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A skin cancer diagnosis can be understandably disconcerting. Be it your first or fifth skin cancer, angst can be significant. Along with concerns about cure rates, recurrence rates, and the potential for metastasis or other medical complications, the uncertainty surrounding aesthetic outcomes can be equally troubling.
While Mohs surgery is the gold standard treatment offering the highest cure rates available for many types of skin cancer, it does necessitate surgical repair or reconstructive surgery. Most Mohs surgery defects can be reconstructed by your Mohs surgeon or one of our plastic surgeons in the office on the day of your Mohs Surgery.
Factors that May Affect Your Mohs Surgery Reconstruction
The most important factors to consider when anticipating what repair/reconstruction options you may have after your Mohs surgery include cancer location, size, and patient specific factors.
Each location of the body has certain optimal reconstructive opportunities based on the skin texture, laxity, and surrounding structures. Reconstructive options may be narrowed based on the defect size and proportion of the structure involved. For example, a 1cm defect on the tip of the nose creates a significant reconstructive challenge due to the sebaceous (oily) nature of the skin and the small size of the overall structure. Comparatively, a 1cm defect on the side of the neck presents almost no reconstructive challenge as the laxity and availability of tissue abound.
Lastly, patient-specific factors such as diabetes, tobacco use, and ability to perform optimal post-operative wound care significantly impact reconstructive options recommended by your surgeon.
This article will briefly describe some of the common reconstructive options that may be considered for your skin repair after curing your cancer with Mohs Surgery.
Mohs Reconstruction Option 1: Granulation
Also called second-intention healing or, colloquially, “healing by mother nature,” granulating a wound is an intentional approach to allow the wound to heal in on its own without using the other surgical options discussed.
At times, a “tertiary” (pursestring) repair is performed by using sutures to pull the wound edges partially together, then allowing the remaining open area to heal on its own. This repair type is especially well suited for medium sized areas on the scalp or legs where other repairs may be especially involved or otherwise not indicated.
Mohs Reconstruction Option 2: Linear Repair
A linear repair is the most common repair chosen by reconstructive surgeons after Mohs Surgery. This repair type results in a single straight-line scar that may be creatively placed within expression lines or facial contours to partially ‘camouflage’ the scar once healed.
The limits of this repair are based upon location and size of the cancer defect. One important consideration when expecting a linear repair is that the final straight line is often 2-3 and sometimes even 4 times longer than the width of the cancer defect. This is depicted with the following pictograph of a linear repair.
Mohs Reconstruction Option 3: Full Thickness Skin Graft
A full thickness skin graft utilizes healthy skin from a separate area on your body to act as a “patch” to cover the cancer defect. While this strategy does create an additional surgical wound, it often allows the advantages of faster healing and better cosmetic appearance as compared to granulation healing. Full thickness skin grafts can require special bandages in the first week but provide exceptional reconstructive options for many defects on the ear, nose, and scalp, amongst other areas.
Mohs Reconstruction Option 4: Local Flap
Local flaps come in a variety of shapes with nearly endless specific names and designs. In concept, local flaps utilize skin directly adjacent to the cancer defect that can be lifted and shifted into place. These are often chosen when the cancer defect is too tight to come together side-to-side, or when doing so would impede upon surrounding structures (i.e. if a linear repair would distort the eyelid or the rim of the nose). Examples of local flaps include rhombic flaps, bilobed flaps, advancement flaps, and rotation flaps, amongst others.
Mohs Reconstruction Option 5: Distant Flap (Interpolation Flap)
An interpolation flap is a technique used when a full thickness graft is sub-optimal (based on skin texture or patient-specific factors) and when a local flap is not feasible based on size, location, or surrounding structures.
Two of the most common types of interpolation flaps (although there are many) include the paramedian forehead flap and the melolabial (cheek-to-nose) interpolation flap. The premise of these reconstructions includes the use of distant tissue to fill the cancer defect using a pedicle (trunk of health tissue) that is left in place for several weeks.
In these instances, the flap would be created and sewn into the defect during the day of Mohs Surgery. The pedicle (trunk) would be left in place attaching the donor site to the cancer defect for several weeks – generally three to five. During this time, the supplies pedicle blood flow to the skin covering the cancer defect while, simultaneously, the cancer defect and flap attach new blood vessels to one another to allow nutrients and survival.
After several weeks, once the new blood flow has been established, the pedicle (trunk) of normal tissue is removed, and the cancer defect and donor site are repaired with a final procedure. While this technique is the most involved and requires the most wound care, it presents several unique advantages that could make it the most optimal reconstructive option for repairing your skin cancer defect.
Speak to a Dermatologist About Your Mohs Surgery Options
For any of these techniques, your reconstructive Mohs surgeon or plastic surgeon can provide extensive insight into the advantages, disadvantages, and available options for repairing your skin after you are cured of your skin cancer using Mohs Micrographic Surgery.
If you have any concerns about new or changing spots, call us at (719) 355-1585 or fill out our online appointment request form to schedule your skin cancer screening today.
Brayden Healey, DO is a board-certified dermatologist and fellowship-trained Mohs surgeon whose professional interests include skin cancer diagnosis and treatment along with various general dermatology conditions such as psoriasis, eczema, acne, and many others.
