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Right I think I'll get started now um So can everyone see the slides okay and hear me okay before I start. I'm going to assume that for you, I think we're all good to go mate, yeah bro, okay, so um today, I've been doing a session on skin cancer um uh My name antoinette, I'm an f. Y. Three Doctor and I currently work um at birmingham City at all. Um So yeah we'll be looking at it's surgical management. It's a really big topic um So this sort of just brushes over things really briefly, um but we'll try and go into some exciting things like um facial reconstruction and flaps and things like that. Um so uh learning objectives today, so we'll be looking at different types of skin cancer, the risk factors and presentation of skin cancer very briefly into the diagnosis and staging um and more importantly the management of the skin cancer, which involves most micrographic surgery and surgical excision and the most exciting part facial reconstruction um So typical types of skin cancer, the most common ones that will be focusing on today are basal cell carcinoma, squamous cell carcinoma, and melanoma um So we sort of categorize this into non melanoma skin cancer so that we you're be CCS and yes CCS um and melanoma. Um These ones down below, Merkel cell carcinoma, sebaceous gland cancer, t cell lymphoma of the skin and capozide sarcoma are very rare um They're very aggressive. We don't really need to go too much into them today, but if you're interested go have a look at what they are um yeah um So risk factors mostly they're pretty much the same for all of them, um So sun exposure is the main culprit here, so um immune suppression as well in all, in all three factors, um age with sec and Bcc age is quite predominant factor in that as well um other things as well pale skin so type one skin um people that burn and that they don't tan are usually more susceptible so really need to use lots of sun cream when they're out in the sun. Um Other risk factors of melon ova, they're having lots of moles might predispose you to getting melanoma um and other things like smoking um actinic keratosis, which is sort of a pre cancerous skin change can predispose you to sec, as well, um so going on to basal cell carcinoma. These are very slow growing there locally invasive um so they're malignant tumor of the epidermal carotene sites um and it's the most common type of skin cancer so luckily for us these ones even though they're the most common, they're the most easily treatable so they're also known as rodent ulcers because sometimes they look like um like a wrap by basically um and the appearance can be very variable. There are different types of basal cell carcinoma which we'll have a look at some pictures in a minute um And the prognosis is pretty good. It rarely metastasizes, but it does increase your recurrence of getting more b. C, c. S, and s ccS. If you've got one um so having a look here, so this the first one is your nodular bcc that is your bog standard one that you probably see in the GP practice, so the pearl pearl rolled, pearl, sorry, pearly rolled edges um and the telangiectasia that you can see the little vessels all over. Sometimes these can ulcerate um looking like the open ulcers um So yeah those are your bog standard. Um Other ones superficial be ccs, so these sort of look like psoriasis and eczema um they're well demarcated, scaly looking plaques um they're quite friable so if you sort of brush past them, they might bleed or weep, um and then more fake or super rosen be ccs often appear on the midface of, like the elderly um as usually like a thick white sort of plaque area um and they can sometimes invade into the nerves um moving onto squamous cell cancer um So these are locally invasive malignant tumor's of the carotid izing cells of the epidermis, or it's appendages, it's got a low chance of metastasis this and can spread to lymph nodes um and the prognosis is quite good with this as it rarely metastasizes, but when it does metastasize, then it's the prognosis doesn't look too good after that, um so they can appear almost anywhere where there is squamous epithelium, so anywhere in the body can get those um yeah, so moving on to some pictures, so here we've got the raised hard cross the edges. It's usually ulcerating um it can bleed and it can week um and often appears in areas where there's a lot of sun exposure. So you know in the elderly, you can find that the tops of ears um and this sort of presentation can often pose quite a big reconstructive challenge and depending on where the lesions are and how big they are. Um I'm moving on to melanoma, so these are invasive malignant tumor's of epidermal melanocytes, so these have a really high risk of metastasis. Um They're more common in women than they are in men um So you can get melanoma in situ which are confined to the epidermis, um but it's considered invasive if it's spread to the dermis and then it can have potential to metastasize to the lymphatic system or to the blood. Um So common sites of metastasis would include the lymph nodes, liver, lung, bone, and brain. So if you see any patient's and you think these patient's might have any metastases you might do like a chest x ray or ct scan, pet scans and things like that just to, to look for those things. Um So four types that will look at today, so superficial spreading nodular lentigo malignant and equal indigenous. So here's some pictures, so with your superficial spreading, this is sort of what you commonly think of as a melanoma, so it's um it's raised or it can be raised or flat, vary in color um irregular borders um Yeah these are these are sort of the ones that you would think of. Um there's also nodulus, so these can appear as like a raised bump, very