I would like to share images of 2 cases where a BCC was excised from the nasal tip and closed with a bilobed flap. This flap has been around since the mid 80’s and was originally designed specifically for closing defects on the nose. It does not pose a risk to collapsing the nasal valve (a problem for more lateral tip and ala lesions) and it gives a good cosmetic result. Patients are often left with minimal scarring that is hard to notice on a normal looking nose. The following photo board, image 2, shows the intra-operative photos from image 1. 

Image 2 - The lesion is excised. The flap is then raised and secured with 5-0 monosyn. The skin is then further closed with 5-0 nylon. The histopathology came back with BCC that was clear of the margins. Sutures are removed at day 7 and by day 14 the wound is already fairly well healed. 

 I perform these in the practice under local anaesthetic utilising a nerve block of the external branch of the ethmoidal nerve. This avoids a lot of the discomfort normally associated with infiltrating local anaesthetic into the nasal tip. The patient normally spends about 50 minutes in the treatment room with minimal to no discomfort being reported. 

Image 3 shows the markup. The lesion is excised and the flap is incised then undermined deep to the Nasalis muscle. It is then secured using 5-0 Monosyn under minimal tension. Most of the tension is held in the closure of the tertiary defect, in this case on the nasal sidewall. The skin is further closed with 5-0 Nylon. Sutures are removed on day 7. Histopathology confirmed BCC with clear margins. 

When to refer for melanoma

It can be difficult to know when to refer for melanoma and when to do the surgery yourself. Here are a few of the rules I use to approach melanoma.

• For a lesion that could be melanoma:

• The gold standard is to do an excisional biopsy with a 2mm margin. This is what should be done in the vast majority of cases.

• If this can’t be done, options include referral, shave biopsy or incisional biopsy (both these options have downsides so it’s best to refer if you are not completely confident.)

• Never do a punch biopsy of a suspected melanoma (this can miss the diagnosis)

• Never close a suspected melanoma with a flap (this can distort the tissue and lead to a larger WLE being needed). 

• For melanoma in situ:

• Wide Local Excision (WLE) with 5-10mm margins is advised.

• Some experts advise 10mm margin for lentigo maligna and this is what I do.

• It is appropriate for melanoma in situ to have the WLE done in primary practice or be referred. I am always happy to do these. 

• For invasive melanoma:

• The most important factor here is whether or not the patient requires a sentinel lymph node biopsy (SLNB). I work this out by using the Melanoma Institute Australia risk calculator. This is a great resource and it’s really useful to be able to give the patient that information early on. Generally speaking, <5% risk does not require SLNB, 5-10% warrants discussion about SLNB, >10% should have SLNB offered. SLNB requires referral to a surgeon.

• If SLNB is not indicated then most WLEs can be done in the primary setting.

Most melanoma patients can be treated within my service but I’m always happy to see them even if I end up referring them elsewhere. Below are the QR codes that link to the melanoma guidelines and the MIA risk calculators. 

Referred patients will only be treated for what is requested in the referral. This is to ensure that patients follow up with their regular GPs for the majority of their skin cancer needs unless that GP specifically requests otherwise. Our goal is high quality, timely, local and affordable care.

Referral to Dr. Oliver Simpson on Medical Objects or fax to Burrum Street. Call/SMS me on 0459403598 as needed to discuss the service or individual patients.