Mohs Cancer Reconstruction

When a defect is small and sits in an area with enough natural skin laxity, the edges can often be brought together and closed directly. Where the anatomy allows, that closure is oriented so the resulting line falls within an existing crease or along the border between two facial subunits — a place where the eye already expects to see a line, and therefore stops noticing one.

The judgment lies in the direction of closure rather than its length. A repair that pulls on a free margin — the edge of an eyelid, the rim of a nostril, the border of the lip — can distort that structure even when the skin itself heals perfectly well. Dr. Shah plans the closure around the tension in the surrounding tissue, because avoiding that distortion usually matters far more to the final appearance than whether the scar is a centimetre shorter.

A local flap moves skin from immediately beside the defect into the gap, keeping its own blood supply attached as it goes. Because the tissue comes from a neighbouring area of the same face, it tends to match the surrounding colour, thickness and texture far more closely than skin brought in from elsewhere — which is why flaps are so often preferred on the face, and particularly on the nose and cheek.

Designing one is where the reconstructive work is really done: which direction the tissue rotates or advances, where the incisions are placed relative to the natural subunits of the face, and how tension is distributed once the flap is inset. Dr. Shah plans each flap around the specific defect in front of him rather than applying a standard pattern, since two defects of identical size in different locations can call for entirely different solutions.

A skin graft takes tissue from a donor site and transfers it without its blood supply, relying on the wound bed beneath to nourish it while it heals in. Grafts are useful where a defect is too broad for the surrounding skin to cover, or where moving adjacent tissue would pull a nearby structure out of position.

Donor site selection matters more than patients expect. Skin from in front of or behind the ear behaves differently from skin taken from the neck or above the collarbone, and the closer the match in thickness, colour and oil content, the better the graft settles. Grafted skin typically passes through a period of visible colour and texture mismatch before it blends, and that settling is measured in months rather than weeks — which is worth knowing at the outset rather than discovering afterwards.

Some defects take more than skin. On the nose and the ear especially, Mohs surgery may remove the cartilage that holds the structure open — and skin laid over that gap will contract as it heals, pulling the shape inward and, in the nose, narrowing the airway with it.

Rebuilding the framework first, usually with cartilage borrowed from the septum or the ear, is what allows the overlying repair to hold its shape and keep breathing clear. This is where reconstruction overlaps most directly with rhinoplasty: the same understanding of how the nasal framework supports the skin above it applies whether the structure is being refined for appearance or restored after cancer.

Larger or deeper defects, particularly those involving most of a nasal subunit, are sometimes best rebuilt across more than one operation. A staged reconstruction brings tissue into position at the first stage, allows several weeks for it to establish its own blood supply in its new location, then divides and refines it at a second — occasionally a third — procedure.

It asks more of the patient in time and patience, and the intermediate stage is not a comfortable period to look at in the mirror. But for certain defects it remains the approach that comes closest to restoring what was there before. Dr. Shah discusses the full sequence, including what each stage looks like while healing, before any decision is made, so that the commitment is understood at the start rather than partway through.