More Than Skin Deep: Mohs Surgery And Reconstruction

Janet Manis is no stranger to skin cancer. Her mother had basal cell carcinoma. She had it once before, too, 10 years ago.

This is not even her first go-round with the Mohs procedure. Named for the physician who developed it in 1938, the technique involves carefully lifting away one layer of skin at a time, analyzing it under a microscope while the patient waits, then repeating the procedure until no more cancerous cells remain. The fair-skinned, 72-year-old Valparaiso, Ind., woman didn’t even ask her husband to accompany her to the visit. She’d been down this road before and knew what to expect, but this time, with every layer that was removed, she grew more concerned.

“‘It is very deep,’ they had said mid-procedure,” Manis said. “‘Do you want us to continue?’”

When the cancer was finally gone, it was impossible to close the wound due to its size. She would need a facial plastic and reconstructive surgeon to take it from there.

Fortunately, Chad Glazer, MD, a dual board-certified facial plastic and reconstructive surgeon and otolaryngologist who practices at Franciscan Physician Network in Chesterton and Michigan City, stood ready.

According to the American Society for Mohs Surgery, about 15% of patients require subsequent complex reconstruction after removal of their cancer. Thankfully for Manis, who fell into that group, the two surgeons were ready to collaborate. Dr. Glazer, one of a handful of physicians in the country prepared to take on cases of this complexity, saw Manis that same week. She faced a multi-stage procedure and at least 10 follow-up appointments over the next few months to try to look as if nothing had ever happened to her face.

Dr. Glazer took the time to fully educate Manis about the process and the timeline, complete with photos from previous cases. The first procedure involved taking skin from her forehead and transferring it to her nose without ever detaching it.

“She was missing too much, and there was too much exposed cartilage to bring in a skin graft or move tissue around on the nose,” Dr. Glazer said. “In this setting, we use the forehead to bring that tissue down. … Where her hairline is, the upper forehead is what eventually will make up the lower part of her nose.”

This transfer of the forehead skin to the nose created a pedicle, or appendage, that sat across the bridge of her nose while the body worked to establish a new network of blood vessels.

Manis chose to stay isolated during her four-week recovery to allow for proper healing and avoid having to answer questions about the wound. She said her husband would take her on picnics where they’d get take-out, sit in their vehicle and eat.

Finally, it was time for the take down or contouring the new nose flesh to put her brow back where it belonged. The procedure took place at Woodland Surgery Center in Michigan City.

“We reconstruct the forehead and eyebrow, define the specific anatomical units that comprise the nose, further contour the flap and suture it all into place,” Dr. Glazer said. “Now the flap has its new blood supply from the surrounding nasal tissue and that’s it.”

Manis said she is grateful, not only because she had access to this level of reconstructive expertise, but because Dr. Glazer’s gentle touch, positivity and compassionate staff helped her through the long recovery. Manis recalled Dr. Glazer saying at her first appointment that when it was all over with, no one would know she had the procedures.

“And you know what? That is the truth,” she said.