Punch biopsy on nose

I have had s punch biopsy for bcc that has infiltrated so am having mohs in s  couple of months on my nose 

Im told a skin graft is not as good as a forehead flap has any one had this done I don't want to look disfigured 

Hi  and welcome to the online community

I'm sorry to hear that you need surgery for a BCC. I haven't had either a skin graft or a forehead flap so don't have the experience you're looking for.

The post that you have replied to is 5 years old so it's quite likely that the people who commented have now left the group and you won't get a reply.

It would be best to start your own post by selecting 'join this group' at the top of the page and then 'start a discussion' next to it. To save you typing your query out again just copy and paste it into the new post.

x

Hi, I had the same as you I was told I would have the mohs done and a few days after the surgery plastics would have to do the forehead flap.  The plastic surgeon was very dismissive of my worries about disfigurement  or the fact that I would have to go home after the mohs with an open wound.

When I had the mohs done the surgeon who performed it was a dermatologist and immediately understood my concerns.  He took several hours to remove the bcc one lay of skin at a time - inbetween each layer it is sent away to be tested and you wait back in the waiting room for the results, this is repeated until the layer they remove tests clear of cancer.  When he'd finished he said that he thought he could close up the wound himself and get a good result if I wanted him to. Having spent the day in the waiting area talking to some of his previous patients with similar facial operations I was confident the result would be good.  My bcc was on the side of my nose and he cut a triangle of skin next to it leaving a small slither attached - he then swiveled this attached skin flap around to close up my wound.

The result was fantastic! you can't see where he took the flap from he apparently pulled the skin over to join the edge of the wound so there is no scar at all on the face where the skin was removed ( at the time I swear my wrinkles that run from the edge of the nose to the corner of the mouth on that side  were smoother but they've come back!) .   The nose it self had a perfect triangle wound with stitches all around the triangle. The skin covering it is a perfect match as it came from next to the skin that was removed.  Once the stitches where out the result was very good (make sure you keep the new skin moist at all times the surgeon sugested vasaline or Ester Lauder 8 hour cream.  Within a month with a good concealer other people said that couldn't see it ( it took me longer to get use to it because I knew it was there)  within a few months the only thing there is a slight indentation which can only be seen from the side  if you where looking for it and  it's not even noticible with out makeup.

I've  been back to his clinic several times over the 5 years since my op. and have met quite a few of his patients in the waiting room who plastics had said they would need grafts or forehead flaps after mohs  and ended up not needing them.  So If you are having a different surgeon doing the mohs then the one doing the closure ask them for a second opinion they will at the least be able to tell you if flap or flap is best for you.

I have seen patients who have had both grafts and forehead flaps and the skin colour match of the flap was better than the graft  as the graft was taken from a different part of their body.

Hope this is of some help if you live near cambridge I can give you name of the dermatologist!   Good luck.

Hi Lee

Thank you for sharing your experience, I live in New Zealand so Cambridge UK is a long way to go.

I  really hope my outcome is as good as yours.

I am going to the best Mohs surgeon in the country and he does all of it but as a forehead flap was mentioned I had to Google it and see all sorts of quite gruesome results.

The punch biopsy I had was 433mm so quite average and indeed the biopsy wound healed within two weeks and looks ok now.

The bcc was the infiltrative kind so until the surgeon starts removing layers I wont know how much tissue is removed or what I will need to repair it and im worrying so much that I will be disfigured if I have to have a forehead flap.

How many layers did you have removed and how long did it take to look your normal self again? Mine is also on the side of the nose not quite up to the centre grisly bit and quite low down but not on the nostril edge either,

Thank you very much for taking the time to explain everything and I hope my outcome is as good as yours

Thanks Janet

Hi Janet,

Your biopsy and position of bcc sounds the same place on nose as mine. My plastic surgeon also told me I may need a skin graft or forehead flap and than your sent away to wait for a couple of weeks for the mohs - its very scary.

I had 6 layers removed  and a little bit extra to make sure the margins where clear. I was there the whole day because each layer is removed one at a time and tested , in between a light dressing is covered on your nose and you wait for the results , while you wait another patient has theirs done (may not be the same where you are.) The lab takes about 45 mins to test skin sample, if it's positive you have another layer removed, so you can see why it takes so long there's a lot of waiting around. The worst part is that most patients only have to have 2 or 3 layers removed so when every one else goes home before you its a bit of a worry. The mohs it self is not painfull the worst bit is the first injection (same as when you have the biopsy) after that it's fine. Take plenty of books, music, food, drink ect its a long day - at lunch time they put a dressing on my nose and sent me to the Hospital Burger king to have lunch!

A good tip from my surgeon was to take a small stress ball with you to squeeze while having mohs done he said research had shown it  distracts the brain from pain messages - it seemed to work.

Also before you go buy your self a reel of Skin/flesh coloured Micropore Tape at least 1 inch wide. Its quite hard to find over here as most chemists only sell the white one but it is available on Ebay. I found it a god send after my op.  you can cut a tiny triangle out to cover your scar, as wound gets smaller so does your triangle. Even though you're told you can leave the dressing off after the stitches were removed  I wasn't confident  to go out straight away. The flesh coloured micropore is so thin and you can blend your makeup over the edges - from a distant you couldn't notice it. The hospital also recommend  Estee Lauder Doublewear Maximum Cover Makeup as it goes over sunblock easily ( I found it very heavy and just used a tiny spot on the scar a couple of times) its quite exspensive but worth a look it might suit your skin type.  The other product was BareMinerals cream concealer which I found covered my scar completely and blended in with the micropore in the early days. Its worth getting these before your treatment because afterwards the last thing you want to do is go to beauty counters.

