Top players in skin cancer recon?

OneWord

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Facial skin cancer reconstruction, particularly on the nose, is definitely one of my main areas of interest along with . So it’s a factor as I consider programs. Who are the top players in this area? Menick and the late Burget wrote the book on forehead flaps and such, but the former is nearing retirement. Who are the other leaders in this area?
 

MrBigglesworth

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Hate to say it, but the big players in skin cancer reconstruction are the Dermatologists and Mohs "Surgeons".

The old days, when the Mohs guys would punt to plastic surgeons are mostly over. Mohs people routinely do forehead flaps / bilobes etc. Most Mohs fellowships in the last 10 years or so are doing the vast majority of recon. This make sense since they do so many cases each day and a lot can be safely done under local anesthesia.

Tri Nguyen and Nathan Jellinek did a good article entitled:
Paramedian Forehead Flap: Advances, Procedural Nuances, and Variations in Technique

The journal "Dermatologic Surgery" is a good one to search through. Let me know if you have more questions or want more names.



Edit. If you are a medical student and are interested in skin cancer reconstruction, I HIGHLY recommend you make the switch to dermatology and pursue a Mohs fellowship. PM me if you want, I am a recently graduated fellow.
 
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XCdude

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I would disagree. A lot depends on your local referral patterns. Given that you only get paid for either the tumor resection or the reconstruction many dermatologists will refer these to a plastic surgeon who will do the flap under local in their office...or ENT...

Like everything, it just depends and referral patterns are key. I would highly recommend that you avoid dogmatic statements like this. I am also surprised given the time value of money a dermatologist would want to undertake a staged procedure like a forehead flap.
 
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MrBigglesworth

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You are welcome to disagree. Are you a practicing Plastic Surgeon that primarily does skin cancer recon?

We do not "only" get paid for resection or reconstruction. We get paid 1/2 as much for recon. Some people do refer out or have a plastic surgeon / ENT in the office. But as mentioned earlier, this model is changing as more Mohs people are trained and older Mohs retire.

Majority of skin cancers are diagnosed by dermatologists (vs family medicine). It is easier to employ one Mohs person in the group that can do the majority of recon (few cases actually need a forehead flap) than hire a Mohs and Plastic Surgeon. Most Mohs people will have a ENT / Plastics person in the community for unusually big cases. If OP wants to do other stuff and every now and then do a forehead flap, that is fine. But if he wants to do primarily skin cancer recon, he should do dermatology and Mohs.

Most Mohs people enjoy the recon and find it very fun. That is why they do it. An experienced and talented Mohs person can safely do a forehead flap in about an hour.
 

310prolene

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The truth is, the term “skin cancer recon” is an awfully vague term. Aside from differences in referral patterns, geographic location, private vs academic, etc There are large differences in anatomic location, type of malignancy, and structures involved. I’m in PRS. At my hospital (2000 bed tertiary refers center), we do 75% of melanoma, including both resection and recon. Basal cells are mostly done by derm, unless the tumor involves deeper structures or patient requests plastic surgery involvement. SCCs vary a little more depending on who diagnosed it. This is just one example. One can do “skin cancer recon” in derm or PRS. With PRS one will have vastly more tools at his or her disposal and can probably expect more complicated recons / bigger whacks.

In terms of your original question — there probably aren’t “big players” anymore because medical literature advances so quickly now with epubs and so many journals. Rather than waiting for one surgeon to publish their 500 nasal recons accrued over 30 years, people are constantly publishing small incremental differences in techniques etc
 
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XCdude

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I am a plastic surgeon and like 310prolene we do most of the melanomas, but locally here, a lot of SCC and BCCa. Our local MOHS guys do not enjoy reconstruction and send us anything that needs to be closed on the face. This is why I recommended dogmatic statements be avoided because there are few black and white things in medicine, as in life.
 

droliver

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I think it comes down to the business model in the US. For many really busy MOHS practices (15-20+ per day), they would lose money by getting tied up with complicated reconstructions that take very long. I'm plastics but am next door for one of the busiest MOHS practices in the country. They actually do most of their own reconstructions unless it involves the eyelid or some of the larger cheek/neck advancements. In practice, most MOHS reconstructions are actually very simple layered closures rather then the exotic flaps you see written about.
 
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