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October 13, 2020

A regenerative approach to facial reconstruction after cancer surgery

By Susan Buckles

Growing up in southern California, Sabrina Falcon was a self-described “sun baby” whose love of the outdoors reached the skies. Years later the flight attendant who is working on her pilot’s license was diagnosed with skin cancer on her nose — the basal cell type that typically grows slowly with low risk of metastasizing. After two cancer surgeries, she began suffering from mysterious headaches and facial pain.

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Sabrina Falcon

“I was a frequent visitor to the emergency room. Medical providers started telling me that there was nothing wrong. One suggested I see a psychologist. So being frustrated, I talked to friends and heard about Mayo Clinic,” says Falcon.

Her appointment at Mayo Clinic’s Arizona campus revealed the elusive answer:  previous surgeries elsewhere did not remove all the cancer. The basal cell tumor spread aggressively through her nose, which put her on a path to an innovative cancer surgery and regenerative reconstruction.

“Anytime you hear the word cancer, I think it would be odd if you weren’t uneasy. I had gone through so many disappointments searching for answers, it was almost like a weight had been taken off me, because they found something,” she says.

Preparing for a long day of surgery

Shari Ochoa, M.D., a dermatologist at Mayo Clinic’s Arizona campus, prepared Ms. Falcon for a long day of surgery to remove the unusually large tumor. Dr. Ochoa performed the Mohs procedure in which she removed the cancer in stages, immediately testing it in the lab while Sabrina was awake under local anesthesia. Her goal: remove all cancer cells while sparing healthy tissue.

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Shari Ochoa, M.D.

“Think of it like a pie. The filling of the pie is the cancer, and I look at the crust to see if there are any holes where the cancer has gotten out.  I look at the whole crust so that if there is a little crack where cancer has gotten out, I identify it and immediately remove it,” says Dr. Ochoa. “It took me four stages. The cancer had extended from one side of her nose to the other, from the nasal bone to the bridge of the nose.”  

Regenerative Approach to Nasal Reconstruction

In a team approach, Brittany Howard, M.D., an otolaryngologist and facial reconstruction surgeon, stepped in to reconstruct a nose to replace the one Falcon lost to cancer.  

Dr. Howard proposed a regenerative approach to restoring form and function that would require five surgeries over six months – one every four weeks.

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Brittany Howard, M.D.

“The challenge is rebuilding a nose to look good and restore breathing through the nose. Balancing both components is huge. It is frustrating for some patients with Sabrina’s condition to hear it might take four or five surgeries to achieve this, but it’s worthwhile,” says Dr. Howard.

“Dr. Howard said pretty much from the beginning, ‘either you’re in or you’re out. And you have to be in if you’re going to go down this road.’  I remember telling her, ‘I just have one request: I don’t ever want to not look like my parents,’” says Falcon.

The first surgery involved transferring skin from Sabrina’s scalp and forehead and bending it downward to create a new external and internal lining of the nose. This leaves the flap connected to the forehead by an umbilical cord-like tissue bridge that provides blood flow to the new nose so that it can survive the transfer. The new nasal tissue needed to remain connected to the forehead until it was mature enough to live on its own.

“That was harder to see my face than it was with no nose, but at the same time, I knew this was all temporary and with each surgery it was getting progressively better. Afterward, if someone would stare, I’d say ‘look at my surgeon’s beautiful work,’” says Falcon.

Second came the shaping surgery in which Dr. Howard added cartilage from Falcon’s ear to rebuild the skeleton of her nose. In an innovative approach informed by research, Dr. Howard used donor cartilage to sculpt a new nose to precisely fit Ms. Falcon’s face.

“Mayo Clinic is one of the first medical centers to perform this procedure. It's using a new, regenerative technique. Donor cartilage is diced and mixed with tissue glue to become a moldable jelly that I can shape into a perfected nose. There were good animal studies that showed dicing cartilage had the best survival of any similar manipulation of tissue,” says Dr. Howard. “This is done in place of a more standard procedure done in which solid pieces of cartilage are carved and placed by the surgeon. Carving sometimes does not give as much flexibility in shaping the nose compared to this new technique.”

Sometimes the tissue transfer from the scalp can leave a small bald spot. In the next surgery, Dr. Howard placed an expander in Sabrina’s forehead that stretched her scalp much larger than normal to regenerate skin and restore the hairline.

“We had conversations about ‘are we good enough? Do we need to keep trying for better?’  In pushing to make her nose more sculpted, more symmetric, it meant spending an additional 3-4 weeks with that elephant-like attachment that went from her forehead to the bottom of her nose,” says Dr. Howard.  “For Sabrina, who has a very public profession as a flight attendant, the extra procedure was worth it.”

Ms. Falcon’s final two surgeries involved removing the expander in the scalp. And, with new, healthy skin securely in place, Dr. Howard removed the elephant trunk-looking, umbilical cord-like tissue that connected the forehead to the nose.

“She has been truly a partner in this process. This reconstruction is a profoundly hard road to walk. She has had extreme faith in her God, in herself in her personal strength and in us as her care team,” says Dr. Howard.

Sabrina Falcon says she is elated with the outcome. Her new nose has all the functions of the one she lost to cancer: she can breathe, smell and generate nasal fluids. Ms. Falcon says she feels great and is excited to once again aim for the skies. She looks forward to her work as a flight attendant, where she plans to educate others about skin cancer and recovery.

“I feel like I look as normal as I did when I started. My nose functions normally. I breathe great. In fact, I probably breathe better than I did before. I think I will look and function better than I did when I walked into the doors of Mayo Clinic.”

Mayo Clinic Center for Regenerative Medicine offers support for new applications of regenerative procedures, such as the ones Dr. Howard preforms, that restore form and function in order to address the unmet needs of patients.

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This article originally was published on the Mayo Clinic Center for Regenerative Medicine blog.

Tags: Basal cell carcinoma, Brittany Howard, Center for Regenerative Medicine, Innovations, Mayo Clinic Otollaryngology, nasal reconstruction, News, People, Shari Ochoa, skin cancer

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