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:
The patient presents with this lesion on the ala:
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.
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.