Mohs Surgery Reconstruction
Reconstruction of the defects left from Mohs surgery is a very common plastic surgery procedure.
Mohs Micrographic Surgery is typically performed by specially trained dermatologists who use this technique to remove skin cancers.
This type of skin cancer removal has multiple advantages including complete removal of the cancerous tissue while minimizing the destruction of the surrounding non-cancerous skin. The area left after Mohs surgery can vary in size making the ability to simply close the skin somewhat unpredictable. Depending on the area of the skin cancer, size of the defect after excision and comfort level of the dermatologist, a plastic surgeon may be asked to close or reconstruct the area of Mohs surgery.
Dr. Trussler has significant experience in reconstruction after Mohs surgery and can reconstruct complex areas of the face, including the nose, eyelid, ear, and lip.
What Are My Options?
Reconstruction after Moh’s surgery can be performed on any body area there is skin. The most common areas are on the face where precise removal of cancerous tissue maintains the surrounding skin which limits the open defect and limits the deformity. The nose, ears, eyelids and cheeks are all common areas of Moh’s reconstruction. The method of reconstruction depends on the size of the defect and the area of Moh’s surgery. There are multiple common methods of plastic surgery reconstruction including:
Straight line closure: brings the two edges of the open wound together creating a straight-line scar.
Rotational flap: brings tissue beside the open defect over to cover the open wound. This typically requires another incision so that the adjacent tissue can be rotated.
Pedicled flap: brings tissue from another area close to the open wound on a “leash” of blood vessels and skin so that the living flap of skin can be transferred a larger distance to cover the area.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area of Moh’s surgery. This skin graft adheres to the open wound and survives as a skin covering to defect.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat which all adheres to the wound to cover and fill the open area.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery.
Location and size are the main issues when considering reconstruction after Moh’s surgery. Small defects on forgiving areas of the face and body can be closed in a straight-line. In difficult areas, like the nose and eyelid even small defects require more complex reconstructive procedures such as rotation or pedicle flaps. Larger areas on the forehead or the body may be covered with a skin graft. If there is exposed bone or exposure of other vital structures, a free tissue transfer may be indicated.
Reconstruction after Mohs surgery can often be coordinated the same day or the day after the clearance procedure. Simple reconstructive procedures can performed in an office based setting under local anesthesia, but more complex procedures may need to be performed in the operating room.
The complete removal of the cancerous lesion is the main goal of Moh’s surgery. The reconstructive goals after Moh’s surgery is the closure or coverage of the open defect with the maintenance of form and function. In the reconstructive process there may be more incisions and/or donor sites created to harvest the tissue used for closure. These incisions will form scars which will heal and fade over time. Additional procedures may be needed such as scar revisions, flap division and inset, and scar care after the area of Moh’s surgery is healed.
Mohs surgery is performed on an outpatient basis in your dermatologist’s office. After the cancerous tissue has been removed completely, the open wound is typically dressed with gauze and arrangements will be made to consult with Dr. Trussler, a reconstructive plastic surgeon, that day or the day after the procedure. Closure of the open area may take place at that time either in the office or in the operating room as an out-patient procedure. Reconstructive surgery after Moh’s surgery may take one to two hours, and depending on the complexity of the procedure and the location, can usually be performed with local anesthesia with or without twilight sedation.
Straight line closure: can usually be performed in the office under local anesthesia and the wound edges may be removed and then elevated so that they can be brought together with limited tension and closed with stitches under the skin and in the skin.
Rotational flap: the design of the flap takes into account the size of the open area and the amount of locally available skin. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin.
Pedicled flap:the design of the flap takes into account the size of the open area, the location of the pedicle which includes the blood vessels, and the location of the donor site for the flap. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin. Pedicle flaps may need a secondary procedure which divides the skin bridges and blood vessels after a couple of weeks of healing. This technique can bring a significant amount of skin from a distant area which will cover the open area with living tissue and restore form and function to the area of Moh’s surgery.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area of Moh’s surgery. This skin graft adheres to the open wound and survives as a living skin covering to defect. Split thickness donor sites will heal on their own and are covered with an occlusive dressing, where as a full thickness graft donor site is closed with stitches.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat which all adheres to the wound to cover and fill the open area. The graft donor site is closed with stitches.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery. This is a complex reconstructive technique which Dr. Trussler has significant experience. The procedure can take over 6 hours and requires a short hospitalization after for free flap care
The incisions for most reconstructive procedures are closed with deeper absorbable sutures and a combination of dissolvable and permanent sutures in the skin. Staples may be used in the scalp. In pedicle flaps there may be open areas which area dressed with non-adherent gauze and anti-bacterial ointment.
After Care & Recovery
After a reconstructive procedure after Moh’s surgery, patients will usually need about a week off from work and other regular activities. There will likely be mild bruising and swelling for the first few days, which can be relieved with cold compresses to the area of surgery, as well as elevation of the head in the procedure involves the face and scalp. Any operation around the eye can lead to swelling and irritation. This is alleviated with gel ice masks and hydrating eye drops for the first week after the operation. Dr. Trussler will provide you with his full post-operative instructions for the reconstructive procedure during the initial consultation. Any stitches and/or staples will be removed in the first week.
Results from reconstructive plastic surgery after Moh’s surgery are immediate though fully appreciated after about 3 weeks once swelling and bruising has subsided.
Scar care will be started at the three week point after surgery to help fade scars. Dermabrasion and laser resurfacing may be needed to help flatten the areas of reconstruction. Revision procedures and flap divisions may usually be considered at the three week to three month point after surgery, however scars will typically take about one year to fully mature and fade.
Whether you have a question or would like to setup a consultation for reconstruction after Moh’s surgery, Dr. Trussler and his staff are here to help. Please fill out our contact form, or call our office at 512-450-1077 to schedule an appointment. Start your journey to not only looking, but feeling better today!