Cancer Reconstruction FAQs – (Cancer Reconstruction Frequently Asked Questions).
- Will insurance cover my cancer operation?
Dr. Lam does not accept insurance.
- What types of cancer reconstruction does Dr. Lam undertake?
Dr. Lam’s specialty is reconstruction of facial defects that have arisen from skin cancer. He reconstructs foreheads, cheeks, eyelids, nose, lip, scalp, ears, and chin defects from small to very large losses of skin and deeper tissues. One of the most complicated reconstructions he undertakes is full thickness and extensive loss of the nose from cancer. Oftentimes, this kind of loss requires multiple stage procedures to achieve the optimal reconstructive result.Dr. Lam no longer reconstructs defects from head and neck cancer that arises from deeper structures like the inside of the nose, the mouth, or the throat. These types of reconstruction are better performed by a specialist who performs this kind of reconstruction regularly.
- Does Dr. Lam remove the cancer in addition to the reconstruction?
Yes, he does. If the cancer is in a non-sensitive area like the cheek or chin, he oftentimes will remove the cancer followed by closure of the defect. However, extensive cancers especially those that require complicated reconstruction or are near areas that do not permit removal of a lot of surrounding tissue that would otherwise cause tissue distortion, Dr. Lam prefers to work with a MOH’s surgeon who will remove the cancer followed by Dr. Lam’s repair usually on the same day.The MOH’s surgeon is a specially trained dermatologist who removes the cancer step by step until all of the cancer appears to be removed. The specialized technique that a MOH’s surgeon uses permits the most tissue-sparing ability, i.e., removal of the least amount of tissue while still removing all the cancer and also has been shown to decrease the incidence of cancer recurrence. For these reasons, Dr. Lam will most likely offer you with most kinds of cancer the services of a MOH’s surgeon.
- What should I expect with my reconstruction?
Reconstruction is as varied as the type and presentation of cancer that you may have. Some general principles will be outlined herein to give you an idea of how Dr. Lam approaches each part of the face.Before outlining each part of the face, it is important to understand the fundamental principles of good reconstructive surgery. First and foremost, the tissue that is used to replace the part of the face that is missing must match in color and texture otherwise the result will be very noticeable and poor. As each facial area is explored, the best type of tissue for reconstruction will be briefly presented and explored. Second, all incisions must be undertaken as much as possible along what are known as facial subunits, i.e., where natural lines and indentations are found to avoid a line or contour change being visible after reconstruction. Also, the way that collagen bundles are naturally arranged on the face, the surgeon should be mindful of what are known as relaxed skin tension lines (RSTLs) discussed and shown in the illustration in the Mole Removal FAQs. Third, the reconstruction must not create or worsen a contour deformity, i.e., appear as a bump or depression after reconstruction. Finally, the areas of the face that have functional importance, e.g., the eyelid, nose, and lip, must retain their functionality to the best of the surgeon’s ability.Nose
The nose is perhaps one of the most complicated areas to reconstruct for three reasons. First, the shape of the nose is a very intricate, three-dimensional structure. Second, the nose is comprised of three layers: the skin, the framework consisting of cartilage and bone, and the mucosa inside. Third, the nose is a respiratory organ that is in charge of air passage and humidification and warming of the airway. Dr. Lam must reconstruct any and all layers of the nose that are involved, while maintaining the functional aspect of the nose. At times to achieve the best functional and aesthetic result, you will need to have several procedures performed. If you have a minor skin defect of the nose, the best type of reconstruction is to rotate tissue from the upper part of the nose to fill the lower part of the nose or to rotate cheek tissue onto the nose for a loss along the side of the nose. Skin grafts on the nose almost always look bad and appear like a piece of gum stuck on the nose, which is unacceptable. Dr. Lam almost never performs a skin graft on the nose for that reason. If the nose involves extensive skin loss, then the best color and texture match is found in the forehead. Dr. Lam will rotate your forehead tissue to fill the defect but this forehead tissue remains attached to the forehead for 3 weeks (4 to 6 weeks if you are a smoker) until the new blood supply is attained and the attachment can be severed. Even after the attachment is severed, you may require an additional touch-up revision to make the nose as perfect and as seamless as possible. To reconstruct the framework of the nose, he uses both nose and ear cartilage to recreate the structure to the nose. Finally, if you have lost tissue from the inside of the nose (the pink lining inside the nose), he will borrow tissue from another part of the inside of the nose like the turbinate or septum to reline the missing inside part of the nose. It is critical to reconstruct all three layers of the nosewhen they are missing.Cheeks
