Surgery in Nose Vestibule Malignancies: The Ablative Phase

Cancers of the nasal vestibule behave differently from squamous cell carcinomas of the skin and from those arising from the nasal cavity proper (i.e. behind the plane passing tantential to the pyriform opening). Surgery is probably the most used treatment modality for nose vestibule malignancies worldwide, and it consists of an ablative phase (resection) and a reconstructive phase. The ablative phase is usually easy, but positive margins and local recurrences are not infrequent. This is due also to the surgeon’s attitude to preserve the osteo-cartilaginous framework for aesthetic appearance and to facilitate the reconstructive phase. Our advice, in surgically treated nose vestibule malignancies, is to complete the resection of primary lesion with the objective of the wider and safer margins as possible, keeping the ablative phase completely separated from the reconstructive one. In case of need, in particular for unexpectedly positive margins in the final histopathology report, the reresection will be far simpler in case of delayed reconstruction or resort to an epithesis. Depending on the extent of the cancer and on the attitude of the surgeon, resection may range from a wide demolition including a maxillectomy to Mohs micrographic surgery, though unluckily such minimal resection is almost never sufficient to eradicate the disease. We do believe that the best way to define, and therefore classify, the resection of a primary nose vestibule malignancy is to stratify the ablative surgery according to the structures included in the resection itself.