Facial Skin Reconstruction (MOHS)

October 11, 2022    -    Cancer, Face, Nose, Skin

If you are planning or already have had a procedure performed by a dermatologic (MOHS) surgeon to remove a neoplasm from your nose, face, scalp, ear or neck area. This is the first, and most important step in the treatment of skin cancers.

Once a growth has been removed, this may leave or may already have left a large and unsightly skin defect. Sometimes, other important structures such as cartilage of the cheek, ear, outer skin of the nose, inner lining of the nasal cavity or eyelid tissue may have been removed.

The technique that was utilized is known as MOHS micrographic surgery, where a Dermatologic surgeon closely examines the neoplasm edges to make sure it is not spreading beyond the visible tumor margins. If it does, your MOHS surgeon would have performed additional tissue removal until there are no more microscopic cancer cells detected. This is a wonderful method to remove all of the cancer and spare as much normal tissue as possible around important structures such as ear, mouth, nose and the eyelid.

The second part of treatment is reconstruction of the wound left behind. Our goals as facial plastic and reconstructive surgeons are to patch the hole in the skin in a way that is least noticeable when fully healed while preserving the function of the facial structures. The aesthetic reconstructive portion of the procedure may be done the day of, or up to seven days after, removal of tumor. This may be done under local anesthesia, with or without sedation, or general anesthetic. You should have a discussion with your surgeon about your choice of anesthesia.

There are many different reconstructive options when it comes to repairing facial, nasal and ear defects after MOHS surgery and this is as much an art as it is a science. Options include no surgery, and letting the wound heal on its own. This option is only reserved for the smallest defects and only in certain areas of the face. This option is NOT recommended around scalp, nose, mouth, ear or eyelid structures as it may lead to scarring and disfigurement as well as functional problems.

Next option is to close the edges of the wound by turning a circular wound into a linear scar. This is done by wide undermining of the surrounding skin and bringing the skin together with multiple layers of suture. This technique works well in some areas, but can distort normal structures. In addition, the linear scar ends up being twice as long as the diameter of the original wound and can be more noticeable.

Another option is a partial or full thickness skin graft. This works well on small areas of the nose or if there is not enough local tissue available. The donor sites are skin in front of the ear, clavicle or the thigh. Skin grafts may not have an exact skin color match or thickness to surrounding skin and may not heal as well and may require prolonged wound care.

One of the best reconstructive options is the use of a local tissue that is similar in color and thickness. Reconstruction is performed by elevating a small flap of skin that is still attached to surrounding tissue and transposing it in the area of reconstruction. The flaps get their much needed nutrients via blood supply from the pedicle during the first weeks of healing. A second stage procedure may be necessary in 3-4 weeks after initial reconstruction when the pedicle is separated and flap is inset to restore normal anatomy. Rarely, additional minor contouring procedures may be necessary. Sometimes additional procedures may include dermabrading the skin or injecting the scar with a steroid to make it less noticeable.

Complications are rare due to face, nose, scalp and neck skin having a robust blood supply. Ear structures have much less blood supply and may have more protracted healing. Smoking or use of any nicotine products (chew, gum or vape) can seriously compromise wound healing and is strongly discouraged during the time of surgery. Blood thinners such as aspirin and Coumadin should be briefly stopped 1 week before surgery if possible. Please check with your prescribing provider if those medications are ok to stop for a few weeks around the time of surgery. This would minimize risk of bleeding, bruising or hematoma formation. Partial and total flap or graft loss can occur on a rare occasion, and may require secondary procedures or prolonged wound care. We use the best practices to prevent or minimize scar, however they may not always be prevented. Surgical wound dressings as well as silicone gel or tape may help your scar look the best long term. It may take up to 12 months for the scar to fully mature and heal. Additional procedures may be needed to deal with unsightly scars.

If you would like to schedule a consultation regarding facial reconstruction after MOHS surgery please visit our Consultation page.