Cheek reconstruction is much easier to undertake than nasal reconstruction. First of all, the cheek does not have the complicated three-dimensional and three-layered structure of the nose. Further, there is usually ample surrounding tissue from the lower cheek or neck that can be recruited to fill almost any size defect, especially in an older person with more lax skin. Finally, the cheek does not possess much functional capacity. Nevertheless, Dr. Lam is very sensitive to follow the facial subunit principle and the relaxed skin tension lines of the face (described above) to ensure that all of his incision lines are hidden along existing facial lines (the orbital rim under the eye and the nasolabial fold or smile line) so that your eye naturally has a harder time in detecting the reconstruction. Because there is abundant adjacent tissue that can be used to reconstruct the cheek, it is always better to bring in tissue from a nearby area like another part of the cheek or neck to reconstruct the area than a skin graft for example.Lips
The lips can be a complicated structure to reconstruct, especially considering their functional importance in eating, talking, and breathing. Small defects of the upper and lower lip can be handled through a vertical excision and primary closure without compromising the function and aesthetic look of the lips. For more extensive loss of red lip and surrounding white lip tissue, there are two principle options. First, tissue from the opposing lip can be used to rotate down or up to fill the other lip, which remains attached for several weeks until the new blood supply forms. Second, the inside red part of the lip can be advanced into the defect to recreate the lost tissue of the red lip. At times, micropigmentation or permanent makeup may be needed as a finishing touch.Eyelids
The eyelids are a very difficult area to reconstruct. Oftentimes borrowing tissue from adjacent areas like the cheek or upper eyelid skin can be used to reconstruct the eyelids, and also sometimes multiple procedures are required to achieve the optimal aesthetic and functional result. At times, Dr. Lam will work with an oculoplastic surgeon in extensive facial and eyelid loss to provide you the most advanced and subspecialized care possible.
The chin area that does not involve loss of the lip is a relatively straightforward area to reconstruct. For smaller defects, a simple primary, vertical-oriented closure can accomplish the reconstructive task. However, for larger areas of loss, tissue must be borrowed from the cheek or neck region to cover the defect. Again, in most instances, Dr. Lam prefers not to use skin grafting, which can be more obvious to detect. Typically, like the cheek, the chin area can be reconstructed in one session and most likely will not require multiple stages to complete the task unless a significant part of the red lip is involved.
The ear is a complex three-dimensional structure. One of the biggest mistakes in ear reconstruction is simply excising skin and cartilage and then closing the area. Doing so will lead to a cup-ear deformity in which the ear sticks out too much on one side making whatever repair look bad. Dr. Lam uses a technique of sliding skin over cartilage to help create a more seamless result. The compromise is to reduce the size of the ear slightly without distorting its orientation to the scalp. Unlike the rest of the face, skin grafts to the ear are actually very well tolerated and preferred in many cases. The skin graft is taken from the skin behind the opposite ear; or if a rotation flap (i.e., rotating adjacent tissue to fill the defect as explained in the other sections) is planned skin behind the same ear will be borrowed.
If a scalp defect is small, then it can be closed simply. However, if a larger area is missing, oftentimes the only way to close the defect is to use a method known as tissue expansion. A tissue expander involves placing a plastic device under the skin and slowly filling it with water for several weeks until the skin and tissue overlying it are stretched out to the point that the skin becomes loose and can be rotated into the defect.
