Mohs micrographic surgery is a specialized procedure for removal of skin cancer from the face or other areas in which, besides the cancer excision, the preservation of non-cancerous tissue is important. The surgery, performed by a dermatologist who is trained in Mohs surgery, may require several steps to ensure complete removal of the tumor.
After removal of the tumor is confirmed through microscopic examination, the skin defect on the face is reconstructed, generally by the Mohs surgeon who performed the excision. On occasion, Dr. Mehta will be consulted to assist in the reconstruction of larger facial defects, particularly large defects involving complex structures, such as the nose.
Dr. Mehta utilizes a multitude of local flaps, skin grafts, and pedicled flaps for reconstruction of these major skin cancer defects. The procedures are generally performed under local anesthesia, occasionally with mild or moderate sedation. The procedures may be done in our in-office procedure room or at a Surgery Center. Sutures are removed 6-7 days after surgery and recovery time is usually minimal. If needed, Dr. Mehta will fine-tune the results using microneedling, laser/BBL treatments, or steroid injections to ensure that the incisions heal as well as possible.
Dr. Mehta has tremendous experience in facial reconstruction, having performed hundreds of such cases over the past twenty years. He brings a well-trained aesthetic eye and attention to detail to optimize his patients’ outcomes. For more information, please contact our office.
Septal Perforation Repair
Dr. Mehta is an expert in septal perforation repair, by virtue of his extensive training and experience both in Head and Neck Surgery as well as Facial Plastic Surgery. Septal perforation repair is a delicate surgery that requires great technical skill and finesse but can be very worthwhile for patients with troublesome symptoms.
Dr. Mehta using the latest technological advance for repair of septal perforations, the PDS™ Flexible Plate. This plate has been a very exciting new development as it facilitates the repair of larger holes and seems to increase the chances of successful closure.
A septal perforation is a hole in the septum, which is the vertical structure that divides the nose into left and right. The septum is made up of bone and cartilage and is covered on each side by the mucosa and soft tissue that lines the inside of the nose. The most common causes of septal perforation include trauma to the nose, drug use (specifically cocaine), nasal sprays, infections, surgery, or repeated cauterizations of the nose for nosebleeds.
Patients with a septal perforation may have a multitude of symptoms, including difficulty breathing through the nose, congestion, whistling, crusting around the perforation, epistaxis (nosebleeds) and runny nose. Severe perforations may affect the structural integrity of the nose, particularly if the perforation involves either the front or the bridge of the nose. If individuals are experiencing any of these symptoms, they may be good candidates for repair of the septum. If the perforation is asymptomatic, meaning that it is not bothering the patient, it is not necessary to repair it. However, it should probably be monitored periodically by a specialist (ENT, facial plastic surgeon, plastic surgeon, etc.) to ensure that the perforation does not change in size over time.
Dr. Mehta typically spends about an hour with patients who come in for evaluation of a septal perforation. He will begin by discussing the duration of symptoms and any medications the patient may have tried to relieve them. Dr. Mehta will then obtain a careful medical history. Of particular importance are any medical conditions that could affect the ability to undergo and recover from surgery and anesthesia.
Next up is a thorough physical examination of the outside and inside of the nose. The inside of the nose is gently examined with an instrument called a nasal speculum. The important factors are the size and location of the perforation, as well as the status of the cartilage and bone in front and behind the hole. Any deviation of the septum, narrowing of the valves of the nose, or enlargement of the turbinates are also documented, as all of these issues can be addressed during your surgery, if needed.
Jill, our Office Coordinator, will help to facilitate insurance coverage for septal perforation repair, as this surgery is often considered medically necessary. She is excellent at explaining all aspects of the insurance process and will work closely with the insurance company to make everything as smooth as possible. She will also schedule the surgery and all pre- and postoperative appointments.
Once patients have decided to proceed with surgery, they would return for a preop visit around three weeks prior to the surgical date. This is basically a chance to ask any questions which may have come to mind and review all of the preoperative and postoperative instructions in detail. Dr. Mehta will also prescribe any prescription medications (pain medication, antibiotic, etc.) needed for surgery. This visit takes approximately 30 minutes.
Dr. Mehta and/or our Aesthetic Nurse, Shannon, will go over the list of prescription and OTC medications as well as supplements. This is done to ensure that patients discontinue (under the guidance of a primary physician) any medications that could increase the risk of bleeding. These include, but are not limited to, Advil (ibuprofen), aspirin, Aleve, heparin, warfarin (Coumadin), Plavix, vitamin E, fish oil and other supplements. Medical clearance and other tests (EKG, blood tests) may be needed, depending on the patient’s age and health status.
The Day of Surgery
Patients arrive at the surgical center with a family member or friend who would drive them home and provide care following surgery. The surgery is nearly always done on an outpatient basis. It is very important to not eat or drink anything at all for at least 8 hours prior to your surgery, including water.
The preoperative area nurse will meet with the patient first to help fill out some paperwork and get changed into a gown. The IV will be started at this time. Patients then meet your anesthesiologist, who will have carefully reviewed the medical and surgical history. This is a great chance to go over the anesthesia plan with him or her and review any questions the patient may have. Lastly, Dr. Mehta will meet with the patient and his/her family and friends to answer any last minute questions.
Septal perforation repair typically takes between 1.5 and 3 hours to perform. The specific techniques used during surgery depend on the size and location of the perforation as well as the surgeon’s preference and experience. The repair can often be done through an endonasal (closed) approach, meaning all the work is done through the nostrils and no external incisions are made. However, larger perforations could necessitate an open approach, meaning a tiny inverted-V shaped incision is made between the nostrils. This incision heals quite well when created and closed with meticulous technique.
For the repair of septal perforations, there are a few common options that Dr. Mehta employs:
-Rotation of mucosal flaps from the portions of the septum which are intact.
-Rotation of tissue from the turbinates, which are structures inside the nose on either side of the septum.
-Repair of the perforation using a temporalis fascia graft, which is a thin piece of tissue taken from the covering of the bite muscle (temporalis muscle). This is taken through a tiny incision made behind the hairline in the temple, which does not require cutting or shaving any hair. This incision usually heals quite well and is nicely camouflaged by the hair.
Use of one of the above three techniques with the additional use of the PDS™ Flexible Plate. This is a thin (0.15 mm) absorbable plate that provides solid structural support to the fascia graft or mucosal flaps during the recovery process. It is made of the same material as some dissolvable sutures. During surgery, Dr. Mehta places this plate to that it spans the perforation and covers both sides with either fascia or mucosa. The PDS plate then slowly dissolves inside the septum over a few months as the repair site heals.
Regardless of which technique is employed, the repair is usually stabilized after the surgery with the use of Doyle Splints, which are placed inside the nose (up against the septum) for approximately 1-2 weeks and removed in the office. Packing is usually not necessary.
Following surgery, patients are observed for 1-2 hours in the recovery room before discharge home. Pain and discomfort are usually mild and either prescription pain medication or Tylenol are taken every 4-6 hours, typically for the first 3-4 days. Because of the placement of the Doyle Splints inside the nose, patients are able to breathe quite well. Nasal saline spray is used 5-6 times daily, to irrigate the lumen, or tube, which runs along the Doyle splint. Your diet should be mild in flavor for the first day after surgery, to minimize nausea. A lower salt diet is advisable for the first few days after surgery, as this may help to reduce swelling. You should avoid any vigorous activity or heavy lifting for 10-14 days after surgery.