Man looking at his cheek with a mirror

Facial Surgery Leads to Cancer Diagnosis

Tom Ashbury complained of numbness and pain a year after facial surgery. Was it typical of recovery or something else?

Tom Ashbury had a left cheek flap reconstruction surgery performed by Dr. James Barkley, a dermatologist. About a year later, Tom started complaining of facial numbness near this area. This is a common side effect—many patients experience numbness and tingling at the surgical site for 12-18 months post-op.  

After 18 months, Tom presented for worsening, constant neurological sensory symptoms on the left side of his face. Dr. Barkley referred him to a different radiologist for another CT scan, which was read as negative. At his subsequent visit, Tom again complained of facial numbness. Dr. Barkley referred him to another radiologist who performed a CT scan that was also read as negative. Following a third complaint and additional testing, cancer was found near the cheek area where Dr. Barkley had performed his procedure.

Dr. Barkley consequently performed a Mohs procedure and removed some skin cancer from Tom’s nasal wall. He viewed the slides from the initial stage of the Mohs surgery and saw the presence of spindle cells, yet he continued the procedure. He didn’t, however, send the slides out for a pathological review or perform a biopsy prior to the Mohs procedure.

After receiving a report indicating possible melanoma and a positive deep margin, Dr. Barkley referred Tom to Dr. Janice Harrison, a plastic surgeon, for further treatment. Dr. Barkley expected Dr. Harrison to treat this as a melanoma and do a wide excision.   

Dr. Harrison spoke to Dr. Barkley about Tom before she saw him. That discussion included Dr. Barkley telling her that Tom may have melanoma, that the lesion on the nasal ala was rapidly growing and that it was ulcerated with raised pearly borders, without pigment. Dr. Harrison also read a pathology report that stated, “I suspect that this lesion may be an atypical fibroxanthoma; however, the Sox 10 reactivity is concerning, and a neural/melanocytic neoplasm cannot be entirely ruled out.”

Dr. Harrison said she spoke to Tom about the fact that he was coming to see her to get a biopsy, about the ambiguity of the current diagnosis and about the options to help determine whether he had AFX, squamous cell carcinoma or a melanoma. Dr. Harrison was adamant that she spoke to Tom about the possibility that he had melanoma at which time he asked if they would have to cut off his nose. She responded that if that was going to be necessary, they would make him a new nose, but she would not be the one doing that.

Dr. Harrison excised the tissue that was directly below or anterior to the area where Dr. Barkley had performed the Mohs surgery but didn’t excise the surgical site or the scar tissue. Her excision was not any wider than Dr. Barkley’s MOHS surgery excisions. Dr. Harrison said that she did not go any wider because there was no lesion on her physical examination and because only one area of concern was identified and that was the deep margin where she did her excision. Dr. Harrison’s surgery and discharge described her surgery as an excisional biopsy.

Both the biopsy and pathology reports were negative and no neoplasm was seen, leading Dr. Harrison to conclude the lesion, whatever it was, was gone. Dr. Harrison did not recommend that any of the slides be sent for additional review. She mentioned she would have expected the pathologists to make that recommendation, if it was needed, and did not offer to refer Tom to a head and neck oncologist. 

Dr. Harrison said she would have given Tom a copy of the pathology report and gone over it with him. She would have told him she did not know what the lesion was, but according to the pathologist, it is completely excised. She did not consider this lesion suspicious for melanoma, though she knew the pathologist said it could not be ruled out. Instead, the pathologist said the lesion was a poorly differentiated neoplasm that was favored to be fibroxanthoma. Dr. Harrison said the various explanations for not finding any neoplasm included that Dr. Barkley had actually excised all the tissue and that the inflammatory process of healing or the use of cautery cleared residual cancer cells. There was no documentation that Tom understood he could have melanoma and was opting for no further treatment. She referred him back to Dr. Barkley for close follow-up.

Tom continued to treat with Dr. Barkley. Other than some numbness at the surgical site, Tom had no complaints and the repair continued to look good without evidence of recurrence of the disease. No further action was taken by Dr. Barkley or Dr. Harrison to treat his melanoma. 

The Patient Sues

Following his last appointment, Tom Ashbury retained an attorney who, in the filing, alleged the following on Tom’s behalf:

  • A failure to diagnose melanoma
  • A failure to refer to multidisciplinary care for the melanoma 
  • A failure to discuss of the risks of proceeding with the Mohs surgery without a biopsy.

The lawsuit named multiple defendants, including Drs. Barkley and Harrison, as well as the laboratories that issued the biopsy and pathology reports. During discovery, a global demand of $6 million was made, but after several years of litigation, the case was ultimately settled in mediation with a global amount of $950,000.

What Can We Learn?

  • Ensure the referral you issue specifically states what you would like the provider to assess and/or perform.
  • Document discussions you have with the patient regarding your treatment plan, test results and findings.
  • Document any discussions had with other health care team members, including other providers.
  • In case of high-risk patients, refer to a specialty that can adequately treat the known or suspected condition.
  • Follow good, informed consent protocols which include communication and documentation of the following components:
    • Your diagnosis, nature/purpose of the proposed treatment, risks/benefits of the treatment, alternatives and their risks/benefits and the risks/benefits of not receiving the proposed treatment
    • Patient’s ability to understand the information provided 
    • Patient’s reason for giving consent/moving forward with proposed treatment
    • Facts related to the patient’s health history
    • Questions posed by the patient and answers provided
    • Education discussed and provided
    • Discussion of expectations and limitations the patient may experience following the procedure.
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