Most forehead defects can be easily closed without difficulty following the principles of good reconstruction, e.g., the relaxed skin tension lines (see Mole Removal FAQs for more information). Hiding incisions within wrinkle lines can also help make the surgical result as invisible as possible.
- What else does Dr. Lam do to make my result as seamless as possible?
Dr. Lam carefully follows you throughout the first year after reconstruction to make sure that the result is as seamless and undetectable as possible. Occasionally, with very complex repairs, he will need to do a very minor refinement procedure between 6 months to a year after the procedure. However, if the line is more visible than desired at 6 weeks to 3 months, he will undertake a procedure known as mechanical dermabrasion that sands down and blends the area to make it less detectable in the patient that should require this procedure. Further, he will follow you carefully to make sure that the area does not thicken, which he will treat with a combination of injectables to reduce any unwanted hardness or fullness in the incision or flap. If the area is slightly depressed, Dr. Lam can easily correct this problem with a few micro-droplets of silicone. If the incision line stays red for too long, Dr. Lam can use his laser to lessen the undesirable redness. If the area becomes slightly darker due to excessive sun exposure during the first 4 to 6 weeks, then he may counsel you about skin bleaching products to expedite resolution of this temporary condition.
- Does Mederma (onion extract), Strivectin, or Vitamin E oil work to help improve the appearance of my incision?
Dr. Lam does not believe that any of these remedies work to help a scar mature well. In fact, rigorous scientific studies that have involved blinded, prospective, randomized, split scar analysis (in other words, good and controlled scientific research) have indicated that these treatments provide no improvement at all in an incision or scar. In fact, Vitamin E oil has been shown actually to worsen wound healing in some cases. In the past, Dr. Lam used Vitamin E oil to help with wound healing. However, with recent evidence to the contrary, he no longer believes that any of these topical ointments do any good to help with scar healing.
- Will Dr. Lam follow me for recurrence of my cancer?
No, Dr. Lam recommends that you are followed carefully by a board-certified dermatologist or MOH’s dermatologic surgeon who are experts at evaluating and managing skin cancer. If you should have another skin cancer arise, Dr. Lam can again work in conjunction with your dermatologist or MOH’s surgeon to reconstruct the defect.
- Will Dr. Lam prescribe medications like Effudex or treat me with liquid nitrogen to manage pre-cancerous conditions?
No, again your dermatologist should help you with this situation. Dr. Lam is not a dermatologist but focuses his career only as a facial plastic and reconstructive surgeon.
- Does Dr. Lam do chemical peels or other skin treatments that can reduce my likelihood for skin-cancer recurrence?
Yes, he does. However, these treatments that Dr. Lam performs is strictly under cash reimbursement as a cosmetic procedure and not through insurance. Before this kind of treatment, Dr. Lam requires an evaluation and recommendation from your dermatologist prior to proceeding. For more information about techniques that Dr. Lam uses to rejuvenate the skin and at the same time possibly reduce the likelihood of some kinds of skin cancer, please read the section Skin Rejuvenation FAQs.
- What are some signs that I can look at to decide if I may have a skin cancer?
Although the only way that you would be certain that you have a skin cancer is a formal consultation with a board-certified dermatologist and oftentimes with a biopsy (i.e., removal of some tissue for inspection), there are certain guidelines that can help you decide the likelihood if something you see on your skin is a skin cancer. Remember that these are only guidelines and should never replace a formal consultation and evaluation with a board-certified dermatologist. A simple mnemonic can be helpful: ABCD. These letters refer to the nature of the skin lesion that may indicate a cancerous lesion. A stands for asymmetry in that the shape of the skin lesion is not purely round or symmetrical on all sides. B refers to the border of the lesion being partly or completely ill defined or irregular in nature. C stands for the color being very light or very dark or having undergone a change in color to become lighter or darker. D refers to the dimensions of the lesion being increasing in size over time. Other helpful clues relate to any bleeding or other changes that you may have noticed over the past few months or a longer period of time.
If you have Cancer Reconstruction Questions please Ask Dr. Lam in the Reconstructive Surgery Forum.