as boarded in head and neck surgery and facial plastic surgery. Uh skin cancer reconstruction has really been a very big part of my practice since I left residency as as I know that it is for a number of other people in our group. We love our son and there are people that actually love wearing leather shoes to the beach and short nylon socks as well. The tanning effects of the sun have some wonderful short term benefits. They also have some long term problems that they induce. Such as in this 39 year old man seen leaving a club at six o'clock in the morning in West Hollywood the other day, the degree of photo aging, the disc row mia's of the face, the exaggeration of fixed and dynamic wrinkling, increasing in the face vascular fragility. All of these things are direct effects of solar exposure. There are some that are more nefarious though here's an example of this Nagy ular Thailand geek tadic lesion of the right lower eyelid that is actually growing into the conjunctivitis of this gentleman. And this is a not regular basil cell carcinoma which is going to if left unattended, create visual problems for him. But it's going to be a reconstructive problem in any case. This is the result of cumulative sun exposure just as is squamous cell carcinoma. But there are other behaviors that that start very early in life that may expose us to individuals severe sunburns and those create different kinds of histological problems later in life melanoma in particular, which is capricious and has a tendency to metastasize in sometimes unpredictable ways. It has a very uneasy stalemate with the immune system so that many years can go by and then at a moment of immunological defensive defenseless nous. Then all of a sudden something crops up which could be a life threatening problem. These lesions actually can be linked to individual bad sunburns and not just to cumulative solar exposure over life. There are a number of available skin cancer treatments. Uh many of these are time honored and have taken their place in dermatologists and primary care offices as well as those in various surgical practices, acid peels, liquid nitrogen, electro desiccation and curettage which is basically scraping and then using low amperage electrical stimulation to desiccated the surface. Those things are effective for superficial skin cancer lesions and are done by the millions every year. There are topical treatments for frequent flyers Like five floral euros. L which under different brand names can be applied as a topical treatment for a couple of weeks. The patient looks like hell during the time that that's on. But then as the recovery from the application resolves, there's a marked improvement in pre malignant and in early stage malignant cells in the skin and for somebody who's just devastated by the kind of solar aging and photo damage that that previous gentleman had. This. This can be a well used effective treatment. Excisions with or without frozen section control are very common in our offices and in the operating room depending on the size of the lesion. Ionizing radiation has been used for a long time. Uh it absolutely can be curative for certain skin cancers. There are concerns about the pigmentation of the skin, um thinning out of the skin, making it less resilient to trauma. But one of the other concerns is that after time ionizing radiation has been shown in cases to induce secondary cancers whether there epithelial or sarcomas, otis. So while it may not happen frequently, it's definitely a concern almost everybody in this room probably as heard of the term moe's surgery. Ah mose excision or microscopically oriented histological sections is a way of trying to excise a lesion so that all aspects of the contact surface of that growth can be histological e evaluated and determined if there's any residual tumor left behind. Uh immune modulators are coming to the fore for advanced or under aceptar ble disease. That will be a topic for future discussion. Most surgery While it has that it has that abbreviation that's been put into practice. It actually was originated by a general surgeon in 1932 named Frederick Moes jr, who in the midwest, I was surrounded by people of Germanic and Swedish background and they didn't tolerate environmental exposure very well. They would get a lot of extensive skin cancers. And so he came up with a method of actually fixing the tissue inside too. So he would have the patient or the patient would have the sink, chloride and bitter root paste applied to the tissue. It would actually fix the tumor where it was. So it didn't matter whether it was on the back of your hand, on your skull, on your chest and once it was fixed, he could then come back and literally just carve it off. It's like going to focus to chow and getting you know, getting that meat carved off on your plate. He would then have the specimen flipped over mapped out and anywhere that there was a residual area of tur there would be more application of paste. It would get fixed and then carved off. This could go on for a long time. I've seen I've seen some of the final pathologies on patients that had chest wall lesions where myocardial was present in the final clearance specimens and a number of cases where there was brain present as the tumor was followed right through the scalp, the skull, the dura and everything in between. So it was a very effective way of getting rid of some massive problems. But it took a long, long time. So that was modified over time, dermatologists really embraced this technique and some specialized dermatologists who are trained in doing most surgery would then utilize frozen section evaluations to try to speed this up actually. When I was in training and had neck surgery, we used most techniques for for following the pathology of upper aero digestive. So we would take tongue jaw next specimens out and we would do the same kind of analysis of of the contact surface of these tumors. And we could trace nine cell wide chords of tumor four or five centimeters. You would never never have any idea that this was going from the larynx up into the nasopharynx and it would take 14 hours to do these cases. But the cure rates were remarkable. The other thing that was remarkable is how much the pathologist hated us because they would have to stay until 3:00 AM to finish the cases off. one of the things that that's especially important with mose is that in the face there are certain areas where embry a logic fusion planes collide with each other like tectonic plates and tumors that develop in those fusion planes have an opportunity to dive deep unsuspected to the clinician. So, in areas near the medial campus along the side of the nose, the central upper lip and around the ear. The recurrence rates for excision of skin cancers in those areas is much higher because of this ability of tumors to go in rather than stay on the surface or relatively superficial. So this is one of the great applications of most surgery. Also in areas where the there's very little available tissue, like on the tip of the nose. The eyelid. Things like that mose may allow us to trace out tumors and and preserve some adjacent tissue. There are some surgical tenants that are important in designing reconstructions for skin cancer. There are relaxed skin tension lines in the face and if one orients an excision along those