10.5826/dpc.1304a228
Introduction: Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmelanoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing properties of MMS are appealing. The nasal tip is a common location of nonmelanoma skin cancer and can be a challenging anatomical structure for reconstructive surgery due to its prominent location in the face, the shortage of spare tissue, as well as the stiffness and composition of different skin types, cartilage and bone.
Objectives: The aim of the present paper is to review and demonstrate how reconstruction of the nasal tip can be done successfully to improve the care for patients undergoing MMS in this area.
Methods: Using selected literature on the area and the surgeons experience, each method of repair are described including their individual advantages and challenges. Pictures and consent were selected from one patient who underwent each repair method and three photos are presented in this paper: one after tumor resection, one immediately after repair, and one minimum 6 months post-surgery.
Results: We present eight surgical methods as well as pictures from previous surgeries.
Conclusions: The results demonstrate obtainable results using very different surgical methods and the importance of an individualized approach to repairing cutaneous defects of the nasal tip.
text/xml
2160-9381
3228
en
Martin Glud
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
flap surgery
Repair of Defects of the Nasal Tip After Mohs Surgery
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-31
2023-02-07
2023-10-31
2024-01-15
e2023228
Dermatol Pract Concept
Introduction: Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmelanoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing properties of MMS are appealing. The nasal tip is a common location of nonmelanoma skin cancer and can be a challenging anatomical structure for reconstructive surgery due to its prominent location in the face, the shortage of spare tissue, as well as the stiffness and composition of different skin types, cartilage and bone.
Objectives: The aim of the present paper is to review and demonstrate how reconstruction of the nasal tip can be done successfully to improve the care for patients undergoing MMS in this area.
Methods: Using selected literature on the area and the surgeons experience, each method of repair are described including their individual advantages and challenges. Pictures and consent were selected from one patient who underwent each repair method and three photos are presented in this paper: one after tumor resection, one immediately after repair, and one minimum 6 months post-surgery.
Results: We present eight surgical methods as well as pictures from previous surgeries.
Conclusions: The results demonstrate obtainable results using very different surgical methods and the importance of an individualized approach to repairing cutaneous defects of the nasal tip.
Martin Glud
2023/10/31
10.5826/dpc.1304a228
e2023228
Department of Dermatology and Venereology, Bispebjerg and Frederiksberg Hospital
2160-9381
flap surgery
en
e2023228
WM Weathers, EM Wolfswinkel, H Nguyen et al. Expanded Uses for the Nasolabial Flap. Semin Plast Surg. 2013;27(2):104–109. DOI: 10.1055/s-0033-1351234. PMID: 24872750. PMCID: PMC3743915.
Repair of Defects of the Nasal Tip After Mohs Surgery
https://dpcj.org/index.php/dpc/article/download/3228/2396
                        Repair of Defects of the Nasal Tip
                               After Mohs Surgery
                   Sasia JV Pedersen1, John Paoli2,3, Robert Gniadecki1, Martin Glud1


1 Department of Dermatology and Venereology, Bispebjerg and Frederiksberg Hospital
2 Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg,
  Sweden
3 Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden



Key words: Mohs Micrograohic Surgery, Basal cell carcinoma, Squamous cell carcinoma, Nasal tip, Flap surgery
Citation: Pedersen SJV, Paoli J, Gniadecki R, Glud M. Repair of Defects of the Nasal Tip After Mohs Surgery. Dermatol Pract Concept.
2023;13(4):e2023228. DOI: https://doi.org/10.5826/dpc.1304a228
Accepted: April 23, 2023; Published: October 2023
Copyright: ©2023 Pedersen et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Sasia JV Pedersen, Department of Dermatology and Venereology, Bispebjerg and Frederiksberg Hospital, Denmark.
Email: sasia.volden@gmail.com




