Mohs/Skin Cancer Reconstructive Plastic Surgery

What Is Mohs Surgery Repair?

Once the Mohs plastic surgeon removes entire Mohs skin cancer, a defect is left in the skin. The defect can consist of only the top-most layers of skin or may extend deeper into the subcutaneous tissue and sometimes may involve muscle, cartilage, nerve, and other important structures. The defect then needs to be closed. The way in which the Mohs skin cancer surgery defect is closed, or repaired, is dependent on the defect location and size, patient comorbidities and preference, and surgeon preference.

Who Is a Good Candidate for Mohs Surgery Repair?

Any person who undergoes Mohs skin cancer surgery for the removal of skin cancer is a candidate for Mohs surgery repair. The options for repair are discussed below.

What Are the Types of Mohs Surgery Repair?

The approach to Mohs surgery repair is often thought of as a reconstructive ladder, in which the simpler options are considered first and the more complex options are reserved for the appropriate clinical scenario.

The Mohs surgery repair reconstructive ladder includes:

1. Secondary intention(healing on its own) – Although healing by second intention is not as commonly employed as it once was, due to the risk of scarring and delay of complete closure, it sometimes is the best way to manage a Mohs skin cancer defect. Wounds located on concave surfaces, such as the temples and medial eyelid, usually heal with a good cosmetic outcome.
2. Primary closure – Edges of the wound can be brought together with sutures. The area removed needs to be elliptical so that the wound closes without dog ears (heaped up the skin at the edges).
3. Delayed primary closure – This method combines secondary intention with primary closure. The wound is left open for a number of days, to reduce the risk of infection for example, and then closed with primary closure technique.
4. Skin and composite graft (split thickness or full thickness) – Skin from another part of the face or body is removed and sutured over the wound. Other tissue types, such as cartilage, may also be brought in to provide structural support when needed.
5. Local flap – Tissue that is adjacent to the Mohs defect is moved to cover the wound while preserving the blood supply to the moved tissue. Many different local flap designs are possible.
6. Regional flap – Donor tissue with a pedicled axial blood supply that is NOT adjacent to the defect. Used to fill larger defects than local flaps. Can provide equivalent form and function while avoiding drawbacks of free flaps (close postop monitoring, donor site morbidity, advanced microsurgical technique, length of surgery, etc.)
7. Free flap – A procedure that involves transplanting tissue from a different part of the body, removing it first, and reconnecting blood vessels in the new location. It is very rare that a Mohs skin cancer defect requires a free flap reconstruction.

What Are the Keys Tenets of Mohs Surgery Repair?

The most important principles of facial Mohs reconstructive surgery include:

• If 50% or more of an aesthetic subunit is missing (mainly for nasal defects) it is best to replace the entire subunit
• Replace like with like. Match skin color and texture. And replace missing cartilage with cartilage from another source.
• Utilize facial rhytids (wrinkles) when designing repair flaps on the face so that the wrinkles hide the scars
• Do not distort natural landmarks and normal facial structures

How to Prepare for the Mohs Surgery Repair?

There are a few steps you should take before your Mohs surgery repair in order to get the best results. These steps include:

• Avoiding certain medications and supplements that may thin the blood, such as:
  • NSAIDs – ibuprofen (Motrin) and naproxen
  • Aspirin
  • Vitamin E
• Stop smoking, as tobacco products can decrease blood flow to the skin and compromise the healing of the surgical site
• Pick up medications at the pharmacy, as your doctor will likely prescribe you certain medications, such as:
  • An antibiotic
  • Pain medication
  • A sedative medication (optional)
• Identify an escort home, as you will need someone to accompany you home if you receive sedative medication during your Mohs reconstructive surgery.

What to Expect on the Day of the Procedure?

On the day of your Mohs surgery repair, it is important not to eat or drink 2 hours before if the procedure is performed in the office and 6 hours before if performed under deep sedation in the operating room. The timing of the Mohs reconstructive surgery varies. Including time spent checking in to the doctor’s office, marking out the surgical sites, anesthesia injections, surgery, and recovery, you should plan to be at your doctor’s office or the surgical facility for at least 4 hours.

What Is the Recovery From Mohs Surgery Repair?

Mohs surgery repair recovery involves some degree of discomfort, bruising, swelling, and bleeding in the initial recovery phase lasting a few days up to 2 weeks. Sutures are often placed and may need to be removed at 5-7 days after surgery, depending on suture type and location on the face. Dressing and bolsters are frequently used to support skin flaps or other repairs. Specific instructions will be provided to you by the top-rated plastic surgeon in Midtown, Manhattan, Dr. Linkov, depending on which exact procedure(s) you undergo.

What Are the Risks and Complications of Mohs Surgery Repair?

Risks and complications are specific to each type of Mohs surgery repair, but a general summary of complications is outlined below:

• Bleeding
• Infection
• Nerve injury
• Poor scarring
• Poor aesthetic outcome
• Vision changes
• Need for revision surgery

Are Patients Satisfied After Mohs Surgery Repair?

Most patients are happy to be cancer-free and most will find the results of their Mohs surgery repair to meet or exceed expectations. The ultimate results of surgery will depend on the initial defect, patient healing ability, and surgeon technique.

Does Insurance Cover Mohs Surgery Repair?

Insurance will most often cover Mohs surgery repair. Check-in advance with your insurance provider regarding the details of your healthcare plan. Please keep in mind that an experienced facial plastic surgeon in Manhattan, NY Dr. Linkov is an out-of-network provider, but does offer financing options. Even if the facility and anesthesia fees are covered by your insurance, the surgeon’s fee will be charged separately.

Who should perform your Mohs surgery repair?

Sometimes your dermatologist who performs the Mohs reconstructive surgery may also repair the wound. For more delicate parts of the face, or depending on patient preference, a facial plastic surgeon may be asked to assist with the Mohs surgery repair.

Who Is the Best Mohs Surgery Repair Surgeon in NYC?

Patients often search for the best Mohs reconstructive surgeon. Dr. Gary Linkov is a board-certified facial plastic surgeon in NYC specializing in facial cosmetic and reconstructive surgery. Best-in-class plastic surgeon in Manhattan’s Upper East Side, Dr. Linkov is a specialist with extensive experience treating all conditions of the face, including those that have been previously operated.

He is the Chief of Otolaryngology and Facial Plastic Surgery for the Veterans Hospital in Brooklyn, NY, where he operates on complex deformities on our country’s veterans. Dr. Linkov’s private practice in UES, Manhattan focuses on facial cosmetic and functional surgery, including Mohs surgery repair. You can view before and after photos of Dr. Linkov’s patients after Mohs repair below:

Mohs Surgery Repair Before and After