After a skin cancer is removed from the face, the wound can be stitched straight together, covered with nearby skin (a local flap), covered with a skin graft taken from elsewhere, or left to heal on its own. Which suits you depends on the size and depth of the wound, where it is on your face, and your general health.
- Small wounds can often be stitched in a straight line. Larger ones may need a local flap or a skin graft.
- On the nose and the middle of the face, a local flap usually matches the surrounding skin more closely than a graft.
- Some wounds in hollow areas, such as the temple, heal well left to close on their own.
- Smoking, diabetes and the size and position of the wound all affect healing.
- Scars keep improving for up to a year, and treatments can refine them later.
Why does the wound need repairing?
Removing a skin cancer leaves a wound, and on the face it has to be closed so the area works and looks as natural as possible. Its size depends on how deep and wide the cancer had spread, so it can be larger than the visible mark.
Mohs surgery removes the cancer a layer at a time, checking each layer under the microscope, so as little healthy skin as possible is taken. There is still a wound to repair, and around the eyelids, lips and nose the repair also has to protect movement and sensation.
Planning for facial reconstruction starts before the operation, based on where the wound sits, how large it is and how much spare skin there is nearby. The reconstruction technique chosen affects both how the area works and how it looks.
What are the main ways to close the wound?
There are five common approaches, and the right one depends on a careful look at your particular wound.
- Stitching straight together (direct or linear closure): the edges of the wound are sewn together in a line. This suits smaller wounds where the skin around them is loose enough to stretch across.
- Local flap: skin right next to the wound is moved or turned to cover it. It usually matches well in colour and texture, but needs enough healthy skin nearby. A bilobed flap is one kind, used on the tip and sides of the nose.
- Skin graft: a piece of skin is taken from another part of the body and laid over the wound. It can cover larger areas, such as on the scalp or eyelid, but the colour may not match exactly.
- Forehead flap: for larger wounds on the nose, skin from the forehead is used to rebuild it. This is done in stages, usually two operations.
- Healing on its own (secondary intention): the wound is left to close naturally without stitches. It can work well in hollow areas such as the temple, the inner corner of the eye or parts of the ear, but it takes longer to heal.
Each method is preferred for different sites and wound sizes.
Is a local flap better than a skin graft?
On the nose and the middle of the face, a local flap usually looks more natural than a graft, because the skin comes from right next to the wound and matches it in colour, thickness and texture. The nose is the part of the face most often reconstructed, and research on nasal repairs found patient satisfaction was higher with flaps than with grafts.
A graft is still the better choice for some wounds. If your cancer is on or near the tip of the nose, it’s reasonable to ask whether a flap is possible rather than assume you’ll have a graft. A flap is a more involved operation, but on the nose the closer match can be worth it.
When you talk through reconstruction after Mohs, weigh up how natural it is likely to look, how your eyelids or lips will move afterwards if the wound is near them, and recovery time, since some repairs are done in stages over several weeks. Grafts and flaps also both leave a second wound, the donor site, that needs to heal.
Any plan for facial reconstruction surgery should be built around your priorities, your anatomy and your general health.
What affects how your scar looks?
The wound itself and your general health matter as much as the technique. These shape how the area looks in the months after surgery:
- Larger, deeper wounds need more complex repairs and are more likely to leave a visible scar.
- The nose, eyelids and lips are the most demanding areas to repair.
- Older skin is looser, which can make a local flap easier, although it also heals differently.
- Smoking reduces the blood supply to the skin and slows healing.
- Diabetes can affect how the tissue heals and raises the risk of infection.
- Scars often look their worst at around six to eight weeks, then improve over the following months.
Research on facial reconstruction found that satisfaction with scars improved over the first year, and that complications were more likely in some parts of the face than others.
How you look after the wound makes a difference too. There are practical guides to reducing scarring and to follow-up care after treatment.
What should you ask before your reconstruction?
Start by telling your surgeon what matters most to you, whether that’s the most natural look, the shortest recovery or keeping full movement, because it helps decide which repair is chosen. Then work through these steps:
- Write down your questions before each appointment, so nothing is forgotten on the day.
- Ask who will repair the wound. It helps when the surgeon removing the cancer and the surgeon doing the repair work closely together, or when one surgeon is trained in both.
- Ask whether a smaller procedure might help later. Once healed, some scars can be improved with dermabrasion, laser resurfacing or steroid injections.
- Follow the aftercare instructions. Protecting the wound from the sun, keeping it hydrated and not smoking make the most difference.
- Go to every follow-up appointment. A thickening scar or uneven contour is easier to treat when it’s picked up early.
Published work on repair complications supports close working between Mohs and plastic surgeons.
For more complex cancers, such as some squamous cell carcinomas, you can ask for a joint consultation before agreeing to a reconstruction plan.
Sometimes the wound is best left to heal on its own
There is no single agreed formula for choosing a repair after Mohs. Flaps are generally preferred for appearance, but letting a wound heal by itself is used less often than it could be.
In hollow areas such as the inner corner of the eye or the temple, a wound left to heal naturally can give a good result without the extra surgery a flap involves. It takes longer and doesn’t suit every site, so ask about it rather than expect it.
Talking to Miss Nayar
Miss Rakhee Nayar is a Consultant Plastic Surgeon, FRCS (Plast), MD, and one of fewer than 10 women in the UK dual-trained in both plastic surgery and Mohs micrographic surgery. With over 20 years of surgical experience, she can talk you through both removing the cancer and the options for repairing the wound. To discuss your own situation, please get in touch.
Frequently asked questions
How long does it take to see the final result after Mohs surgery?
Scars usually keep improving for up to a year after surgery. Much of the swelling settles within about three months, but the scar goes on softening and fading after that.
Are flaps always better than skin grafts?
No. Flaps usually give a more natural look on the nose and cheeks, but a graft is sometimes the better choice because of the size or position of the wound.
What happens if there’s a problem with healing or the scar?
Many problems can be improved, especially when they’re picked up early at a follow-up appointment. Options include steroid injections, laser treatment and minor procedures.
Which health factors affect healing after surgery?
Smoking, diabetes, your age and skin quality, and the size and position of the wound can all affect healing and the final appearance. Larger wounds, smoking and diabetes are linked to harder repairs and longer recovery.
Recommended
- How to minimise scarring after skin cancer removal
- Reconstruction After Mohs Surgery
- SCC: Diagnosis, Mohs surgery and facial reconstruction
- Essential follow-up steps after skin cancer treatment
Filed under Facial Reconstruction