  ABSTRACT             Introduction: Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmel-
                       anoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing properties of
                       MMS are appealing. The nasal tip is a common location of nonmelanoma skin cancer and can be a
                       challenging anatomical structure for reconstructive surgery due to its prominent location in the face,
                       the shortage of spare tissue, as well as the stiffness and composition of different skin types, cartilage
                       and bone.
                       Objectives: The aim of the present paper is to review and demonstrate how reconstruction of the
                       nasal tip can be done successfully to improve the care for patients undergoing MMS in this area.
                       Methods: Using selected literature on the area and the surgeons experience, each method of repair
                       are described including their individual advantages and challenges. Pictures and consent were selected
                       from one patient who underwent each repair method and three photos are presented in this paper: one
                       after tumor resection, one immediately after repair, and one minimum 6 months post-surgery.
                       Results: We present eight surgical methods as well as pictures from previous surgeries.
                       Conclusions: The results demonstrate obtainable results using very different surgical methods and the
                       importance of an individualized approach to repairing cutaneous defects of the nasal tip.




Review | Dermatol Pract Concept. 2023;13(4):e2023228                                                                                      1
Introduction                                                              columella and alar lobules. It’s defined as being bordered by
                                                                          the nasal dorsum, nasal sidewalls, the soft triangles and the
Mohs micrographic surgery (MMS) is the gold standard                      nasal alae [17]. The primary goals of the repair after MMS
for treatment of high-risk facial nonmelanoma skin cancer                 are to preserve anatomy, aesthetics and function of the nose,
(NMSC) in the United States and many countries in Europe                  while preventing nostril size reduction, internal and external
[1-5] . The micrographic technique of MMS progressively                   deformation, and nasal tip elevation. For optimal cosmetic
examines the complete margin of surgically excised cancer                 results, careful selection of the reconstructive method is nec-
-containing skin until only tumor-free tissue remains. MMS                essary taking into account the characteristics of the defect,
offers 99% cure rates in primary basal cell carcinoma (BCC)               nasal anatomy, patient expectations and the surgeon’s ex-
cases, in contrast to the 87%-90% rate provided by tradi-                 perience [17]. There are four major wound closure options:
tional excision with histopathological examination using ver-             second intention healing, primary closure, local or distant
tical sectioning [6-12] . Besides high cure rates, MMS spares             flaps and skin grafts [11,17] .
healthy tissue promoting optimal conditions for repair and
cosmesis. Preservation of healthy tissue is particularly signif-
icant in maintaining important structures and their function
                                                                          Methods for One-step Repair of
in essential areas like the nose, where the majority of facial            Nasal Tip Defects
BCCs are located [13-15] . Therefore, knowledge related to
                                                                          Direct Linear Closure
different methods of repair is necessary.
                                                                          Direct linear closure (Figure 1) can be the best option for clo-
                                                                          sure in certain cases. It is a simple one-stage procedure, which
Objectives                                                                is less time consuming compared to more complex closure
                                                                          options such as flaps or grafts. Moreover, there is less risk of
The aim of this paper is to review and demonstrate how one-
                                                                          flap loss or hematomas. The aesthetic outcome is predictable
step reconstruction of the nasal tip (apex nasi) can be done
                                                                          and often excellent. Although direct linear closure probably
successfully to improve the care for patients undergoing
                                                                          is best used for defects involving the upper-two-thirds of the
MMS in this area.
                                                                          nose where the surrounding skin is more mobile, the method
                                                                          can also be applied on defects involving the nasal tip. It is
Results                                                                   a reasonable option for closure of smaller defects less than
                                                                          10 mm, as well as for elderly patients, who commonly pres-
Repair of Defects on the Nasal Tip                                        ent with greater skin laxity. Vertically orientated closure is
Reconstruction of surgical defects of the nose are challeng-              preferred to horizontal, as the latter carries a risk of tip el-
ing, in part due to the shortage of spare tissue, as well as              evation. Generally, horizontal closure should be restricted
the stiffness and composition of different skin types, carti-             to patients with nasal tip ptosis or convexity of the nasal
lage and bone [16,17] . The nasal tip is part of the lower                dorsum. Furthermore, retraction of the nasal ala is also a
one-third of the nose, in conjunction with the soft triangles,            risk, but can be minimized by performing wide undermining




Figure 1. Side-to-side repair of defect on the nasal tip. Pictures of a) defect after Moh’s surgery, b) suture, and c) result post-surgery.



