Paramedian Forehead Flap

Hi Mooomm,

Thanks so much for getting back to me. It means a lot!  :-)

When the MOHS was planned, I was told having a skin flap of some kind would be the best way forward. I elected to go privately, as the wait for an NHS 'slot' to become available, even on the 'urgent' list, felt too long for my comfort. The MOHS surgeon could do the MOHS two weeks later, but there was no plastic surgeon available on that date. He offered to put off the operation, but I knew it would be another month or so before he would next be available privately, so as he sounded confident about going ahead and thought it important to get the cancer out, I decided to proceed on 13.4. 

After completing the MOHS the surgeon tried to work out how a flap could be done, but because I have a big nose (!) and the hole from the MOHS was 28mm stretching across the whole tip of my nose, he couldn't find enough skin from around my nose to do one. I asked about the forehead flap which he couldn't do there and then (I think it would require a plastic surgeon and full anaesthetic) and he reflected that he wasn't sure if that was a good idea, because the length of my nose would mean the flap would go into the hair line, and I would have hairs on my nose. 

We agreed on a graft from my clavicle (again - the amount of skin required was too much to take from in front of my ear) on the basis that, if it didn't look good enough in the end, a plastic surgeon could put it right later. If he tried to do a flap and it didn't look right, it would be more difficult to put right. 

So my questions are a) around his concern about having hair on your nose - should I worry about that or can it be dealt with, and b) should I ask to see a plastic surgeon now, or wait for 6-12 months as was suggested, to see the final result of the graft, and whether / how it could be improved on?

Thanks again for your thoughts. With all my best, 

Sorry - I should use my name for here, shouldn't I - Ilona!  :-)

Hello Illona,

Thanks I understand now. I am not a plastic surgeon or a dermatologist and ultimately you should take their advice. When mine was done my understanding was that the gold standard to achieve best aesthetic result was to reconstruct the nose tip with a paramedian forehead flap. My defect was similar in size to your and as deep as the cartilage but not into it. 

My Mohs surgeon worked as a team with a plastic surgeon. I understood that after the MOHs removal it was best to proceed to paramedian forehead flap within a few days, Of course your case could be different. I was told that my forehead was too short so the end of the pedicle extended into my hairline. This means that more than half of the graft on my nose is from the hairline and grows hair. I had to wait until the plastic surgeon was happy and make do with daily shaving. Then I started laser hair removal which is a long slow process. As some of my hair was grey laser does not work on it so I am now about to begin a long course of electrolysis to try to remove more. 

I was warned that I would require grit to deal with the whole reconstruction. Others have posted photos and details of their journeys with this kind of sugery. I suggest you might want to view their  accounts on this site. Only you can decide if you are happy as you are . 

For me I had no choice if I wanted to have a nose . As it is the plastic surgeon has done a great job with the shape. The colour of the graft is still improving. I use camouflage make up daily. I find the hair growth very difficult to accept hence my efforts to remove it. It needs to be shaved well to allow make up to be applied. 

It seems to me you need a Professional opinion as to whether you should act now or even whether the first graft would have to be left to heal a while before disturbing it..

I hope I have been of some help, Best wishes with what ever you decide, 

Dear Mooomm,

Thanks for your very helpful reply. I am seeing the doctor tomorrow for the dermabrasion so hopefully I can talk with him.

I think you're right and your defect is about the same as mine (also to the cartilage, but not into it - though the final histology report hasn't come back yet). You had the same problem - that the length of your forehead was not enough to cover the length of your nose down to the tip, and so the flap had to go into the hairline. That is what I'm struggling with, too, as I have a hooked nose - it's too long for my forehead! (Who ever thought of these things!)

What you say gives me confidence to ask the doctor again about whether I should see a plastic surgeon now rather than later. On an intuitive level, it does seem sensible to do everything in one go, rather than let it all heal, and then cut me open again ... 

Where would I find the photos on this site from people who have had this surgery? I have seen before and after photos elsewhere, but not on this site. I thought I'd read a post from an admin to say they aren't allowed to post medical photos on the site. 

Thanks very much again, and with my very best. I hope the electrolysis works well for you and doesn't take too long. Sending much love.

Ilona  :-)

Hi Peneloperae,

I'm new to this forum and I'm seeing a dermatologist on December 11, 2019.  I have a sore on the end of my nose that hasn't healed and it's been about a year that I can recall I've had this.  It started out tiny and dark red, like a blood blister, and now it's a little larger and pale pink.  It's bled a few times over the past year but then stopped and seemed just like a small pimple.  Now I'm realizing I need to have it looked at.  I'd guess it's 1/4 inch in diameter, round, no raised edges, no crusting, just shiny and pink.  But in researching this, I've also discovered that almost my entire nose has a waxy, shiny appearance like scarring and I'm concerned it's morphaeform BCC.  It looks like a lot of photos I've seen on the web.  I'm fair skinned, freckled, blue eyed and had lots of sun exposure as a child and a couple of severe sunburns on my nose and chin.  I've also been on an excessive amount of steroids for the past 5 years for asthma and chronic sinus infections, and I just read that the risk of non-melanoma skin cancers is increased by 50-150% when there is excessive steroid use.  Figures.  I'm a 60 year old female.  I'm wondering if you would be willing to private message me and wondering if you have any photos of your morphaeform BCC before treatment, as well as during and after treatment that you would be willing to share?  I haven't been diagnosed yet, but there is definitely something going on and I find so little on the web about morphaeform BCC!  I don't know how to use this forum yet so I don't know how to request you as a friend (?) but am hoping you can connect with me.  Thanks so much!

Hello - so good you have joined the site as it is very supportive and helpful.   I am sorry you're facing this uncertainty about your nose - such a hard part of the experience actually.   It is excellent that you will see your dermatologist - and i appreciate your concern about it. 

I would be happy to figure out how to private message you (I think I remember how) about this.  From what you described it is important to emphasize with your doctor your concern about the waxy shiny appearance of your nose - my own concern was dismissed by a few dermatologists at first!  It is worth having them biopsy (maybe in a discrete area) the different areas you are concerned about.  Honestly, we really know our own faces best- so please trust yourself.   

I will try to send a photo through private message of what my nose looked like that alerted me to the morphaeform - it is subtle but was visible after I took a run (due to the shift in blood circulation).   I don't think it will be helpful for you to see my other photos of the process right now as each person's experience is very different and let's wait and see how your biopsies go.   I will assure you that now, two years later, the result is excellent.  Of course, I still notice and the scars are visible to me but no one else seems to really take note.  And it is amazing what makeup can do!   This all happened to me in my 50th year - and yes, I too (like so many of our generation) had a lot of sun exposure - ugh! 

Warm wishes and I'll connect soon!!

Penelope 

Thank you so much, Penelope!  I see your invite and will go accept.  I really appreciate your response and I guess at this point, the most important thing for me to see is your before photo(s).  So thank you very much.  I will respond to you in the other message, and I will definitely keep you posted.  I am grateful you took the time to respond and are willing to help me through this.

Cheryl