How surgeons repair the wound left by skin cancer removal, from natural healing to flaps, grafts, and staged repairs, who does the work, and what to expect over months.
Removing a skin cancer leaves a hole, and the hole is often larger than the spot you saw in the mirror. Reconstruction is the plan for closing it. Surgeons pick the simplest method that protects function first (an eyelid that closes, a nostril that stays open) and appearance second.
Doctors call this healing by second intention. The wound fills from the bottom with new tissue, shrinks inward, and skins over from the edges. Healing time rises with wound size, from about 3 weeks for a small wound to 2 months or more for a large one or one on the lower leg.
Location predicts the result. Concave areas do best: the inner corner of the eye, the crease beside the nostril, the hollows of the ear, and the temple. In one study of second intention healing, 97% of wounds in these favorable zones had a cosmetically acceptable outcome. Convex surfaces such as the nasal tip and chin tend to heal with a depressed or pale scar.
Shrinkage is the hazard. A contracting wound close to the edge of an eyelid, lip, or nostril can pull that edge out of position, so surgeons repair those wounds another way.
Primary closure, a straight line of stitches, is the most common repair. The surgeon converts the round wound into a longer ellipse so the ends lie flat and closes it in 2 layers. The scar ends up about 3 times as long as the wound was wide. Surgeons place it, where they can, in natural creases such as the fold between the cheek and the nose.
When the edges will not meet without distorting something, the surgeon can borrow loose skin from next door. A flap is a section of skin and fat that is cut on 3 sides, left attached on the fourth, and moved into the wound. That attachment carries its blood supply. A flap matches the missing skin in color and thickness because it comes from the same neighborhood.
Flaps slide forward (advancement), swing in along an arc (rotation), or lift over a bridge of normal skin (transposition). Flap scars are longer and more geometric than people expect, and the design aims to hide them in existing lines.
Early on, a flap may look swollen, bruised, or dusky. Smoking is the biggest threat, since nicotine narrows the small vessels a flap depends on, and part of the flap can die.
A graft is skin cut completely free from one site and stitched into the wound. With no blood supply of its own, it survives the first days by absorbing nutrients from the wound bed, and new vessels grow into it over 5 to 7 days. A padded dressing is often stitched over the top for about a week to hold it still. Blood or fluid collecting under the graft and infection are the main reasons grafts fail.
The 2 kinds differ in thickness:
Grafts can look worrying early. Purple, dark, or crusted patches in the first 2 weeks are common and often recover. DermNet notes that the area can take 1 to 2 years to settle fully.
Large, deep wounds of the nasal tip and side of the nose need more tissue than the nose can lend. Forehead skin matches it best. In a paramedian forehead flap, the surgeon raises a strip of forehead skin based on an artery near the inner eyebrow, turns it down, and stitches its end into the nasal wound.
The flap stays connected to the brow by a stalk of skin, the pedicle, for about 3 weeks while new vessels grow in from the nose. During that time the pedicle crosses between the eyes, glasses are hard to wear, and the raw underside needs daily care. A second operation divides the pedicle and sets in the flap, and some surgeons add a middle stage to thin it.
Mohs surgeons repair most of the wounds they create, the same day. They bring in a colleague when the wound calls for it. An oculoplastic surgeon handles eyelids and the tear drainage system. A facial plastic surgeon (trained in ear, nose, and throat surgery) or a plastic surgeon handles major nasal, lip, or ear reconstruction.
Reasonable requests for any of them include the number of stages planned and photos of similar results at 1 week and at 1 year.
Repairs look their worst at 1 to 3 weeks. Redness, firmness, and lumpiness build for the first couple of months and then recede over a year or longer. Numbness around the repair is expected because small skin nerves were cut. Sensation returns slowly over months and may stay incomplete.
Touch-ups are common. They include steroid injections for thick scars, dermabrasion or laser at around 6 to 8 weeks to blend a graft or flap edge, and thinning of a bulky flap. Surgeons treat these steps as part of the plan.