2                                                                                       Review | Dermatol Pract Concept. 2023;13(4):e2023228
extending on both sides [17]. Removal of standing cones is                Bilobed Flap
necessary so that margins are readily approximated under                  The bilobed transposition flap (Figure 3) is widely used
minimal tension. The resulting scar after direct linear closure           for nasal reconstruction [16], though with many variations
is often longer than patients anticipate and must therefore be            upon the original design. The flap was initially described as
explained. The surgical defect can be closed with 4-0 or 5-0              a tissue transposition over two arcs of 90° each, but subse-
absorbable sutures buried deep in the reticular dermis and                quently a modified flap designed by Zitelli limited the arc of
subcutaneous tissue, followed by 5-0 or 6-0 non-absorbable,               rotation to 45-50° for each lobe [20]. The double transpo-
running or interrupted cutaneous sutures.                                 sition flap design allows for greater distribution of tension
                                                                          compared to a single transposition flap (the rhombic or note
East-West Flap                                                            flap). Also, it permits harvesting the lax and matching skin
The horizontal advancement flap, also known as the East-                  of the nasal dorsum to transpose and rotate into defects of
West flap (Figure 2) or Burrow wedge advancement flap, is                 the nasal tip [17]. The base of the bilobed flap is prefera-
a simple technique in repairing even larger, full-thickness de-           bly located laterally, where the angular artery provides solid
fects on the nasal tip after Mohs surgery [18]. The horizontal            vascular supply to the flap. The pivot point of the laterally
advancement flap is conceptually equivalent to the vertical               based flap is placed one defect radius away from the edge of
primary closure, in the need of removal of two standing                   the defect preferable in or towards the alar groove allowing
cones. The superior cone, as it would be in a primary clo-                for the standing cone to be removed with optimal cosmesis.
sure, is adjacent to the defect and parallel to the long axis             Then, two lines are drawn from the pivot point directed 45°
of the nose. The inferior cone, however, is shifted medially              and 90° from the axis of the wound, marking the central
to the exact center of the nasal tip and/or the columella, in             axis of the first and second lobe, respectively. Two arcs are
order to avoid excision of the alar rim and the soft triangle.            then drawn going through the center and the edge of the de-
Both standing cones are then removed. Wide undermining                    fect to guide shaping of the two transposition flaps. The first
above the perichondrium is necessary for tissue advance-                  lobe should be nearly the same size and width as the defect,
ment into the original defect without tension. The flap is                whereas the size of the second lobe can be somewhat under-
best for dermal defects of the lateral nasal supra-tip that do            sized (75%-80% of the defect size) to avoid pincushioning.
not exceed 15 mm in size. Vascular supply is excellent and                Importantly, if the tertiary defect is not vertically placed on
cosmetically, the risk of lifting of the alar rim or distortion           the dorsum it can lead to secondary tip distortion. Wide un-
of the nasal tip is minimal [19]. Caution should be taken                 dermining is performed at the submuscular level. Primary
for defects approaching the alar crease or moving down the                closure of the secondary lobe donor site is preceded by ex-
nasal sidewall, as decreasing tissue laxity increases the risk            cision of a standing cone deformity. Then follows closure of
of nasal asymmetry. It should also be noted that sebaceous                the secondary and primary defects before the standing cone
nasal tips are at risk for dehiscence. The surgical defect can            of the pivot point is trimmed and sutured. 4-0 or 5-0 ab-
be closed with 4-0 or 5-0 absorbable subcutaneous sutures                 sorbable subcutaneous and 5-0 or 6-0 running or interrupted
and 5-0 or 6-0 running or interrupted non-absorbable cuta-                non-absorbable cutaneous sutures are suitable. A superiorly
neous sutures.                                                            based bilobed flap has been described, where the standing




 Figure 2. East-West flap. Pictures of a) defect after Moh’s surgery, b) suture, and c) result post-surgery.