well demarcated, black in color or purple, um and these are quite locally invasive um move onto lentigo malignancy, so these ones are very flat, varying in sort of shades and colors um and um more common in the elderly and then equal indigenous. So these are found on the nails and soles of the feet um. And quite invasive famously, bob Marley died of of this form of melanoma um and it's more common in darker skinned people okay um So yeah, so to assess malignant melanoma, you might use the abcde tool so when looking at moles and assessing whether you might think that they're normal or not you'd look at the symmetry so if it's asymmetrical uh that is more likely to lead to uh melanoma. Um If the borders are uneven so be, um if you've got multiple colors in one mole, then you might be concerned if the mole is larger than a quarter inch or two centimeters or a centimeter rather um then you might be concerned as well, and if there's any evolution of the mole so changing shape, color, or size, that's also another red flag of melanoma, so how would you diagnose, so say. For example, you know you're in the gp practice, you've seen someone has a mole that you're a bit concerned about you'd refer them to the dermatologist via a two week wait pathway um What the dermatologists would usually do is probably just have a look through the day. Matter scope, assess whether they think it's likely to be a cancer or not, and then what they might do might be a variation of things so um in order to diagnose it properly, they'd need to send a sample off a biopsy, so there are several ways that they could do that um and the, the thing that that most people do is um an excisional biopsy, so if they can cut out the whole lesion, then with, with a good sort of healthy margin of tissue, um then they will so this is done usually under local anesthetic, the dumb, the dermatologists can do this in clinic um and yeah it's just just a scalpel, so it's quite easy um and then they can just put a dressing on it and let it heal by itself or put in a few stitches. Um An incisional biopsy is pretty much the same thing but instead of taking the whole thing out, they just remove a sort of a part of the a part of the lesion and then they'll they'll sew it back up again um So these are for sort of larger lesions where they can't cut the whole thing out with both of these, they would biopsy the full thickness of the skin, so they make sure they get all the layers and they know how far and deep it's spreading. Um Other things, so you can use a punch biopsy, So this is performed using a sort of circle circular blade which is attached like a pen, pencil like handle um um and then they just rotate the instrument down um almost like a cookie cutter, um and they do it through the epidermis, the dermis, and into the sub cup fat um And then lastly, they can also use a razor biopsy um sorry a shave biopsy made a little typo there, but this is a shave biopsy um and it's used it's performed using a tall similar to sort of like a razor blade, and they only shave off the top layers of the skin, So this one doesn't go all the way down, so those are the sort of thing initial things that one might do um for diagnosing um other things, and once they send off the sample then they can look at um staging, so I'm not going to go too deeply into staging because really it's just a lot of tables A lot of information. Um b. C, c and sec have their own sort of staging system, but I've just got up the melanoma Tmm staging system here, so if you're interested go have a look um later on, um but yeah another staging um tool is the breslow thickness, so depending on the thickness well, you can sort of manage and tailor your um interventions towards this. So um for tumors in situ, the melanoma cells are only in the top layer of the skin, so you can so you know get good margins and get rid of that. Um If the melanoma is one millimeter thick or less um then it's then it's t one anything anything above, t one you'd likely to do you'd be likely to do sentinel lymph node biopsy, so basically the lymph nodes that sort of follow on from from that melanoma you want to biopsy to see if there's any spread or metastasis to those lymph nodes okay um and the management for skin cancer, so curative treatment is basically surgical excision or wide local excision with tumor free margins and this can be used for be CCS, CCS, and melanoma. Those micrographic surgery um is pretty much exclusively for nonmelanoma skin cancer, um So we'll go a little bit more into that later, but yeah just explain what surgical excision is, but the tumor is just basically cut out vertically rather than horizontally with a predetermined tumor free margin so um as I explained later, most micrographic surgery is done horizontally, so um it's slightly different in in technique, but surgical excision as you might accept. They just cut the chunk out. Very simple. Other non surgical treatments um include primary adjuvant radiotherapy, cryotherapy, phototherapy, immune response modulators, so creams like imiquimod and chemotherapy, which is last line um So, yeah we won't focus too much on those because we're looking um at that surgery at the moment. So yeah, um So most micrographic surgery, this is basically um quite a time consuming procedure um in which the tumor is removed in horizontal layers, so when each layer is removed, what they'll do is, they'll take the layer and put it under a microscope to look at the histology, and examine each layer, so they'll keep doing this repeatedly until there's a tumor free margin, so the good thing about this is that removes the cancer tissue completely as well as minimizes the amount of healthy tissue that is lost, So you've got better aesthetic outcome and better functionality as well