What you are dealing with
Mohs micrographic surgery removes a skin cancer in thin layers, each one mapped and read under the microscope before the next is taken. The surgeon stops the moment the margins are clear. It spares more healthy tissue than a wide excision and it has the highest cure rate available for the common facial skin cancers.
The consequence is a wound of unpredictable shape and depth. Nobody planned it around your features. It was planned around the tumor, and the tumor did not care that it sat on the edge of your nostril.
The removal is decided by the cancer. The repair is decided by the face.
Why the face is a special case
The face is divided into regions the eye reads as units: the nose with its own subunits, the lip, the eyelid, the cheek, the ear. Their borders are where light changes and where skin changes texture, and a scar that follows one of those borders disappears into it.
Some of these structures also have free edges. The eyelid margin, the nostril rim and the vermilion border of the lip are not anchored to anything. Close a wound near them with tension running the wrong way and the edge is pulled out of position. An eyelid that no longer sits against the eye is a functional problem as well as a visible one, and it is far easier to prevent than to correct.
How the wound gets closed
There is a ladder of options, and the right one is the simplest that gives a good result for that particular wound.
Layered primary closure is the first choice where the wound can be brought together directly. The deep layers take the tension so the skin edges meet without being pulled, and the line is oriented along a natural crease.
Local flaps move skin from an adjacent area into the defect, keeping its own blood supply. This is the workhorse for the nose and the cheek. The value of a flap is that it brings tissue of matching thickness, color and texture from next door, and it lets the incisions be hidden along subunit borders.
Skin grafts take tissue from elsewhere when there is not enough nearby to move. A graft is thinner and has no blood supply of its own at first, and the match is rarely as good as a flap, so it is chosen where geometry leaves no better option.
Cartilage grafting comes in when the wound has taken structural support with it, which happens around the nose and the ear. Without rebuilding that framework, the soft tissue repair collapses inward over the following months.
Timing
Most reconstructions happen the same day as the Mohs surgery or within a few days of it, once the margins are confirmed clear. Some wounds do better left to heal on their own, and where that is true I will say so.
Planning ahead helps a great deal. If you know a Mohs appointment is coming, a conversation before the removal means we can talk about what the reconstruction is likely to involve while you are still comfortable and not sitting in a chair with a dressing on your face.
What to expect afterward
Faces bruise and swell, and both are worse around the eyes. Sutures generally come out within a week to ten days depending on where they are. Facial skin has an excellent blood supply, which is why these repairs heal as well as they do.
Scars take a year to finish maturing. A repair that looks pink and firm at six weeks is behaving normally, and judging the final result early is the commonest reason patients worry unnecessarily. I follow these patients through that period, and if something needs refining once the tissue has settled, that is a conversation we have with the benefit of a healed scar in front of us.
Risks
Bleeding and infection apply to any surgery. Partial flap or graft loss is uncommon on the face but possible, and matters most where tissue was moved a long way. Distortion of a free edge is the risk the planning is designed around. Numbness in and around the repair is usual at first and generally improves.
The other thing worth saying plainly: having had one skin cancer raises the chance of another. Reconstruction does not change that. Keep seeing your dermatologist on the schedule they set.
Common questions
- Who removes the cancer?
- Your Mohs surgeon, usually a dermatologist trained in the technique. They take the cancer in stages, checking each layer under the microscope until the margins are clear. That is their expertise and it is why Mohs has such high cure rates. My part starts once they are certain the cancer is gone.
- Why is a second surgeon involved at all?
- Often there is not, because many defects are small and closed beautifully by the Mohs surgeon. Where a facial plastic surgeon is asked in, it is usually because the wound sits somewhere unforgiving. The nose, the eyelid, the lip and the ear all have free edges that pull out of shape if the repair puts tension in the wrong direction.
- Will I be left with a scar?
- Yes. Any full-thickness wound heals with a scar, and I would distrust anyone who told you otherwise. What is within my control is where the scar sits, which direction it runs, and whether it is closed under tension. Those three things are most of what separates a repair you notice from one you do not.
- Can it be done the same day?
- Sometimes, and it is often the most comfortable option for the patient. It depends on how long the Mohs stages take, how large the defect turns out to be, and what the reconstruction needs. Call us as soon as your Mohs date is set and we will work out the sequencing.
- How is this billed?
- Reconstruction after skin cancer removal sits in a different category from cosmetic surgery, and how it is handled depends on your plan. Ask us when you call. You will know where you stand before anything is scheduled.
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