Review | Dermatol Pract Concept. 2023;13(4):e2023228                                                                                   3
 Figure 3. Biloped flap. Pictures of a) defect after Moh’s surgery, b) suture, c) result post-surgery.




 Figure 4. The Peng flap. Pictures of a) defect after Moh’s surgery, b) suture, c) result post-surgery.




cone of the secondary lobe is placed within or close to the                contained within a cosmetic unit no larger than 20 mm
nasolabial fold whereas the pivot point is directed toward                 in diameter. For midline defects, incision of the rotation
the medial canthus. This design could be advantageous in                   arms of the flap begins at the distal portion of the defect,
larger defects of the nasal tip. The cosmetic result following             continues laterally into the alar grooves until the junction
closure with the bilobed flap is often satisfactory. However,              between the cheek and nasal sidewall is reached. Incisions
pincushioning can be a problem and should be managed by                    are then directed towards the medial canthus area running
injection of Triamcinolone or simple surgical revision if it oc-           between these two cosmetic units. Both flaps are raised from
curs. Nasal valve problems due to pressure of the soft tissue              the submuscular level and followed by wide undermining of
or weak underlying structures of the ala nasi can also occur.              surrounding areas. Both flaps are then rotated centrally into
Finally, it is should also be observed that this bilobed flap              the defect and sutured with buried sutures starting centrally.
creates a linear and two sequential curvilinear scars.                     The secondary defects along the nasal sidewall are closed
                                                                           before the standing cone at the center of the flap is removed,
Peng Flap                                                                  preferably as a 30° vertical midline wedge. The superficial
The Peng flap (Figure 4) is a double rotation flap originally              layer is closed using 5-0 or 6-0 interrupted non-absorbable
designed for repair of midline surgical defect of the distal               cutaneous sutures. Basically, closure of eccentrically located
nose [21]. Since its introduction in the late eighties, modifica-          defects are designed similarly, but the standing cone would
tions of the flap design have improved the applicability to in-            then become a 30° wedge into the wider of the two arms.
clude even larger and eccentrically located surgical defects of            Vascular supply from branches of the angular and infrat-
the distal nose [22]. The flap seems best suitable for defects             rochlear arteries is excellent. The cosmetic result of this flap



4                                                                                       Review | Dermatol Pract Concept. 2023;13(4):e2023228
is often excellent, partly due to the perfect tissue match for             the Burow triangle that often occurs during rotation and re-
sebaceous nasal skin as well as the fact that scar lines can be            duces pedicle tension. The flap should then be elevated at
placed in the junctions of cosmetic units. The flap is quite               the submuscular plane with proper undermining of the pivot
mobile and can reach even large defects of the distal nose                 point. Closure is made using 2-layered closures starting with
without much tension. A drawback of this flap is nasal tip-                the glabellar portion of the flap thereby forcing the flap into
or bilateral alar elevation, resulting in distortion of the shape          position. Subsequently, the primary defect is closed. Cosmet-
of the nostrils [17].                                                      ically, the outcome is good, as tissue match is perfect, and
                                                                           scars are located in less noticeable anatomical areas [17].
Dorsal Rotation With Back-cut                                              However, extending the flap too inferiorly can result in el-
The dorsal nasal flap (Figure 5), also known as the Rieger                 evation of the tip or cause alar retraction and asymmetry.
flap, is a rotational flap that allows for reconstruction of
intermediate to large defects (≤ 25 mm), affecting several ar-             Island Flap
eas of the nose including the apex. The flap is generated by               The island flap (Figure 6) differs from the other flaps men-
starting at the medial part of the defect or alternatively, at             tioned by the pedicle of the island flap solely consisting of
the base of the defect. From there, the arc of the rotation                subcutaneous tissue or an artery and vein. It can be either
flap is drawn towards the glabella. If possible, incisions are             rotation or advancement flaps, with the first being most
placed at the border between the nasal dorsum and sidewall                 common for closure of nasal defects with the cheeks or the
subunits. A back-cut at the end of the incision line removes               forehead as donor areas [23]. The design of island flaps




 Figure 5. Dorsal Rotation With Back-Cut. Pictures of a) defect after Moh’s surgery, b) suture, c) result post-surgery.