because you're losing less healthy tissue um which yeah and here's a diagram just to show you sort of how they would do that. So, yeah, you might wonder if most micrographic surgery so good why are we still doing surgical excision, So if we compare the two yes, my mohs micrographic surgery is better cosmetic outcomes, better functional outcomes, um but it is more time consuming and laborious as well as more expensive given the fact that there's more steps to it, you need more people to do the procedure, whereas if you do a surgical excision, it's just in out, you cut it out and, and then that's it um It's also so another reason why it's probably less commonly used as well is because it's a specialist service, so you're going to have to have the whole set up in a hospital, so usually it's like it would be like a tertiary center or a specialist center. Whereas you know many surgeons can use, can just do the technique with surgical excision um and it's available in most hospitals um. So yeah, so once once you cut out your your lesion, um you're probably left with a big hole in body, so what what do we do for those like how do we fix those, so um you might turn to the plastic surgeons in this case um in which they will use the principle of the reconstructive bladder, So this is basically um a ladder just to say which is the best technique to you. So if you can you start at the bottom, so healing by secondary in tension, so these two things will go through a bit later, we'll go through grafts and flaps as well, so um at the bottom, we've got the least invasive method of um healing and at the top, you've got the most invasive one, so that would be tissue transplantation, so we always start at the bottom first, and if we can't do say, for example healing by secondary attention, then we would look at primary in tension and skin grass and so on um so yeah that's quite an important principle in reconstructive surgery um So yeah, so so for example, we've cut out your b. C. C. Or sec, on, on a part of your body like your arm, your chest. Your back um you might do you might um just leave it to heal so we'd either leave it to heal via secondary attention, so this is basically when the wound edges are not opposed, so you cut it out and you just let the granulation tissue fill up um and it's just left open, so this is usually good for any wound that might be contaminated or infected or the lesion is not too deep, um but it has increased risks of scarring. Um The other option is pre healing by primary in tension, so um they might choose to close the wound up so when they cut out, the, the lesion like the tumor, they might do it in an oval shape so that that way they can close it together with sutures and it doesn't create too much tension um that way, if it's small um and then they can close by primary in tension where the wound edges are opposed to each other, so they're touching, so it's good for clean fresh wounds and it's good for vascularized areas because it needs that blood supply to heal up um and then when we can't use those techniques, we might consider a graft or a flap, so the difference between a graft and a flap is that the graphs rely on the recipient blood supply and flaps rely on donor blood supply, so what we mean by recipient blood supply is that the graft is usually like a layer of skin, so um that layer of skin doesn't have any blood supply, they'll put it on too another area that's missing it the skin and the blood supply in the capillaries um of that area will supply the graft. Um. Sometimes, this can fail, so you can hear you hear a graft failure, where it doesn't it doesn't take to the to the blood, blood supply and flaps um They rely on the donor supply, So when you when you raise a flap, the blood needs, the blood supply usually comes with it so and that will basically supply whatever you're going to put the flat on, um so it can sometimes be attached so like a pedicle flat, but we'll go into that a bit later. Um it can be attached to the skin or it could be a free flat where you completely remove it and then re re attach it onto another area um So on the face, um It's particularly relevant because there are some places where you know you've got less less blood supply, so places like the nose, the chin, um so you wouldn't use graft on that and you you would rather use flaps um So flaps are required on tissues like bone, cartage, and tendons because those places don't have any blood supply to, to keep keep the graft alive basically um So yeah so there are different types of grafts and flaps, so split skin thickness split skin thickness skin grafts um do not contain the whole dermis, so it's very superficial full thickness skin graft contain the whole dermis um and also you can transplant hair follicles with that as well, which is quite fun um actual flap so a designated fascia containing artery that runs beneath the flats, longitudinal axis is brought up with the flap, so or you can also have random flaps, and there's no designated named artery that provides the blood supply to the flap, but the blood supply is via the subdermal plexus or you could do a pedicle flap, where the tissues completely raised on a name vessel from the donor site and it's transferred to the recipient. So yeah, so as as you might think or know that the face you know there's a lot more to the face than there is to say your arm or your chest or your back because you might not care how what a scar looks on your back, but on your face, it's it's it's a big deal. So yeah there's a lot of surgical challenge surrounding facial reconstruction so basically the way that you reconstruct uh yeah lesions on the face is that you need to consider the size, the depth, and the location um and as we've previously previously talked about, it requires