MOHs - Inner Ear: Heal on Own Vs Graph?

Question

Had MOHs surgery today to remove basal cell inside my ear. 42 yr old white male. Most of the inside skin was scraped out. At a glance it was missing so much the skin it was all white. I was told there was cartilage involvement which was scraped also, but the structure remained intact. I initiated a conversation about a graph for repair. He said it would be best healing on its own. He did punch about 9 holes and said this will help the skin fill in the area. Am considering a plastic surgeon. Thoughts?

Sonia Badreshia-Bansal, MD · Answer

Thank you for your question. In this location, this was a very good choice of repair.  A graft would also be a good choice, but this would cause a new wound (and thus another area that would need to then heal, and is at risk for infection), and so would be a bit less favorable depending on the depth of the wound.  I hope this helps.

Matthew J. Mahlberg, MD · Answer

Thank you for your question regarding the common scenario that dermatologic surgeons face on an almost daily basis.  First, I am glad you chose to have your skin cancer treated with Mohs micrographic surgery.  It is well-established as the standard of care and highest cure rate procedure for non-melanoma skin cancers such as yours.  
	Regarding the choice to let the surgical wound heal in on its own, that is a more complex choice, and I agree that every surgeon has their own techniques and reasons for choosing a particular way of healing a surgical wound.  Areas that are concave, such as the area you had treated, are a very reasonable place to consider "second-intention healing", meaning letting it heal on its own.  Sometimes, this provides a superior "repair" than another more involved procedure could achieve, although the healing time is typically longer.  A skin graft is also a reasonable option in this area, so long as there is sufficent tissue remaining over the cartilage.  Ultimately, I often make these types of decisions based on the best alternative after a thorough discussion with the patient to understand his or her expectations.  Before seeking a second opinion, I'd first consider discussing further with your surgeon to further understand why he chose that option.  If you still would feel more comfortable seeking another opinion, I'd suggest a consultation with a fellowship-trained dermatologic surgeon, certified by the American College of Mohs Surgery (ACMS).

Omar Ibrahimi, MD, PhD · Answer

Glad to hear your skin cancer was removed. Mohs surgeons are trained in the removal of skin cancer while sparing normal tissue and are also experts in reconstructive surgery. No other specialist does as much reconstructive surgery on the face than a busy Mohs surgeon. Once the cancer is out, there are a few options to reconstruct the wound and letting it heal on its own is an option. This option takes several weeks to heal but the advantage is that you are able to resume activity much sooner than if you were to have stitching. The Mohs surgeon you had punched some holes to help stimulate granulation tissue and the wound healing process. Letting it heal on its own can lead to as good if not better cosmetic outcomes in properly selected cases, as Dr. Kaufman mentioned, concave areas do very well. If you are concerned about this, call your Mohs surgeon to let him know, it sounds like you left with some unanswered questions and perhaps he/she can address these for you. You are also welcomed to consult a plastic surgeon if you would feel more comfortable as well, but I echo Dr. Kaufman's comments. Keep in mind that if some sowing is done, you will have some activity restrictions and if you have a skin graft, you would be creating another wound site to cover this one.

Andrew Kaufman, MD · Answer

Concave areas tend to heal well by secondary intention healing (i.e. allowing the wound to heal by itself). The conchal bowl, that concave area near the external auditory canal (ear canal), frequently heals well by itself. If the area surrounding the ear canal is involved, a graft might be used to minimize scarring around the canal. Fenestration of the cartilage (punching holes in it) is sometimes used to faciliate healing.

	No one can give you an informed opinion over the internet. A specialist should examine the site and discuss what your options are. If you have doubts about the person who performed the Mohs surgery, I would suggest seeking a second opinion. In my opinion, best options would be a Mohs surgeon who has completed a fellowship in Mohs surgery and is a member of the American College of Mohs Surgery (ACMS). You could also see a board-certified plastic surgeon or facial plastic surgeon, just make sure that reconstruction on the ear is something that the particular doctors does on a regular basis in their practice. Good luck.

Robert E. Zaworski, MD (retired) · Answer

Every surgeon has their own techniques. When in doubt, it is best to seek a second opinion. Consult with a Board Certified Plastic Surgeon, certified by the American Society of Plastic Surgeons (ASPS) to discuss your expectations and concerns.

MOHs - Inner Ear: Heal on Own Vs Graph?

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