 Figure 6. Island Flap. Pictures of a) defect after Moh’s surgery, b) suture, c) result post-surgery.



Review | Dermatol Pract Concept. 2023;13(4):e2023228                                                                                    5
varies. The present island flap is a flap hinged on the nasalis        as long or longer than the height of the defect to be able to
muscle. In general, the flap is designed by marking a triangle         cover it. Reaching the junction between the nasal sidewall
from the defect towards the nasal dorsum or laterally onto             and the cheek, the arc is linked to an advancement limb.
the nasal sidewall. The width of the island should be equal            Importantly, the width of this limb must match the vertical
to the defect. The flap is incised at the submuscular plane            height of the surgical defect. The flap is incised at the sub-
creating an island from the surrounding areas. The underlay-           muscular layer followed by wide undermining laterally on
ing subcutaneous tissue is carefully loosened with scissors.           the cheek. Flap advancement is achieved by orienting the pri-
Next, the leading and lagging part of the flap is undermined           mary stich (an absorbable, buried suture) parallel to the free
leaving the middle one-third part intact as a deep pedicle.            margin of the lower eyelid. The following movement of the
Undermining around the defect is performed before setting              flap is an inferior rotation, in which the primary defect can
the first absorbable buried suture that pulls together the             be reached without tension. A standing cone along the alar
leading edge across the defect. A second buried suture can             groove is produced during flap rotation. Upon cone removal,
be used to close the secondary defect. Then interrupted non-­          5-0 or 6-0 running- or interrupted non-absorbable cutane-
absorbable cutaneous sutures are placed. The Island flap is            ous sutures are placed in standard fashion. The curvilinear
ideal for smaller defects and locations with well vascularized         scar associated with the AIRNS flap might be more visible
and elastic subcutaneous tissue. Advantages of this flap are           than the alternating scar line of the bilobed flap.
great viability and mobility of the flap [16]. Drawbacks are
the risk of pincushioning, nasal tip elevation and a triangular        Skin Graft
shaped scar difficult to place in a less visible anatomical area.      Full thickness skin grafting (FTSG) (Figure 8) in nasal recon-
                                                                       struction, especially for defects located at the lower third of
Advancement and Inferior Rotation of the Nasal                         the nose, is commonly used. Although many still consider
Sidewalls (AIRNS) Flap                                                 this closure method inferior, the outcome of a FTSG, when
This random pattern, single-stage flap uses principles of              appropriately applied, can be acceptable for the patient.
advancement and rotation with a primary rotation arc and               Proper patient selection and donor sites are imperative to
pivot point similar to the bilobed flap in addition to an              obtain optimal results [12]. The skin texture of the nasal tip
added advancement limb (Figure 7). Some authors consider               is thick and composed of sebaceous glands. For defects of the
the design of the flap and its execution to be simpler than            lower third, the lateral lower forehead is an ideal location to
that of the bilobed flap. The AIRNS is best suited for defects         harvest a graft since the skin is structurally similar to that
of the distal nose sized ≤15 mm, preferably with horizontal            of the nasal tip, and the scar can be hidden in the junction
orientation. An arc is drawn from the superior edge of the             of the hair-bearing and nonhair-bearing scalp. Other possi-
surgical defect towards the medial canthus. The arc must be            ble donor sites could be the preauricular or postauricular




 Figure 7. Advancement and Inferior Rotation of the Nasal Sidewalls (AIRNS) flap. Pictures of a) defect after Moh’s surgery, b) suture, c)
 result post-surgery.