flaps, so you need to think about skin thickness, the color, the texture contour, So you know you can't use like a flat from. Um you know your leg on your on your eyelids, basically because the skin is very different there, so areas that you would sort of the face is sort of split up into areas where they have different reconstructive principles um So we'll have a look into those reconstructive principles for each of the each of the areas of the face um So reconstruction principles of the eyelid This is quite complex, so I've gone quite superficial on this, but basically um it depends on the side location and thickness of the eyelid defect, but if you've got less than 20 to 30% of the horizontal eyelid with, if that lesion is less than 20 to 30% then primary closure so just making sure the edges are closed together produce the best aesthetic and functional outcomes for eyelid lesion's um for lesions that are 30 to 50% of the eyelid uh with something called the tans, a semi circular rotational flat is used where they use the skin directly lateral to the campus and they rotate it around and use that as a flat for your eyelid, so the skin is sort of similar in um texture and vascularies, ation, and if it's 50% or more of the eyelid horizontal width, then the flaps would be from the retro uh a regular area, so behind the ear or the cutler beard flaps so have a look of that, what have a have a google of what those are in your free time, but I'm not going to go through it just with purposes of keeping this within an hour um So yeah that's eyelids is, are quite fun, so basically um the the is not very well vascularized it requires uh sorry it's it's dependent on the perichondrium, which surrounds the cartilage to provide good blood supply um So if a wound um uh yeah if the wind is is where it's basically where the perichondrium is still intact um then the it can heal by secondary intentions, so you can just heal by itself or via a skin graft because the blood supply is still intact. But if you cut the cartilage or if you have or if the skin cancer is like, um because you know in in the cartilage as well and you need to cut part of that out, then you need to have some sort of reconstructive procedure afterwards because the cartilage no longer has a blood supply because the perichondrium is technically damaged or removed by the procedure, So there are several options, option one for reconstruction for small defects um mostly in the helix, so sort of like you know the scc, we saw earlier on the, on the helix of the gentleman, um so we use wedge shaped full thickness excisions with primary closure so basically to avoid distortion and tension, so the top of the excision will extend into the concert, which is like the C shape of the ear um also point towards the roof of the helix so that's like the edge of the ear, so they make a sort of wedge shape and then what they do sort of zip it up, basically so they'll make triangle and then close it back up, and that basically reduces the tension. Because if we use straight lines in reconstruction, you can basically pull it, so tight that the, the vascular ization doesn't actually um allow the wound to heal because it's too tight. So by doing this, um it gives it a bit of laxity to the ear. Um yeah and for slightly larger but still small lesion's you might have a star excision, so they make a wedge excision and with two additional triangular receptions just to distribute the tension and then they'll suture that up, so yeah, this can result in a slightly shorter ear, but it has good cosmetic outcomes um So it's it's actually really simple and easy moving on to medium defects, so this is a helical advancement flap um So what what is meant by an advancement flap is basically a flat that is pushed forward um so here, what they do is they make an incision from the anterior and posterior surfaces surfaces of the helix, so go all the way down and savory, see here and be where they cut along the top. That's probably where the lesion would have been um um and then what they do is they just close up and suture up um So that it's it's curve around it's it's quite hard to imagine or to explain, but they basically join those two edges together um And this is helped by the, the, the incision because that just increases it's sort of laxity of the air, so this would definitely make it smaller, but it has very good cosmetic outcomes and it also keeps all the landmarks of the ears um and there's also quite a low risk of flat necrosis, so um it keeps all the blood supply intact, so you're peri, condoms intact, yeah and then for large defects, um you would probably do a post auricular advancement flap, So what they do is they outline a flat behind the ear um um and this would include the postauricular skin, subcutaneous tissue, and muscle, so this is like a political flap um and um this flap is good because it's um reliable skin color matching, it's just from the same sort of area, a similar responsiveness to sun exposure as the native areas um and has a reliable vascular supply, so what they'll do is they'll they can sometimes bring it um around. It just depends on the defect, depends on the surgeons preferences where they can bring the the flat ground and reconstruct the helix or depending on on where the lesion is, they can also bring it in through the concerta, um moving on to reconstruction principles of the lip so for mucosal defects. Um People usually use um primary in tension um so direct closure, so if yeah um because there's lots of highly vascularized area, it can also use a cell poaching biological wound assistance, so this allows to help heal by secondary in tension and also buckle advancement flaps, so if a patient is unable to care for the wound um and aesthetic outcome is not a priority, then