lines or closes a reconstruction along those lines, The results tend to be better. On the right side is a map of the aesthetic units that are perceived by observers. When when we look at someone's face, we see depressions. We see hi Point's ridges, salsa. Those are expectable topographic landmarks. And we then if we can place reconstructions into these aesthetic units, Avoid crossing from one aesthetic unit to another or place scars in the boundaries between. We will get superior results. There are a number of challenges of facial reconstruction. We, like all animals, are highly attuned two very small imperfections in other people's faces. And in our own the portals to the eyes, ears and mouth are complex or emphases. They are made of multiple different kinds of tissue. It could be skin al valor tissue underneath cartilaginous tissue, sometimes bone. So to restore all all of those things and to get natural looking results and contour restoration is a challenge. Movement in the face as dr Kochar very well demonstrated is supremely important and we do have the ability to preserve sensation and motion if reconstructions are planned out properly. Hair bearing areas. Obviously you can't take hair bearing donor tissue and plunk it right in the middle of the face. I remember seeing one patient in the clinic as a resident who came in with a kind of an unnaturally curly looking mustache. And I looked at him oddly for a minute until I realized that a previous plastic surgery service had taken an inguinal skin graft and repaired his skin, his facial skin cancer with it. So we want to avoid those kind of mistakes. Mhm. Ah So these uh these examples will show some of the problematic scarring that occurs if we don't pay attention to relax contention lines, if we don't pay attention to aesthetic units. Uh If we don't make sure that if we're close to a vital structure, like the eyelid or the corner of the mouth that that our reconstruction is going to supply enough tissue so that we can support those structures and avoid distorting them. Ah The nose on the lower left shows a skin graft which is leaves a depressed and unsightly result. And scars that cross convex cities are much, much more likely to be visible. So I'm gonna cut through a few of the things that have to do with flap design and categories other than to say that we're looking for soft tissue that has its own blood supply that can be kept intact so that we're not transplanting de vascular arised skin from one location to another, tends not to have the same color and texture match that we might want. But we can harvest tissue that has different levels of vascular charity and contains uh skin, skin and subcutaneous or fashionable tissue and our muscle tissue that can be left attached and then moved into an area of need. There are a lot of different geometric designs which are very, very well thought out. And ingenious sliding tissue along a linear access is called a horizontal advancement flap. We can flip tissue from one location over intervening skin. So I'm going to get to the holy part of this talk. The Holy part. It has to do with some bad defects that happened in the face of very good people. Ah This lady on the far left has a large defect from squamous cell carcinoma that was excised with proper planning transposition flap from the right cheek is used to fill the defect and support the lower eyelid and also gives her satisfactory protection and function. This lady has a much more complicated defect that takes the part of her the side of her nose and her upper lip off along with part of the cheek. She also has a large flap that mobilizes the entire right side of the face from the jaw line and then we'll will reconstruct all of those areas. one ingenious flap that was devised 2300 years ago by a cast of indian pot makers. Uh It was designed to take care of the social predilections for amputating the noses of women that were thought to be well, I thought too take their sexual prowess and places that it shouldn't be. So, A flap was designed from the middle of the forehead that could be turned around, brought over the upper part of the nose to deposit tissue in the lower part of the nose. Ah Here's a nasal defect that's small enough to be grafted with a graph that has skin and cartilage from the ear on one side. But when you get bigger defects than that, then you need a lot more powerful tools. So here this man has lost most of his nose on the right side, his upper lip and his cheek. I reconstructed his cheek with the transposition flap and his upper lip as well. And then secondarily brought a forehead flap down to rebuild his nose. This lady ah who is obviously very well put together and uh has lots of friends and lots of important places to go. She wound up with a devastating defect in her cheek on one side. If you look at the lower right, you may be able to barely detect the line that goes from part of the chest along the hair line up behind the ear. So the entire neck and her cheek on that side was rotated up as a flap to resurface the entire side of her face. The aesthetic units become very important in the central part of the face where this young woman had skin cancer defect that took out a lot of the tissue in her upper lip. She actually did much better by me removing the remaining part of the skin and the aesthetic unit and then sliding her cheek immediately and replacing the entire upper lip on that side with one continuous reconstruction rather than a patchwork approach lip defects, another full thickness defect. This is devastating because it took the muscular function of her lip out as well. She had the inside of her lip reconstructed and also a flap of nerve and muscle that brought her cheek and lateral lip muscle to the midline and then the outside of her lip were reconstructed with a cheek flap. So she maintained her aesthetics and also a function of the mouth. The last case that I'll show is also another devastating defect with the entire compound defect of the knows she has no cartilage or any internal lining of her nose as well as the external that affects her lip and her cheek too. So this is with her median forehead flap in place brought down from the center of the forehead. A lip flap slid up to resurface the lip and her cheek brought over to the nose. The second stage divides the forehead flap, leaving the forehead tissue on her nose and turn to the inside of the nose to reconstruct the internal lining. And that's her ultimate result in about three months. So long story short. Our very best friend is the ozone layer. Our next best friends, our zinc and titanium oxide for for using that as protective topical treatment, umbrellas, hats, sunglasses and other sunscreens. There are new frontiers that are going to change everything that I've been talking about. Face transplantation is already in practice. So more limited versions of those kind of free flaps will be used for facial reconstruction. Stem cell population of bio metamorphic frameworks to grow new organs is already in development. We will be using 3D printing with biological substrates To print tissue directly onto human bodies. It's going to happen within 10 years and I hope to be along with and that one of those people that's doing some of that printing. So Uh really appreciate your attention and let's all imagine what the next 2300 years will bring.