Mohs Surgery on Nostril: Should I let it heal on it's own (and what would scarring look like) or have plastic surgery? (photo)

I recently had Mohs Surgery. I was considering doing plastic surgery, but after hearing that it may take 4 surgeries total to fix and worrying about going under the knife and coming out of anesthesia, I wish I could let it heal on it's own. I'm curious what a scar may look like if left to heal--if anyone has pictures or could explain. If it's a scar I could live with and avoid surgeries, I'd go for it, but I don't want to end up with a deformity that is extremely obvious.

Doctor Answers 5

Secondary intention

If this is superficial then you could leave this to heal and then see what it looks like. If there is a problem such as constricted alar then you could have reconstruction at a later date. A small local flap could be used currently or secondarily and it is uncommon to need more than one op for a defect this small.  If the defect is deep then secondary intention will take a while to heal.
Often when one consents patient pre MOHS excision fro reconstruction on the nose you are consented for the need for a number of stages and flaps because one cannot predict the size of the defect. I do not see how it would take at max 2 stages to reconstruct this and in my experience this is reconstructable in one operation. The wound will be healed much quicker than leaving to heal by secondary intention.
For a defect this small a small local flap would give the best result and it is likely that this could be reconstructed in one stage. I would get a second opinion if your PS has seen this defect and is advising the need for 4 surgeries.

Manchester Plastic Surgeon
5.0 out of 5 stars 164 reviews

Give yourself time to heal. Then see.

Hi there - I would like to offer a different opinion. Although I am an ACGME fellowship-trained Mohs surgeon, I always believe in letting nature do its best for you and I was taught that way. Flaps and grafts are creative and nice, but oftentimes nature can do wonderful things. 

Keep the area moist with an ointment such as Vaseline or Aquaphor at all times. Keep a small band-aid over it. It will heal by hopefully 4-6 weeks, and it will continue to fill in over several months. Sometimes it will completely fill in and the scar will be barely noticeable, especially in that area. Sometimes you might have a small divot, at which time you have filled in nicely and we can do a few cosmetic procedures to even out the divot.

Thoughts - I have had great success with microneedling, which encourages your body to create new collagen and it also smooths out the area. Filler (such as Juvederm or Belotero) can "plump" up the divot and stimulate new collagen. Finally, we could graft after you've grown your "sod," is the way I like to think about it - the best part is, the scar will be very small at that point and we can do a small graft.

You have choices. Let your body heal first! It's a bit of a commitment, but you deserve a chance to try and let your body do the work it was meant to do. 

Andrea Hui, MD
San Francisco Dermatologic Surgeon
5.0 out of 5 stars 35 reviews

MOHS on Nose, Plastic Surgery Or Not

This area is one of the toughest areas to reconstruct.  There are options such as grafting or flaps in terms of surgery, or granulation.  Its pretty deep and if you let it heal on its own (granulation) you will be left with a contracted nostril and circular scar.  My suggestion is if you are worried about cutting, a graft may be better for you and later you can do dermabrasion or scar.  But I would speak to a dermatologic surgeon or plastic surgeon and see what they think.  Most will likely offer a mesolabial/nasolabial fold flap which requires multiple surgeries.  The results are very good in the end, but again its more downtime than the other option which may also give you a great cosmetic result.  Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 190 reviews

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Nasal defect after Mohs surgery

Once your tumor is extirpated with Mohs surgery, you're often left with a decision to make with your dermatologic surgeon about how to close the defect.

Reconstruction options include letting the defect heal on its own (secondary intention healing), a local flap or even a skin graft from a distant piece of skin. Your surgeon may refer to this as the reconstructive ladder.

Based on your photo and the short description you gave of a four stage procedure, I would assume that your surgeon is talking about a paramedian forehead flap, which in my opinion seems a bit excessive for the defect that you have.

Seek a second opinion from a fellowship trained dermatologic surgeon. This specific fellowship training ensures that they are very well-versed and competent in reconstruction themselves, and they work closely with our colleagues in oculoplastic surgery, facial plastic surgery and plastic surgery to ensure that you get the best reconstructive result that you can get.

Cameron Chesnut, MD, FAAD, FACMS
Spokane Dermatologic Surgeon
4.9 out of 5 stars 104 reviews

Mohs Defect

Hello heidims1, 

Thank you for this quesiton. 

Without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of any treatments it is difficult to be comprehensive.

There is a reconstruction ladder.  The lowest rung is secondary intention healing meaning local wound care and let your body do the work.  Unfortunately, in this area these is risk of contracture and pulling your nostril up.

The easiest option is to borrow skin just above your collar bone and patch the hole.  It is one stage and would give you a great result.   You don't have to go to sleep for this and it can be done under local anesthesia.

The other options of surgery include more complex flaps and techniques which can give you a superior result, but are more involved.

The other consideration is the strength of the nostril.  Sometimes cartilage grafting is necessary.

Good luck,

Dr. Shadfar

Scott Shadfar, MD
Edmond Facial Plastic Surgeon
5.0 out of 5 stars 4 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.