Skin cancer case challenge: What would you cut?

We invite you to take part in this case challenge moderated by A/Prof Tony Dicker. Consider the real-life scenario below, then submit your surgical management plan — including your closure drawing — for a chance to be featured and win a free seat at the 2025 Surgery Masterclass in Brisbane.

Your task

Answer the 3 questions below.

Email your name, answers, and drawing to marketing@healthcert.com by Monday 30 June 2025.

Submissions will be published on this blog and discussed at the 2025 Surgery Masterclass.

The winner of the free Masterclass seat (or refund) will be announced 1 July.

The case

The patient:

• A 56-year-old female.
• History of previous BCCs on her cheek and forehead.
• No problems encountered during previous surgery on the face.
• Well, no medications, no blood thinning herbs or vitamins.

The patient presents with this lesion on the ala:

The diagnosis:

This exercise is about management rather than diagnosis. Assume the lesion is a nodular BCC (or, if you prefer to biopsy the lesion, then assume the pathology report shows nodular BCC).

The management plan:

In describing your approach for managing this BCC on the ala, please answer the following three questions.

Question 1: Is there any other information or images that you wish to capture that would be significant for this patient's care?

Question 2: Are there any non-surgical managements you might consider suitable for this lesion, and would you consider any of these options to be a better treatment than surgery?

Question 3: Assume the patient has agreed to a surgical management of this lesion. What is you preferred type of closure for this lesion?

Please save/download the below image and draw your answer.

Thank you for participating in this challenge!

The Surgery Masterclass

Eligible submissions will go in the draw to receive a complimentary place at the Surgery Masterclass (upcoming on 15-16 August 2025 in Brisbane), led by A/Prof Tony Dicker and Dr Tony Azzi. (If you have already registered, we will refund your full fee!) Click here to learn more about the Masterclass.

Your colleagues' responses

Dr Hoang Le
1: Medical history - Age, general health, nutrition. Current medications - blood thinners, diet. Compliance. Cost.
2: Cryo, Chemotherapy (Efudix/ Aldara), Curette and diathermy only if the patient is not suitable for surgery (but high risk of recurrence, need to explain to the patient) for example: Doctor skills, facility, general health, nutrition, blood thinners which would affect wound healing. Otherwise, WLE Surgery will be the best option for nodular BCC.
3: Can do ellipse, advancement or modified rhomboid as per photos. However, excision (Mohs Micrographic Surgery if possible) and grafting would be the best cosmetic choice for her. Donor graft could be taken from the base of the neck. Dressing intact for 5 days then graft take to check. Need to inform regarding the senseless grafting site. This method is preferrable given it can be repeated if the tumor is not clear from previous excision (no Mohs) and grafting. With a margin of 4-6mm. My preferable approach will be Modified Rhomboid (in first photo). If not clear, will consider excision and grafting.

Dr Mostafa Ziabari
1. Any info RE perineural invasion in the biopsy report to consider wider margin?
2. Metvix PDT, Rhenium-SCT (skin cancer therapy) and radiotherapy. I believe surgical treatment is considered superior compared to these options.
3. My preferred surgical solution: FTSG (pic 1), Shark island pedicle advancement flap (pic 2) and transposition flap (pic 3).

Dr Srikumaran Shan
1: I would like to know the size of the lesion (defect would be less than 6mm or over 6mm) which is important to decide about management of the surgical excision. In addition, I would like to check the forehead (glabellar area and pre auricular area) for any previous scar (in case if a skin graft involves for a donor site).
2: If the size of the defect is smaller than (less than 6mm) secondary intention of healing is suitable for this location. I wouldn't recommend any curettage and cautery for this location.
3: I have two surgical options for the closure. Option 1- Full thickness skin graft (donor site, glabellar or pre auricular area). Option 2- Bilobed flap. Advantage of flap- one wound site to manage compared to graft flap healing better, no mismatch skin colour. I will give advantages and disadvantages to the patient regarding both options and involve patient in the decision making.

Dr Seyedeh Maryam Sahafi
1: I look at full face picture from front, where was previous lesion on cheek, same side, how is the scar - to understand the nature of skin reaction. Any previous cosmetic treatment in the area, feeling skin mobility, expectation of patient about the procedure and outcome. 
2: High risk area , chance of recurrence, looks more than 6mm diameter nodular BCC, not suitable to Aldara, age as well another reason not choose it. PDT may be helpful not in the area, ellipse will distort the nasolabial fold -- will not do it. graft can be considered as recommended by ladder with periauricular area, considering mobility of skin in the area ,or supra clavicular.
3: Considering flap, advancement, bilobed, if the mobility of skin be suitable. I am not confident to do it at the moment.

