Rates of cutaneous malignancy continue to rise, especially on the sun-exposed face. Approximately 80% of basal cell carcinomas (BCCs) occur on the face, and 25% to 30% of these are found on the nose.1 At our high-volume quaternary care hospital system, patients with early cutaneous squamous cell carcinoma or BCC of the face usually undergo Mohs surgery with a dermatologic surgeon followed by reconstruction, typically on the same day. Ancillary procedures performed after the original reconstructive surgery may further improve aesthetic results, which may affect long-term quality of life.2 In our practice, we have the most experience with dermabrasion and pulsed dye laser (PDL) after Mohs reconstruction. However, there is a paucity of data comparing ancillary procedures. We aimed to study among patients undergoing nasal reconstruction after skin cancer resection (Mohs defect), does dermabrasion compared with laser resurfacing result in a different aesthetic outcome, as measured by blinded photograph analysis.
University of Michigan DataDirect was queried for patients who underwent post-Mohs nasal reconstruction with the institution's seven Facial Plastic and Reconstructive Surgeons between 2016 and 2020.3 Thirty-nine patients had high-quality studio photographs accessible after ancillary procedure. These photographs were placed into a HIPAA-compliant Qualtrics (SAP, Provo, UT) survey to be rated in a blinded manner by seven members of the Facial Plastic and Reconstructive Surgery faculty using the Manchester Scar Scale (MSS) and Visual Analogue Scale (VAS), validated scales with utility in the plastic surgery literature.4
Among the subjects who had high-quality photographs, there were no significant demographic or primary lesion characteristics between those who underwent dermabrasion versus pulsed dye laser (Table 1). Race was self-reported. The panel of seven blinded surgeons did not find a difference in photographic scar between the groups; there was no significant difference in assessments in VAS (p = 0.52) or MSS (p = 0.58) using ANOVA (Table 2). We also find no statistically significant difference between dermabrasion and PDL in predicting need for surgical revision.
Table 1.
Characteristics by ancillary treatment of patients with photographs
| Dermabrasion vs. PDL with photographs | ||||
|---|---|---|---|---|
| Variable | Overalla, N = 38b | Dermabrasion, N = 21 b | PDL, N = 17 b | p c |
| Gender (female) | 31 (81.6%) | 17 (81.0%) | 14 (82.4%) | >0.9 |
| Age at first ancillary procedure (in years) | 65.3 (32.8–87.4) | 65.3 (32.8–87.4) | 68.7 (51.8–78.2) | 0.5 |
| Smoking status | ||||
| Never smoker | 27 (71.1%) | 15 (71.4%) | 12 (70.6%) | >0.9 |
| Ever smoker | 11 (28.9%) | 6 (28.6%) | 5 (29.4%) | |
| Race (non-White) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | |
| Diagnosis of diabetes | 6 (15.8%) | 5 (23.8%) | 1 (5.9%) | 0.2 |
| Location of primary lesion | ||||
| Ala | 9 (23.7%) | 7 (33.3%) | 2 (11.8%) | 0.14 |
| Dorsum | 3 (7.9%) | 2 (9.5%) | 1 (5.9%) | |
| Sidewall | 4 (10.5%) | 1 (4.8%) | 3 (17.6%) | |
| Tip | 19 (50.0%) | 11 (52.4%) | 8 (47.1%) | |
| Lesion spans multiple subsites | 3 (7.9%) | 0 (0.0%) | 3 (17.6%) | |
| Size of defect (in sq cm) | 1.2 (0.48–7.5) | 1.2 (0.64–7.2) | 1.2 (0.48–7.5) | >0.9 |
| Type of reconstruction | ||||
| ATT | 17 (44.7%) | 11 (52.4%) | 6 (35.3%) | 0.3 |
| FTSG | 19 (50.0%) | 10 (47.6%) | 9 (52.9%) | |
| Both ATT and FTSG | 2 (5.3%) | 0 (0.0%) | 2 (11.8%) | |
| Time between first surgery and first ancillary procedure (in days) | 102 (22–498) | 123 (93–498) | 50 (22–169) | <0.001 |
| Time between first surgery and photo (in days) | 247 (152–953) | 399 (152–953) | 213 (182–534) | 0.012 |
| Time between dermabrasion or PDL and photo (in days) | 169 (37–773) | 242 (37–773) | 161 (95–497) | 0.3 |
| Total No. of ancillary procedures | 2 (1–5) | 1 (1–3) | 3 (2–5) | <0.001 |
| Scar revision surgery | 1 (2.6%) | 1 (4.8%) | 0 (0.0%) | >0.9 |
One patient was omitted among the 39 total who had high-quality photographs of their scars because they underwent both PDL and dermabrasion treatment.
