What Can Be Done to Correct Asymmetrical Nostril Flare After MOHs? It's Been 1 Month

There are many reasons why there may be asymmetry after a bilobed transposition flap, some of these resolve with time, some with treatment and some may not resolve completely. The best starting option is to return to the doctor who performed the reconstruction and discuss what has happened and what can be done.

Bilobed flaps can developing what's referred to as "trapdooring." This is a bulging of the flap, caused by the development of scar tissue beneath the flap contracting centrally and producing a pincushioned or trapdoor appearance. This contraction could result in lift of the nasal alar rim and nostril asymmetry. Trapdooring frequently responds to massage and a series of intralesional steroids.

There are many other reasons that there could be asymmetry or lift of the alar rim. Was the flap designed and executed correctly? Was there any complications afterwards like infection or bleeding?

The best opiton is to see the doctor who performed the surgery and discuss your concerns. If after a period of time and treatments you are not satisfied, it doesn't hurt to seek a second opinion. If you see another doctor, make sure that they have significant  training and experience in nasal reconstruction. Members of the American College of Mohs Surgery frequently have a great deal of experience in nasal reconstruction following Mohs surgery. Another option is a plastic surgeon or facial plastic surgeon but make sure whichever doctor you might choose that they perform a great deal of nasal reconstruction.

It sounds as if the nostril flare or pulling up of the nostril will fall over time if it is a small amount of pull, sometimes massaging the nose in a downward motion can help the nostril fall back down. If there is a larger amount of pull, this can be corrected in a second procedure to push the nostril back down- this may be necessary to correct the pin-cushioning or puffy appearance of the flap itself. Your Mohs surgeon will be able to evaluate you and recommend further treatment.

You have mentioned two common side effects of bilobed flaps:  nostril distortion and pin cushioning.  Without seeing your post-operative defect, it is impossible to see if your bilobed flap was done properly or not.  Proper design of the bilobed flap along with extensive undermining usually ensures that this nostril flaring does not occur, but with large defects, this can sometimes be inevitable.  Usually 1-2mm of nostril flare will relax itself in a few months.  If it does not, it can be challenging to fix.  Sometimes a Z Plasty can be utilized to correct the distortion.  I would talk to your original surgeon who did the repair, as he/she should be willing to revise it at a reduced or no cost.

In regards to the pin cushioning ("puffiness"), that can be addressed with intralesional steroids frequently.  In my opinion, this results because not enough subcutaneous sutures were placed.