Recurrent BCC of the nasal tip in a previously irradiated field
A 78-year-old retired teacher with previous primary radiotherapy to the nose for BCC in 2004 presents with a new pearly papule on the nasal tip.
Diagnosis
Recurrent infiltrative BCC of the nasal tip — Mohs with paramedian forehead flap reconstruction
Learning points
Radiation-field recurrent BCC behaves more aggressively, with subclinical extension and a higher recurrence rate after re-treatment.
Mohs micrographic surgery is indicated for H-zone, recurrent, > 2 cm, or aggressive-subtype BCC (BAD 2021 / Mohs service standards).
Further radiotherapy in a previously irradiated field is generally contraindicated — accumulated dose risk and poor wound healing on a thin-skinned nose.
Subunit principle (Burget & Menick): if > 50% of an aesthetic subunit is involved, consider reconstructing the whole subunit so scars sit at subunit borders.
Paramedian forehead flap — pedicled on the supratrochlear artery (1.2–1.5 cm pedicle, centred on the supratrochlear notch at the medial brow) — is the workhorse for major nasal reconstruction.
NICE TA489 (2017) did NOT recommend vismodegib for routine NHS commissioning; if considered for locally advanced / metastatic BCC, any funding route needs specialist MDT and current NHS England / local commissioning or IFR confirmation.
Source basis
This page was launch-reviewed on 19 May 2026. See the source-control register for the NICE, NHS England, BAD, RCPath, WHO, AJCC / TNM and pivotal-trial sources used across the site; check live guidance and local MDT policy before applying recommendations.
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