n (%); median (range).
Fisher's exact test; Wilcoxon rank sum exact test; Wilcoxon rank sum test.
ATT, adjacent tissue transfer; FTSG, full thickness skin graft; PDL, pulsed dye laser.
Table 2.
Aesthetic differences between dermabrasion and laser as judged by blinded facial plastic and reconstructive surgeons
| MSS a average b | VAS c average b | |
|---|---|---|
| All dermabrasion (n = 21) | 7.57 (6.14–10.4) | 26.3 (7.29–77.9) |
| All laser (n = 17) | 7.71 (5.71–11.4) | 39.9 (8.71–70.4) |
| Both (n = 1) | 8.29 | 40.7 |
MSS rated on scale of 5–18, with lower numbers being more aesthetically pleasing.
Median (range).
VAS on a scale from 0 to 100 with 0 being excellent and 100 being poor.
MSS, Manchester Scar Scale; VAS, Visual Analogue Scale.
Post-Mohs nasal reconstruction remains challenging given the aesthetic and functional importance of the nose. In this era of videoconferencing, patients are increasingly concerned about operative sequelae. Paradoxically, as cutaneous malignancies are increasing, so too is the desire to minimize any evidence of intervention, decrease nasal width, and enhance appearance.1,5 Another resurfacing laser option, the carbon dioxide (CO2) laser, is noted for its ability to break down fibrotic scar. The mechanism of action of this ablative laser is more similar to that of dermabrasion than the PDL. For this reason, our office has started to incorporate profractional laser technology for our patients with thick fibrotic scars.
This comparison of dermabrasion and laser must be interpreted within the context of the study design of a retrospective cohort. We did not randomize patients to surgical procedure or to ancillary procedure, although we were able to randomize our photographic analysis. We note that patients and physicians are both more likely to elect laser resurfacing over time, commensurate with national trends. Laser intervention occurred earlier after surgery (p < 0.001) and we noted shorter downtime compared with dermabrasion; many physicians in our practice will wait 3 months before ancillary procedure intervention, but this is highly variable and an area of future research. We had quality post-ancillary procedure photographs of only 39 out of 261 patients. Although these photographed patients appear to be representative, their results might not be appropriately representative of the group as a whole.
We would encourage surgeons to incorporate ancillary procedures into their practice to provide superior reconstructive care, especially for patients with noticeable scars 3 months after Mohs reconstruction.6 These procedures will likely continue to be driven by provider comfortability, patient preference, and availability.
Authors' Contributions
Conceptualization, data curation, formal analysis, investigation, methodology, and writing by N.J. Data curation, formal analysis, methodology, and writing by C.Y.R. Conceptualization, formal analysis, and supervision by S.F.R. Data curation and formal analysis by E.L.B. Formal analysis and investigation by J.C.K. Formal analysis, investigation, and supervision by S.B. Conceptualization, data curation, formal analysis, investigation, methodology, resources, supervision, validation, and writing by J.S.M. All coauthors have reviewed and approved of the article before submission.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
C.Y.R. is supported by a grant from the National Institutes of Health (NIH; 5 TL1 TR002242-05).
References
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