Scar Revision

Primary Closure

Primary Closure using sutures is the most straightforward method when repairing a skin cancer defect. This technique converts the wound from a circular opening to a linear scar. The wound will first be made longer to allow the edges to come together evenly and avoid skin bunching, with the final scar tending to be two to three times the length of the original defect. A longer scar with smooth skin edges is often less visible than a shorter scar with bunched edges. 

There are natural lines that correspond to tissue elasticity called relaxed skin tension lines (RSTL). When incisions are placed in the same direction as these lines, the scars blend in much better and are less visible than incisions that are placed across these lines. Dr. Dedhia takes a great amount of care when selecting the best orientation of the final scar concerning these skin lines, as well as the scar’s proximity to your surrounding facial structures.

Flap Surgery

Flap Surgery is the most utilized form of skin cancer reconstruction. It involves using skin that is immediately adjacent to the site of the cancer. There are a number of different types of local flaps that each have different designs and specific methods of movement. The exact type of flap chosen is based on the location and size of the defect left after skin cancer removal, along with the unique characteristics of the skin in that location. 

Many local flaps involve extending incisions from the original cancer defect to allow for a flap of skin to be rotated or advanced to cover the defect. The final shape of the scar created may have an irregular shape (as opposed to a straight line) and the scar length may be quite a bit longer than the size of the original defect. The primary goal is to re-drape the skin smoothly and hide scarring as much as possible in existing facial lines and creases. 

More complex flaps such as forehead flaps and melolabial flaps take tissue from an area more distant to the defect and are used for more complex reconstructions, particularly of the nose. These may require multiple stages of surgery to optimize the reconstruction.

Some of the advantages of flap surgery include a closer color and contour match, and it can be designed with the best thickness to match the depth of the cancer defect. Typically following flap repair, sutures will remain in place for up to one week and will be removed in the office at follow-up.

Skin Graft

Skin Grafting involves removing skin from one portion of the body to repair a defect in another location. Skin grafts can be taken as partial thickness (shaving off the very top layer of skin without an incision) or full thickness (surgically removed and sutured closed). Partial thickness grafts tend to heal with significant contraction and may appear lighter in color and shinier than the surrounding skin, so they may be utilized in certain locations, but are rarely the first choice for repairing defects.

One advantage of skin grafts includes avoiding extending or placing additional incisions at the skin cancer removal site which are designed to perfectly match the shape of the defect. Commonly selected sites include high on the forehead, behind or just in front of the ear, or low on the neck. Dr. Dedhia will carefully choose the location of the donor tissue that has the best color, surface, and thickness to match the cancer defect. One of the key disadvantages of skin grafting is the limited color and contour match to the skin; since the skin is taken from a different location on the body, the match isn’t always seamless.

During surgery, Dr. Dedhia will remove the graft and suture the incision closed in a fine line. He then takes the removed skin and sutures it into its new location. This can be a very quick and reliable method to repair some facial defects. A special dressing called a “bolster” is often placed at the time of surgery and sewn in place to prevent the graft from moving. This is typically kept for one week and is then removed in the office at follow-up.

Skin grafts can only be used to repair fairly shallow cancer defects because taking a very thick graft decreases the chance of it receiving enough new blood supply to survive following the procedure. Despite these limitations, a skin graft provides a very reliable and good aesthetic outcome without the need for lengthening incisions around the defect and keeps the operative time short.

Using these advanced techniques, any scarring or disfigurement left in the skin tissue after Mohs surgery can be repaired or improved to achieve the best aesthetic result. During your consultation, Dr. Dedhia will discuss the pros and cons of each approach.