering’ at the same time that we do the stitching. We use this technique for cosmetic procedures, as well as skin cancer reconstruction, to blend everything, so you often don’t see a scar or there’s less of a scar.”

Another cosmetic pearl, according to Dr. Moy: taking tension off wounds by using buried sutures.

“During a facelift, you use underneath sutures when repositioning the SMAS muscle, to take tension off the skin,” Dr. Moy said. “We try to do that with our skin cancer reconstruction patients. We use buried [absorbable] sutures to take tension off the wound. Anytime you do that, the excision heals better.”

The experts are unanimous in their assessment of the ultimate goal: quality patient care. “It’s important for the patient to have the best cosmetic outcomes possible,” Dr. Moy said. “In doing so, we improve our specialty and build our practices.”

Note: Insurance generally won’t cover cosmetic procedures for the purpose of skin cancer reconstruction the way it does breast cancer reconstruction. Accordingly, dermatologists need to address these costs, upfront, with patients.