Fernando Luiz Dias


The nose challenges the oncologic and reconstructive surgeon with special difficulties related to its central location on the face and its complex three-dimensional architecture. The prominent position of the nose accounts for its constant exposure to sunlight and thus for its predisposition to the development of cancer of the skin. The nose is the most common site of involvement of cancer of the skin, and it is also the most common site of recurrence. Rhinectomy is defined as the removal of the vast majority of the nasal framework, soft tissues, and skin. It is a relatively uncommon procedure with most published series including small numbers of patients managed with a three-dimensional nasal resection for cancers of the skin. The multiple factors that make the cancer of the nose an area at increased risk for aggressive behavior and high recurrence include:

Increased actinic exposure

Relative lack of subcutaneous tissue

Enhanced access to perichondrium and periosteum

Close proximity of embryologic fusion planes

Overly conservative treatment (in order to avoid cosmetic deformity)

Complex three-dimensional architecture

Multicentricity of cutaneous malignancy


Although the clinical characteristics of an advanced cancer of the nose are usually obvious under observation, a careful bimanual palpation is advisable in order to evaluate the involvement of the upper lip, columella, and floor of the nasal cavity (Fig. 21.1A). Endoscopic evaluation of the nasal cavity is crucial in accurate clinical assessment of an intranasal lesion. Despite the low incidence of lymph node metastases found in most
published series, even in patients with other histologic types than basal cell carcinoma, a careful palpation of the facial, periparotid, and cervical lymph nodes (particularly levels I and II) is advisable (Fig. 21.1B).

FIGURE 21.1 A: Squamous cell carcinoma of the nose with involvement of the upper lip and gingivobuccal sulcus. B: Lymph node metastases from cutaneous nasal SCC.


There are few contraindications to surgery based on the local factors, all related to the invasion of critical intracranial structures. Although uncommon, these situations are associated with huge invasive/destructive lesions of the midface and share the same contraindications as the resection of skull base tumors. Patients with comorbidities such as severe cardiovascular and/or pulmonary disease, markedly debilitated or demented patients, or those with end-stage renal disease are usually not candidates for surgery.


Imaging Studies

Imaging studies should always be performed as they provide valuable information that can help in the evaluation of tumor extension, particularly the involvement of paranasal sinuses and orbital cavities. Both computed tomography (CT) and magnetic resonance imaging (MRI) are used in the evaluation of large cancers and the surrounding bone structures. Evaluation of periosteal/bone invasion, as well as invasion of nasal and paranasal sinus cavities, is of utmost importance for surgical planning (Fig. 21.3A-D).


Due to the bewildering array of malignancies arising on the skin of the face, accurate pathologic diagnosis is critical. If the patient has not been biopsied previously, obviously biopsies must be done. If patients have been biopsied elsewhere, the slides should be reviewed to make certain of the correct diagnosis.


Under general endotracheal anesthesia, the oropharynx is packed with a damp gauze bolster to prevent aspiration. The patient is prepped and draped, with the face, forehead, and neck exposed for those patients who will receive a neck dissection. Ointment is placed in both eyes, and the eyelids are taped or sutured shut. The proposed area of surgical excision is marked with the surgical pen to delineate adequate surgical margins (Fig. 21.4A).

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