6                                                                                   Review | Dermatol Pract Concept. 2023;13(4):e2023228
 Figure 8. Full thickness king graft. Pictures of a) defect after Moh’s surgery, b) suture, c) result post-surgery.



regions. Specifically, the conchal bowl is often chosen as a               areas of maximal laxity with potential for tissue recruitment.
suitable donor site due to its’s thickness and sebaceous sim-              Facial lines and borders of subunits are well-suited for plac-
ilarity to the nasal tip. It is desirable to select the donor site         ing scars. In addition, general skin condition is important.
from a location with minimal actinic damage to minimize                    Often in older patients, skin laxity is more pronounced than
the potential for another skin cancer at the site.                         in younger patients. In patients with nasal ptosis, some tip
    FTSG is suitable for small, shallow defects (< 10 mm) on               elevation is acceptable. Skin diseases such as severe rosacea,
the nose tip. However, it could also be applied on complete                should prompt conversations with the patient about subop-
subunit reconstruction. When the donor site has been cho-                  timal healing conditions as well as an increased risk of unsat-
sen, the graft is designed to match the exact defect dimen-                isfactory cosmetic outcomes.
sions or oversized by 10%-20%. The donor-site markings                          The size of the lesion, and to a lesser extent, the loca-
are extended beyond the template to form an ellipse along                  tion of the defect (i.e. whether its mid-tip or more eccentric)
relaxed skin tension lines in order to remove dog ears from                is equally important when choosing the optimal technique.
the donor site incision. The donor site is then closed appro-              Excessive advancement of flaps will result in alar retraction
priately. Once harvested, the graft tissue is trimmed from fat             or nostril obstruction. If required, advancement of flaps with
and in some cases fenestrated to allow for blood and lymph                 partial wound closure with minimum tension and distortion
drainage. Next, skin edges of the graft and wound are care-                can be aimed for followed by a FTSG (either a Burow graft
fully apposed using continuous 5-0 or 6-0 fast-absorbing su-               or harvested). FTSG used alone is seldom the first choice, but
tures. To ensure that the base does not lift, tie-over dressings           in difficult areas such as the soft triangle or in full subunit
and/or basting sutures can be added. FTSG complications                    defects it can be used with acceptable outcomes.
include full or partial graft loss. In such cases, new skin will                Reconstructive algorithms for closure of nasal defects
eventually appear below the necrotized graft, although cos-                have been proposed in which the size of the defect is de-
mesis could be less acceptable. Additionally, the risk of color            cisive. Defects after tumor extirpation of the nasal tip are
and texture mismatch can yield a patch-like appearance.                    classified as small (<10 mm), medium (between 10-30 mm)
                                                                           and large (>30 mm) [17]. For a small defect, direct closure or

Conclusions                                                                the East-West flap is often the best and simplest choice. An
                                                                           island flap could be a wise alternative if defects are deep. Sec-
Nasal tip reconstruction is challenging due to the complex                 ondary intention healing (granulation) also provides good
anatomical structure of this subunit. In order to obtain op-               cosmetic results but may entail more discomfort for the pa-
timal functional and cosmetic results, the surgeon must take               tient and takes a longer time to heal than other options. For
several aspects into consideration in choosing the best clo-               medium-sized defects <15 mm, the bilobed flap is the flap of
sure method. Attention to immobile landmarks is imperative,                choice in many circumstances. However, the Peng flap is a
since alar retraction or twisting of the nasal tip usually is              good alternative in central and distally located defects. The
unacceptable, both for the patient and the surgeon. As sur-                AIRNS flap is another flap well-suited for the eccentrically
rounding tissue of the nasal tip is sparse, one should identify            located defect. In larger defects, the dorsal rotation flap with