Dr Hooi inn Neoh-Solman 
1. Patient’s lifestyle and surgical preference.
2. I will discuss with patient other options to treat this area. But I would not recommend other options - chemotherapy, radiotherapy because of her age and location of the lesion. Will recommend Mohs surgery to excise this area.
3. Mohs surgery can minimise tissue loss, my preference is healing by secondary intention if the defect is small. The scar will looks better and colour match too. If patient choose not to go ahead with the option or the defect is bigger and deeper, island pedicle flap will be my option close this defect (from the photo, should have sufficient tissue and movement to close the defect).

Dr Peter Morero
1.  Previous surgery on the nose or FTG sites, medical comorbidities, smoker?, home environment and ability to manage.
2.  Imiquimod is an option with recurrence rates less than 2 % according to a systematic review from 2020 (https://pubmed.ncbi.nlm.nih.gov/32527151/).  5FU not indicated for nodular BCC.  Radiotherapy an option but potentially scarring.  I wouldn’t see the point of curettage/diathermy - likely the worst possible cosmetic outcome.
3.  I would want to keep the alar crease as far away from any involvement as this could have an effect of the final cosmesis.  Bilobed flaps have always worked quite well for me on the nose so this would be my preferred approach with the flap rotating medial to lateral.  FTG from glabellar a reasonable alternative but I would prefer the flap.

Dr Prashanta Kumar Mitra 
1. I think enough information has been given.
2. The patient has been previously operated for BCCs on her face , Such patients have tendencies to respond to surgical management . Moreover cryo, curettage, application of Aldara or Efudix etc has disadvantage of incomplete removal, ugly scarring ,recurrences etc. Moreover you never know that you have removed the lesion completely or not. I will explain the patient that excision is the only answer .
3. I have developed a complete new approach to such patient and this has come through my long experience of coming across chances of incomplete excisions ,perineural invasion on histology and subjecting the patient re-excisions etc .I will explain the patient that I shall excise the lesion under local anaesthesia with 4 mm of margin around the visible cancer area and deep to the cartilage. I will use the electrocautery and/or running sutures with 5/0 monosyn to achieve the haemostasis, Mark the specimen at 12'0çlock  send the specimen for histopathology. I will wait for the microscopic report. Depending upon the report my further action will be as follows: a) If the excision is complete I will do the second stage full thickness skin graft to close the wound; b) If the histology result suggests that that it is very close to or incompletely excised at particular area such as 3'0çlock or 6 or 9 '0' clock  then I will excise more and do the skin graft. Advantage of my approach: I practice in rural area where the patients can not afford the time, travelling, or finance to seek the skin specialist surgeons who are located in the metropolitan cities. This is a time saving, money saving alternative to MOH'S surgery.

Dr Heather Lawson
1. I would definitely do a punch biopsy, for diagnosis, depth and PNI elimination. 
2. Imiquimod 5% has at least a 70% clinical and historical clearance according to studies, so this is a consideration. It may leave an unsightly scar and wouldn’t be my first choice in a woman of only 56.
3. There are a number of surgical options available for this lady. She may well be very concerned about scarring and prefer to see a plastic surgeon, or she may not. The lesion is on the lateral alar, which precludes side to side closure or an island pedicle flap. Bilobed flap is an option but will give more scar lines on the nose and is an option I was once discouraged from using by a plastic surgeon!
FTSG is a good option (from a preauricular donor site, if available) but there is always a risk that it will leave a white scar. The lesion isn’t big, and if it isn’t deep (as per my biopsy result), secondary intention healing can give a good cosmetic result on the alar. There are 3 flaps that I would consider using: a nasolabial transposition flap (picture 1), which gives a good skin match but can result in obscuring the alar groove; a shark island pedicle flap (picture 2), which can distort the alar noticeably, and I would be wary of using this in a woman concerned about cosmesis. Another flap that I’ve seen on the SCCA blog is a jigsaw flap (picture 3), which would probably give the best scar, although might obscure the alar groove.