Skin Cancer: Skin cancer is the most common cancer in the United States and the world. The 3 main types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Surgical removal is the mainstay for treatment of skin cancers. This includes traditional surgical excision as well as Mohs micrographic surgery.
Mohs micrographic surgery is a highly effective treatment performed primarily for basal cell and squamous cell carcinomas, and can be done over the entire body, but is most frequently performed when the skin cancer is located in areas where conserving normal tissue is critical, such as on the face and especially on the nose, eyelids, lips, and ears. This type of skin cancer removal surgery is usually performed by dermatologists specially trained in Mohs surgery.
Post-Mohs Reconstruction: Mohs surgery for excision of a skin cancer inevitably results in an open wound. In closing this wound or filling in this defect, special reconstructive procedures performed by plastic surgeons are often needed to optimize healing and restoring proper form and function to the area. At Samra Plastic Surgery, our surgeons specialize in this form of reconstruction.
The benefit of having post-Mohs wound reconstruction performed by a skilled and experienced plastic surgeon is to maximize the potential to restore proper form and function to the wounded area following the necessary skin cancer removal process. Many wounds that are left to heal on their own or if stitched closed with excessive tension can lead to poor healing and scarring, which over time can be disfiguring and affect function. The use of special plastic surgical techniques can facilitate optimal healing.
Good candidates for post-Mohs reconstruction are any patients who have wounds resulting from skin cancer removal that cannot be closed well just with simple stitches or without excessive tension. In particular, patients with wounds on their face following Mohs surgery frequently benefit from reconstruction. The reconstruction is often able to be performed under local anesthesia. In the event that IV sedation (“twilight” anesthesia) or general anesthesia is required, patients need to be healthy enough to undergo this. It is ideal to be nonsmoking or to quit smoking for several weeks before and after surgery for optimal healing. Also, to minimize risk of bleeding, patients should not be on blood thinning medications, or should be able to stop them with clearance from their primary physician or cardiologist.
Our surgeons meet with patients in consultation well in advance of their planned Mohs surgery to evaluate skin cancer site, assess candidacy for reconstruction of the anticipated wound, and discuss possible reconstructive options to help patients best prepare for the process. Then our surgeons meet with patients soon after their Mohs surgery to evaluate the final wound created after skin cancer removal, and to finalize the plan for reconstruction.
The post-Mohs reconstruction is performed by our plastic surgeons either in a minor procedure room under local anesthesia or in the operating room under IV sedation or general anesthesia, depending on the size and extent of the wound and the complexity of the reconstruction needed. It may be performed on the same day as the Mohs surgery done by the dermatologist, or it may be scheduled for within a few days afterwards, in which case a dressing is maintained over the wound in the interim. At time of reconstruction, after applying antiseptic to the skin, providing the appropriate anesthetic, and placing any necessary markings for the planned closure, our surgeons will prepare the wound by debriding and cleaning it to reveal an optimally healthy wound bed. After this, the closure is performed. There are multiple options for closure which our surgeons will discuss with patients beforehand. The options for closure include the following:
Layered closure: If the wound is deep, but the wound edges are still able to be brought together in the proper orientation, our surgeons will meticulously perform a layer by layer repair (of muscle, fat, and skin as needed) using sutures to close the wound. Sometimes this process is helped by undermining some tissue on both sides of the wound to allow the edges to advance toward each other without tension.
Local or regional flap: In cases where the wound is too wide to allow for direct edge to edge closure, and when the wound is very deep, possibly with exposure of structures like cartilage or bone, then our surgeons can often borrow skin along with other layers of tissue as needed (such as fat and/or muscle) from neighboring areas to cover the wound. These neighboring flaps of tissue are lifted up and then rotated and/or advanced into this wound, while maintaining some connection to their original location, so that the blood supply into the flap is preserved. For example, to close a deep wound on top of the nose, a flap may be derived from an adjacent part of the nose or sometimes from a nearby region like the inner cheek fold or central forehead. In some cases, it requires staged procedures to complete the entire transfer of the flap to the recipient wound, and to optimize healing and contour at both the donor and recipient areas.
Grafts: Grafts are tissues that are removed completely from a distant site and brought into the wound to achieve closure.
– Skin autograft (most common graft) – When a local or regional flap is either not possible or optimal, and the wound is superficial enough that it requires only skin replacement, a skin graft can be harvested from a distant part of the face or body, and placed and sutured to the wound to provide coverage. Unlike a flap, a skin graft does not remain connected to its donor site and therefore does not have its own blood supply. It relies on nourishment from the recipient wound to become revitalized and incorporated into the new location. The donor site where the skin is taken from is sutured closed. The donor skin is usually selected based on optimal matching of its color, texture, and thickness to the recipient area surrounding the wound, and also based on the ability to leave a less conspicuous scar at the donor site (such as donor site behind the ear).
