Thursday, May 30, 2019

Infiltrating BCC of the Ala

The patient is a 58 yo man in fair health.  He suffers from anxiety and depression as well as diabetes and coronary heart disease and is status past CABG.  He was brought in by his female companion who noticed a lesion of the left ala.

O/E There is a nine mm indurated lesion with some surface erosion.


A 3 mm punch biopsy was difficult because of his severe agitation.  The pathology showed a deeply infiltrating basal cell.

Given this patient’s pervasive anxieties, should one consider XRT over Mohs surgery?  The latter might also cause some deformity and may require a complicated reconstruction.  Of course, I will lay out the choices to the patient and his companion; but I thought this was a good question for our members to consider and weigh in on.  Some great unknown medical sage said, “Sometimes, it is may be more important to treat the patient who has the lesion, than it is to simply treat the lesion the patient has.”


  1. Dr. Bhushan KumarMay 30, 2019

    No Radiation please

  2. My preference would be to pre-treat the patient with Xanax 1 hour prior and do Mohs. We have treated many anxious patients this way successfully. The repair could be referred to a plastics or ENT doc who would be able to do the reconstruction under sedation. He likely will need a flap to reconstruct the alar rim. Radiation would be less preferable, as the resulting atrophy may significantly distort the alar rim.
    Jenny Stone

  3. I have found XRT is quite anxiety provoking. They make a large plastic mask like mesh that covers the surrounding area - the face - the eyes and mouth etc. A good Mohs surgeon being able to talk through the procedure with the patient can go a long way. Alternatively, plastic surgeon evaluating with frozen sections or “slow mohs“ under general anesthesia could be considered.


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