The simplest way to repair a wound that results from the surgical removal of skin cancer is primary closure. This term means simply closing the wound from side to side with sutures (stitches). A large number of the wounds that we repair after Mohs surgery are closed in this manner. This is because it is fairly simple and can give an excellent long-term cosmetic outcome. After the cancer has been removed and we know the final extent (size, shape, and depth) of the final wound, the determination of the method of repair will be made. If there is enough surrounding tissue to move back together to close the wound, then a decision will be made to repair the wound with primary closure.
Most Mohs surgical wounds are circular in shape. As the skin edges are moved together, some redundant tissue at the edges may become evident, forming small puckers, or bumps at the wound edges. These areas of redundant skin are removed at the time of closure to make the contour smooth. Then the wound is closed with two layers of sutures (stitches). The sutures underneath the skin dissolve on their own, while the sutures on top of the skin are usually removed in 5 - 14 days, depending on the location of the wound.
The final result is a straight, or slightly curved line. We employ excellent technique to minimize scarring for the best possible long-term outcome.
While primary closure is an excellent option, there are many instances in which it is not the best option, and other approaches are more feasible. There may not be enough surrounding tissue to close primarily, or a primary closure could result in distortion of the surrounding structures such as the eyelid, nose, lip, or ear. In such cases, a skin flap or skin graft may be a better choice.
In some cases, a wound may be large or in an area with a lack of surrounding skin that makes primary closure or a skin flap impossible. In such a case, a skin graft may be necessary. A skin graft is performed when skin is entirely removed from a another location, and stitched into place to cover the wound. The donor skin is chosen from an area in which the skin color and texture is a good match for the skin surrounding the recipient wound, so that the graft can heal and blend in nicely. It is also taken from a site that is not noticeable and will heal nicely when the resulting donor wound is stitched closed.
Grafts are somewhat more unpredictable in their outcome than a primary closure or skin flap repair, and are thus usually an acceptable choice if those procedures are not a good option. We will discuss these options with you before the decision is made to proceed with skin graft repair.
The skin graft is completely removed from the donor area, and has no blood circulation feeding it until new blood vessels grow into the grafted skin. Therefore, it is critical that the skin graft is cared for properly during the 1-2 weeks after the procedure. Proper care includes keeping the required bandage in place for 1 week until it is removed by our staff, and complete cessation of smoking or the use of any nicotine products. Nicotine constricts blood vessels, and may starve the graft of circulation so that it fails.
If you are a smoker, we will discuss this with you. A smoking cessation program can be instituted prior to your procedure to guarantee the best possible outcome.
Second Intention Healing
Most wounds that result from Mohs micrographic surgery need to be reconstructed for cosmetic or functional reasons. A wound created by removing a carcinoma from the middle of the cheek below the eye would result in a depressed, unsightly scar if it were not repaired with stitches. However, some wounds end up being small, shallow, or in a suitable location to allow them to heal on their own. Wounds in some locations can heal so effectively as to have an excellent cosmetic outcome. Such wounds tend to be located in concave areas of the body, or in locations that will not be normally visible, such as behind the ears. This is an option that will be discussed with the patient if we feel that it is medically appropriate, and the final decision will be made taking the patient's preferences into account.
Referral to a Plastic Surgeon
Although in most cases the Mohs surgeon performs both the cancer removal and the reconstruction of the wound, there are many instances in which a team approach with both a Mohs surgeon and a Plastic surgeon is appropriate.
In many cases, the patient with skin cancer may be referred from the plastic surgeon who wants to be sure the patient has the higher cure rate associated with Mohs surgery before they proceed with an extensive plastic surgical reconstructive procedure that will be necessary.
In other cases, the Mohs surgeon will call on the plastic surgeon for their expertise when a reconstructive procedure is expected to be quite extensive or in a difficult location. For example, for large tumors of the nose or lips, a facial plastic surgeon may be consulted.
Even small tumors of the eyelids or skin around the eye can pose particularly difficult challenges. More than just a cosmetic issue, the removal of these tumors around the eye can lead to functional problems (poor draining of tears, distortion of the eyelid margins, and improper opening and closing of the lids) unless the wounds are adequately addressed and reconstructed. In such cases, the expertise of an oculoplastic surgeon (a plastic surgeon with specialized training in surgery around the eyes) can be essential.
At the time of consultation, we will examine you and assess these issues with you. We work with several excellent and experienced plastic surgeons and can recommend their services if we feel it may be appropriate. In some cases, if we anticipate this before your consultation, we can arrange for you to meet with Drs. O'Quinn and the plastic surgeon on the same day at South Texas Skin Cancer Center.
For smaller and more straightforward skin cancers, the Mohs procedure can be performed at South Texas Skin Cancer Center, and the plastic surgeon can perform the reconstruction immediately following in the South Texas Ambulatory Surgery Center in the same building. Larger tumors may require the reconstruction to be performed on the following day at the South Texas Ambulatory Surgery Center so that we are sure that we have plenty of time to address both cancer removal and wound reconstruction.