Review | Dermatol Pract Concept. 2023;13(4):e2023228                                                                                      7
back-cut is superior. Skin grafts could to some extent be                   management of basal cell carcinoma. J Am Acad Dermatol.
used in combination with all the above-mentioned flaps. It                  2018r;78(3):540-559. DOI: 10.1016/j.jaad.2017.10.006. PMID:
                                                                            29331385.
should be noted, however, that regardless of the defect size,
                                                                       4.   Stratigos AJ, Garbe C, Dessinioti C, Lebbe C, Bataille V, Bastholt L,
the abovementioned considerations and guidelines on recon-
                                                                            et al. European interdisciplinary guideline on invasive squamous
structive approaches must not be viewed as definitive rules.                cell carcinoma of the skin: Part 2. Treatment. Eur J Cancer.
    Additional methods not included in the present review                   2020;128:83-102. DOI: 10.1016/j.ejca.2020.01.008. PMID:
can be superior options for certain defects and patients. The               32113942.
present review focuses solely on outpatient surgery using one-         5.   Peris K, Fargnoli MC, Garbe C, et al. Diagnosis and treatment
                                                                            of basal cell carcinoma: European consensus–based interdisci-
stage procedures and local anesthesia, which is particularly
                                                                            plinary guidelines. Eur J Cancer. 2019;118:10-34. DOI: 10.1016
suitable for older patients or those who are not candidates for
                                                                            /j.ejca.2019.06.003. PMID: 31288208.
general anesthesia. An example of a two-stage procedure not            6.   Tolkachjov SN, Brodland DG, Coldiron BM, et al. Understand-
included in the present review is the nasolabial flap which is              ing Mohs Micrographic Surgery. Mayo Clin Proc. 2017;92(8):
commonly used for lateral defects and very suitable for nasal               1261-1271. DOI: 10.1016/j.mayocp.2017.04.009. PMID: 287
tip defects due to its ideal scar placement in the nasolabial fold          78259.
                                                                       7.   Benedetto PX, Poblete-Lopez C. Mohs Micrographic Surgery
as well as the similar tissue structure and often similar amount
                                                                            Technique. Dermatol Clin. 2011;29(2):141-151, vii. DOI:
of sun exposure of the skin flap compared to the nose [24].
                                                                            10.1016/j.det.2011.02.002. PMID: 21421140.
    The nose is a prominent and distinguishing point of the            8.   Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma. J Am
face, and even minor irregularities after repair can alter the              Acad Dermatol. 2019;80(2):321-339. DOI: 10.1016/j.jaad.2018
patient’s appearance. Consequently, the site is a source of                 .02.083. PMID: 29782901.
concern for both patient and surgeon. For surgeons, it’s im-           9.   Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell
                                                                            carcinoma treated with Mohs surgery in Australia I. Experience
portant to have an individualized approach to repairing the
                                                                            over 10 years. J Am Acad Dermatol. 2005;53(3):445-451. DOI:
cutaneous defect. A similarly sized defect in an identical an-
                                                                            10.1016/j.jaad.2005.04.083. PMID: 16112351.
atomical location in two different patients should not neces-         10.   Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence
sarily be handled the same way. Treatment priorities for each               Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcino-
patient should be taken into consideration along with indi-                 mas) in the US Population, 2012. JAMA Dermatol. 2015;151(10):
vidual health factors (age, concomitant medication and dis-                 1081-1086. DOI 10.1001/jamadermatol.2015.1187. PMID:
                                                                            25928283.
eases). Also, patients are entitled to a full understanding of
                                                                      11.   Mansouri B, Bicknell LM, Hill D, Walker GD, Fiala K,
the rationale behind the choice of closure method, especially
                                                                            ­Housewright C. Mohs Micrographic Surgery for the Manage-
when the risk of suboptimal cosmetic outcome is foreseeable.                 ment of Cutaneous Malignancies. Facial Plast Surg Clin North
                                                                             Am. 2017;25(3):291-301. DOI: 10.1016/j.fsc.2017.03.002.
                                                                             PMID: 28676157.
Acknowledgement: The authors thank the patients who
                                                                      12.    van Loo E, Mosterd K, Krekels GAM, Roozeboom MH,
generously allowed the use of clinical photos from their sur-                ­Ostertag JU, Dirksen CD, et al. Surgical excision versus Mohs’
geries. The patients in this manuscript have given informed                   micrographic surgery for basal cell carcinoma of the face: A
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