you can just you buckle a advancement flap, so buckle being in the mouth and um advancement flap like I said a flat that pushes forward um like before um skin defects, so if it does not cross the vermillion border um then you can use direct closure, so the vermillion border is the line where your lip um and your skin joined, so it's like yeah, just because it's where the transition from lip to normal skin is um yeah or if there isn't too much tension when you close it, then direct closure is probably best um If you've got upper lip defects, then you might use a Got should flap, which is a small local rotational flap, and I've got some pictures of those later just to help you clarify what that is sometimes, if that's not good enough, then they might change that to a v. Y. Advancement flap um and I'll show you pictures of that too um and if it's large or if the defect is near the lip a lot of cheek junction, so that's like around the nose, the cheek um lip area, then you can use a perrier lot crescentic advancement flap sounds very long, but it's actually very self explanatory as to what that is. Um If there's a combined skin and new kozel defect, then you might use an ab flat for an upper lip involvement or a cara pansy flap for lower involvement. Um They're quite the still quite complex, so I'm not going to go into them, but if you're interested, have a look and have a google, um but for the purposes of time, we're not going to go into them today, so this is uh images of an ago tried flap, so in picture, a you can see the lesion what they'll do is they'll remove the lesion with margins and then in order to reconstruct that area, they'll take a local flap um as demarcated there and then once they have the flap, so this is the ago tried flap um They'll basically do some temporary sutures just to see if the tension is okay, so if if wounds are too tight, then they can't heal very well, so that would not cause a flap to fail, So if they yeah, if the tension is fine, then they'll just use the ogletree flap. If it's if it's too tight, then what they might do is turn it into a v. Y. Advancement flap and what they do there is, they make uh an inferior decision on the flap, and they extend that V shape um seen and see um into a a. Y. By doing like an inferior incision at the bottom and basically they'll just sutures the flat back on, but in e, as you can see it, sort of zips, so from the bottom, they'll zip that up and push the air got tried flap forward so advancing it up um and then they can so back on or sutra back on um and it creates a bit of extra laxity basically so that the wound can heal well, so these are for perhaps slightly larger or more difficult um uh yeah reconstructions of the lip um and this one is a picture of the Perriello crescentic advancement flap, so it does what it says on the tin soap, Ariela sits around the a lot and it's in a crescent shape so once they remove the lesion has seen in a and b um they'll they'll rotate that flap around um and then basically use that use that skin to to reconstruct um that area of um around the lips basically and as you can see the cosmetic outcomes are really good, so indeed you can barely notice it just almost looks like a little frown line, so so yeah, and that's that's because the skin is similar to that from the, from the the lip and the cheek, so um this one you need good luck city in the cheeks, I suppose probably a bit better for old people um so that things aren't too tight and things can heal well um moving on to the nose, so the nose is quite tricky one to, to reconstruct um due to the convex and concave services, the nose is usually broken up into sub units so like the nares, the tip of the nose, and um the body of the nose. What's really important is to preserve or reinforce the cartilage in the structure of the nose because this is how your nose gets it shape um So that needs to be intact before you start fiddling around with any soft tissue so lots of different ways that you can really construct the nose, so I'm just I'm keeping it that simple with the principles, so you can use skin grafts, so these can be used if the defect area is superficial and two large for any local flaps. Um You can use local flaps if the defect is small, um you can use distant flaps. If the area of the defect is really large and not really suitable for local flaps of graphs, um so usually they might take a bit of skin from the forehead. It usually has quite good cosmetic outcome for the nose, but I might leave a scar on your forehead, so it's very patient dependent you have to sort of tailor what they want with their surgery, so here we've got some pictures of a forehead flap, so this is a para median forehead flap um and as you can see there's there's a lesion on the tip of the nose and what they'll do is, they'll cut that cut that flap out and then um rotate it round, and suture it back on to the to the nose um. And yeah it's got really good postoperative outcomes, um and it looks quite nice to be honest. I can't really see, can't really see the difference, which is quite good moving on. We've got this is more local flap, so it's a bilobed nasal flat for a smaller nasal defect, so what they'll do well. You can see the two markings is, they'll use the two flaps and that gives more sort of like rotational um uh laxity by having to flaps for having a bilobed flap um and they just sort of rotate it around and and down onto the nose. So two weeks postoperative um it's healed quite well and then three months post operatively, you can see there's barely barely a scar there and it just all fits and and yes not too tight, so the skin heals very well um and then we've got reconstruction principles of the forehead so so with the forehead healing by primary in tension is probably