The scar to start with was triangular but this was probably the skin flap, once the stitches had gone and small scab the center was like a like a larger punch biopsy wound - maybe twice the size  and as its over the original biopsy site its not too bad.After 2 weeks it looked OK and I could of gone out uncovered but I was very self conscious after 4 weeks I was happy to go out with concealer. within a couple of months the tiny marks where the stitches had been completely faded and there's not sign of the skin flap, the only thing there is and oval shaped indentation (like 2 punch biopsy scars joined together) where the mohs was done. Also if you look up my nostril you can see the indentation - but no one looks up there!  Most of all don't forget to keep it moist, for best results. So get shopping at least you'll feel like your doing something positive.

And to make you feel better google photos of Hugh Jackman he's had it done 3 times now and he's not looking too shabby!! His first bcc was very deep like ours. You can be a Hugh Jackman nose twin.

Good luck, let me know how you get on. If I can figure out how to attach photo from my phone I'll send you pic. of my scar.

Lee.

Hi 

Thank you for providing Janet with such excellent information and advice. I shall be able to point other people who come here looking for information to this thread in future!

Unfortunately the Community Guidelines do not allow medical photographs of any type, even if it is just a photo of your scar, but thanks for offering to do this.

All the best

x

Hi Lee

Thanks so much for all that information it made me feel a bit better and you described every part so well.

I don't have any problem getting the flesh coloured tape here but not sure about the BareMinerals cream concealer.

Can you remember whether you got the stick variety or a round shaped one and also how did you work out the colour that was best for you, I am fair skinned but not sure which shade would suit best.

as time gets closer for the mohs I cant help thinking about what if they found it was much larger than the biopsy that came back as 433mm and deep with no clear margins either side,

As you had six pieces taken off did it leave a big hole that had to be filled and what do they fill it with?

Questions I have so many doubts of a good outcome and to make things more scary I have a holiday cottage where I live so have to greet the guests when they stay im so worried that I wont be able to ever do this again as my face is the first thing they see and I don't want to give them a fright.

Ive already Googled Hugh Jackman I didn't no he had Mohs I thought he just had 6 separate bccs reoccurring but as you say he looks pretty good.

Anyway im sorry you were not able to upload any photos of your surgery. [edited by admin]

Thanks for all your help and suggestions

Janet

Hi, Janet

Before I forget I put the wrong brand name for the 8 hour cream - it's Elizabeth Arden not Estee Lauder, its worth getting as you can put it on at night and its still there in the morning, were as vasaline ends up on the pillow! 

The BareMinerals is the round one, like a mini compact. I have fair skin and got number Fair 02 .  If I'm buying foundation/concealer in the shop I go for the ivory type colour not the palest Porceline just to give you an idea.  Also what I did was if you go on Ebay there are buyers that sell little tiny sample pots, what you can do is buy a Fair 02 and then a sample of the two colours either side and blend it in .They also have the mini samples of the Estee Lauder camoflauge foundation on there, its worth getting just a sample to keep in just so you know you have it, if you want that little bit of extra coverage when you first go out - you need so little of it that the mini pot should be enough

My biopsy was 435mm with no clear margins the same and I had visions of coming home with 1/2 a nose left, I think if it was anywhere else on the face it would be easier to cope with - you could change your hair, but your nose is the first thing people see but honestly you will be ok. 

After he removed the layers my surgeon let me look before he closed it up - it looked liked I'd been attacked with a paper hole punch, and like you I wondered how he was going to fill it in. But this was all done with the triangle skin flap I told you about. When he said he was going to take a skin flap from my cheek I thought I was going to have a chunk of skin taken from there as well but what he did was to pull the skin next to the nose over so there was no cut marks on my cheek - apparently after a certain age there's plenty of loose skin on the face  to play with.  I like you was worried about facing people that's why I wore the tiny micropore plasters longer than i needed to but it made me feel more confident. Later a few people who didn't know thought I had been covering up a cat scratch or a large spot!  One of the nurses at the hospital said that they often tell patients who work in the customer industry what should they say if a stranger asks whats happened to their face to just say you were playing with a friends puppy and it nipped/scatched your nose.

I found out Hugh Jackman had Mohs on his first bcc by my surgeon who showed me an article in a skin medical journal about him as I had told him the only reason I had persisted in seeing a second opinion (first Dr. told me nothing was there) was because of Hugh Jackman.

Lee.

Hello Janet

I am sorry to hear what you are going through.  I too work in a client facing industry and after a procedure to have a mole on my face removed, I was left with a big plaster on my face measuring 2 x 2 inches.  I then had further treatment which left my left cheek red, scabby and weeping for a further four months.

If I could, when I was having a bad day, I would ask someone at work to greet clients but I do appreciate that this might not be possible for you.  You could always forewarn any clients so that you don't feel that you need to explain anything upon their arrival and so that you aren't subjected to any comments.

I found that people had a mix of reactions - they were either extremely kind, extremely nosey, said nothing at all, or were really rude and insensitive!!  I ended up getting used to it in the end and just found my own way of dealing with reactions, depending on how I felt on the day.

Good luck with your journey.

Rebecca xx

Dear Lee53,

Thanks for sharing your experience. I'm glad you had such a good outcome!

I just wanted to say 'hi'. I live in Cambridge and have just had MOHS done for an infiltrative BCC on the tip of my nose. The dermatologist did a graft (I didn't have enough skin for him to do a flap, which is what he first intended) and he said I could consider plastic surgery (probably a flap) later. I get the feeling the graft has to heal first, and that any further work would only be considered after 6-12 months. I'm sad I couldn't have the flap there and then, though I'm sure the doctor made the right decision in not risking something that would be difficult to put right later, if it went wrong. I wonder if I should at least ask to see a plastic surgeon to get advice now, though.

Sending you my very best, 

Jeannet  :-)