This 49 year-old from Camarillo referred herself for Mohs micrographic surgery of a lentigo maligna (melanoma in situ) on the left nasal ala (wing of the nose). The lesion first appeared seven years earlier and had been treated with liquid nitrogen three times. Approximately 3 years ago the skin cancer was excised and repaired with a full-thickness skin graft. The skin cancer recurred one year ago, and her Los Angeles dermatologist recommended treatment with a topical medication (Aldara). She used the medication for six months without improvement and presented to our office for definitive treatment. On examination the skin cancer extended around the rim of the ala to the lining of the nose. A biopsy showed lentigo maligna (melanoma in situ).
The tumor was removed in a one-stage Mohs procedure with immunostain evaluation of the surgical margins. The surgical defect measured 3.5 x 3.2 cm and involved the full thickness of her nasal ala. To reconstruct the defect, the remaining nasal mucosa was recruited to line the nostril, and a cartilage graft from the left ear was used to provide structural support for her nose. A paramedian forehead flap was used to reconstruct the nasal ala and alar rim. The second stage of this flap entailed division and inset of the pedicle that ran from her eyebrow to her nose. The second stage is performed after good blood flow is developed between the nose and the flap (approximately 3 weeks later). The patient was very satisfied with the final appearance of her nose and followed up with a dermatologist to monitor for new skin cancers.