– Other grafts – Sometimes there is a requirement to replace missing structural framework, such as when cartilage is lost from the nose due to a deep skin cancer removal. In such cases, a small composite graft of skin, fat, and cartilage can be obtained from the ear and placed into the nose wound. Another option may be to replace missing cartilage with a small cartilage-only graft and then cover this with a local or regional flap.
Skin substitute: In some cases when a flap or skin graft cannot be initially performed due to wound conditions or patient’s health status, a bioengineered skin substitute can be applied and secured to the wound under local anesthetic to allow some initial healing. It serves as a scaffold to allow some ordered ingrowth of local tissue to fill in part of the wound. In a few cases, this can lead to complete healing. In most other cases, a skin graft is applied 2 to 3 weeks later, once there has been enough tissue incorporation at the skin substitute site. The skin graft then allows definitive healing.
The length of the reconstructive surgery depends on the extent of the post-Mohs wound and the complexity of the reconstruction needed. The procedure can range from 30 minutes to a couple of hours.
If the reconstruction is performed under local anesthetic, our patients can go home immediately afterwards by themselves without any escort. If IV sedation (“twilight” anesthesia) or general anesthesia is required for the reconstruction, then our patients are asked to have a friend or family member accompany them home after surgery.
Our patients receive clear instructions on how to take care of the surgical closure, which will differ depending on the type of reconstruction performed (i.e. layered closure, flap, skin graft, or skin substitute). Length of time that dressings will be needed to cover the closure will generally range from a few days to 2 to 3 weeks, depending on type of reconstruction.
Recovery following reconstruction of a post-Mohs wound depends on several factors, including the extent of the initial skin cancer removal, complexity of the reconstructive surgery needed, and whether multiple stages of reconstruction are needed. Our surgeons provide clear instructions to our patients and family members in regards to care of the surgical site, dressing changes, activity, limitations of activity, and precautions during the recovery period. Some temporary soreness following the reconstruction is expected. Often over the counter medications, such as Tylenol, suffice to alleviate discomfort. Depending on the extent of the procedure, pain medication may be prescribed to help with this. In regards to care of the surgical site, some procedures such as direct layered closure and many small flaps require very simple care (such as daily cleansing with soap and water and antibiotic ointment) and minimal or basic dressings, while other procedures such as more complex flaps or grafts require more attentive care and more specialized dressings to optimize early healing. Generally, healing time can vary from a couple of weeks for most direct closures and small flaps to 3 to 4 weeks for skin grafts to several weeks for more complex multi-staged procedures.
As with any surgery, some scar is generated at the site of any surgical incision. This is also true for the site of post-Mohs wound reconstruction, regardless of whether a direct closure, flap, graft, or skin substitute is performed. Also, in the case of a flap or a graft, the donor site from where the skin or tissue is borrowed and then closed will also generate a scar. Our surgeons are very attentive to minimizing scar appearance by carefully selecting procedures that leave the least scarring, choosing donor sites where scar would be relative inconspicuous, performing closures with the least tissue tension possible, and advising our patients on an optimal scar care regimen.
In a very small number of instances, in which the wound is quite small and superficial, topical treatments along with dressing changes can lead to satisfactory wound healing without significant scarring. However, in the vast majority of cases, given the nature of the original skin cancer removal as an invasive surgical procedure, closure of the wound that results from this also requires a surgical procedure to restore proper form and function of the area.
Our plastic surgeons are highly skilled and experienced in a wide variety of reconstructive techniques, allowing them to successfully treat the wide spectrum of wounds that can result from Mohs excision of skin cancer. Moreover, our plastic surgery office will work closely with your dermatologist’s office to coordinate the timing of the reconstruction with that of the skin cancer removal. We also understand that dealing with the skin cancer diagnosis and its related treatment can be emotionally difficult for patients, and our caring surgeons and staff will support you throughout the entire process.
If you are interested in more information or seek evaluation for post-Mohs wound reconstruction surgery, please contact us today at (732) 739-2100 to schedule a personal or virtual consultation with one of our expert plastic surgeons.
Elective surgeries have resumed in NJ. Samra Plastic Surgery’s private facility, the Ambulatory Surgery Center of Old Bridge, is a safe environment for patients requiring emergency and elective surgeries. Choosing a private facility like ASCOB provides patients an alternative to having their procedures performed in a busy hospital during the COVID-19 pandemic.
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