the preferred way. Um So, if there's a you know if if they cut cut out the lesion, then actually just trying to suture that back up in like a linear fashion is actually the third way, but sometimes the lesion is too big or the defect left is too big, then the other preferred method is the advancement flap so really good um method for this area because the forehead is quite flat um and it's a good method for repair of the large defects in proximity to free margins, it's like the eyebrows and the temple so a uh here, this is I think this is the Borough advancement flat so basically uh you've got two triangles um and then you make the flaps of the lesion. You can sort of see it in these two pictures here, so um where the defect is um you make to look triangles at the side and then you sort of push it forward, push the flat forward and then suture it back on and it heals usually quite well um and that yeah that's usually the main sort of root for for four heads, but there are lots of different variations of that in literature um So you can have a look um in your own time with regards to to to the different types of alterations on Borough flap and x. Y. Z. So yeah, other ones that you can look up deep plane, cervico facial advancement flaps and perry glabella advancement flaps are also used for the forehead um. So yeah in summary, um the most common types of skin cancer are b. C, c, sec, and melanomas um Definitive diagnosis is usually achieved through skin biopsy, which can be taken by excision, incision, shave, and punch biopsy um curative treatment is achieved by surgical excision or most micrographic surgery if it's a non nonmelanoma skin cancer um and the surgical procedure depends on the site of the cancer. The reconstructive bladder is the basis of consideration when approaching any facial reconstruction, Grass fly and recipient blood supply and flats around donors, blood supply, and the chosen method of facial reconstruction is non exhaustive and depends on a variety of factors such as location, size, and depth. So looking at sort of the methods that I've described, They're only just the very basics um facial reconstruction is literally a black hole of information, and it's super interesting, so I would definitely encourage you to go and if you're interested to go look at um different methods of facial reconstruction um There's loads of literature on it, but in trying to keep it brief and sort of um holistic, I guess, in terms of how to manage things with the principles, we've kept it to what they are so um yeah, if you have any questions with regards to anything you've heard, feel free to ask um in the chat function or just use the microphone. Um Yeah, thank you for listening, and I hope you found it interesting um and yeah please fill in the feedback that would be really great. Thank you, I'll stick around for a little bit um just if there's any questions um just pop them into the chat, and I'll um answer them okay High Internet really good session like I felt like I learned loads I've seen some skin cancer surgery myself, but obviously there's so much that you can't see it all on one list. Um My question was just relating to age because we all know how when skin ages, it loses collagen um uh Skin ages. It's just much more difficult to handle as a tissue can be very thin uh and obviously a lot of these cancers happen in older people, so I don't know if you have any thoughts or uh can discuss just the impact of uh skin like older skin and, and what considerations might have just yeah That's a really good question. I think um it's difficult to say because I'm not not totally you know to include up on that, but what my sort of guess would be is that a lot of these cancers happen um well appear on older aged people um and people are very different skin types, so some um some elderly people might have more sort of thin, friable skin, so you know sometimes in hospital were putting cannulas into patient's where you know the skin can just break from from just just you know a small needle or something like that, So, I think people have to take into consideration when reconstructing whether the skin is viable to go through to go through that and also um I suppose it depends really on where the lesion sites are or where they can get grafts from. So if you know some people might not have viable skin in certain places, then they could look elsewhere, um where in, in the LD where the skin is like thicker or thinner depending on on where it may be another thing as well is that in the elderly, uh there's a lot more laxity in the skin, so when doing grafts or flaps that you probably need to take into consideration um yeah the laxity of the skin um and and yeah so certain flaps like the peri ala flap you need a bit of wax in the cheek, so it's actually better for old people, um whereas you know maybe some a different flap would not be so much appropriate, so, I hope that sort of as it, but yeah, thanks, charlie any other questions at all okay. I guess if there are no more questions, I think we can call it a day. Um If you have any questions and it, sort of pops up in your head um then feel free to like pop us a message anytime soon or maybe at the next session, um yep anything more to add charlie or add um anyone anything else to add thanks antoinette yeah I think the only thing to add is just next week, we're back here again at the same time, we'll be going over breast cancer surgery, so there'll be some overlaps with this skin cancer talking about reconstructive technique, but if you enjoyed the session, please leave the feedback for antoinette and charlie, and me, and we'll see you next week at 6 30 we'll we'll send you out the sign up links for that and see you all there. Thanks for coming guys. Thanks, everyone, bye.