Mohs Skin Graft on my Nose Appears to Be Healing with a Significant Indentation/depression - Will It Improve?

A thick split thickness skin-graft contracts better than a full thickness skin graft.  The graft is sutured with a running suture biting the deep skin edge to hold the graft down on the bottom of the wound.  A small puncture is made in the graft to allow drainage.  The graft is now in a deep hole.  A cotton ball the size of the hole is soaked in clindamycin/gentamycin solution and pushed into the hole over a small patch of xeroform gauze to keep the graft down.  The nose is wiped clear of  oils and a steri-strip is glued over the cotton stent.  At first the graft is depressed.  Then, over a few weeks and months it contracts and the hole fills.  For some unknown reason, the wound levels off flat with the surrounding tissue in most cases.  This is not the case in other parts of the face and body.  The nose is special.  We have high success with this technique and every time it happens I am still amazed after 30 years of using this technique.  Best wishes. Knowledge is power.  Luis F. Villar MD FACS

Thank you for your question. It can take months for a fully mature scar to form after surgery, and many times early depressions are improved with time. Typically, it is advised to not fully judge a scar as a permanent result until it has time to evolve into a mature scar (typically after 6-12 mo. of healing). In cases that do result in an unwanted scar or a depression, scar revision surgery may be considered. I hope this helps.

Thanks for your question. 

Skin grafting is one of many options on the reconstructive ladder to fix defects of the nose. The best areas of the nose that heal with skin grafts are the areas with thin and less sebaceous skin. Sometimes, it is ideal to wait a 2-3 weeks for the wound to fill in from bottom up (by granulation) and then place a skin graft. This allows for better contour matches of the skin graft 

 

It is still very early to make a decision about the final result of your skin graft. I tell most of my patients to hold out on making any decisions about revision surgery until 9-12 months have passed. There are times when the tissue can fill in under the skin graft to give it a better contour match. 

 

Best of luck,

Sachin Parikh MD 

Skin grafts are a good option for repairing skin removed due to cancer on the nose. In general, however, they are not the best match possible for color, texture, pore size, and tissue thickness. In almost every case, local flap repair of the nose yields a better result.

Since you have already had the skin graft, continue to follow your doctor's advice and see how the final result is at 9-12 months. If you are still not satisfied, consult with a facial plastic surgeon very experienced with flap repair to consider cutting out the skin graft and replacing it with a flap. 

Full thickness skin grafts are a common method of repairing surgical defects after Mohs surgery. They definitely improve aeshetically with time, with most grafts continuing to mature for 6-24 months. However, at our center, we treat many of these grafts (and other surgical scars) with fractional resurfacing lasers. This greatly improves both the color and texture of the graft scar. Laser treatment can be initiated wihtin a month after the surgical procedure.

I do several hundred closures a year for Mohs surgeons locally. I use grafts a lot and I also use flaps a lot. Only the surgeon can determine what is best for you. When I use a graft I will often allow the wound to heal from the bottom up for a few weeks then graft them. The problem with a graft right away is what you describe, but it is early and I have seen the tissue beneath the graft fill in with time. One month is very early so you need to give this 6-12 months. Keep communicating with your surgeon and give it time. I never make promises like it will fill in over time, however things can be done to grafts such as dermabrasion to make them better down the road.

 I agree with the other physicians who have said that you are still early in the healing process at one month. From your description, it sounds as if  the graft has contracted, which is a normal part of healing. The other factor to consider is that a portion of the underside of the graft may not have survived and thus sunken down compared to the surrounding tissue. This is a limitation of skin grafts. 

 

I would discuss your concerns with your surgeon. There are many things which can be done to improve the appearance of the scar once you have healed. Options would run from injections, dermabrasion, to surgical scar revision. Be sure to discuss all of these with you surgeon. 

 

Best

Dr S

 

Generally, it takes 6-12 months to get the final cosmetic result after surgery so there may be some improvement with time. Grafts do well in some cases to reconstruct the surface; flaps may be preferred if the defect is deep because flaps reconstruct depth as well as surface. Your best option is to discuss your concern with the doctor who performed the repair. Sometimes scarabrasion (a.k.a dermabrasion) may improve the final appearance  and make the surfaces more level. Good luck.

Hi, one month is still fairly soon after the procedure. I would recommend following up with your Mohs surgeon in a few months to check in on how the healing is going. There are plenty if ways to improve the appearance of the graft down the line.

I agree that it is still too early in the overall healing of the graft.  It is hard to say at this point whether or not the defect after the mohs surgery is deeper and still needs to fill in with the graft or whether the scar has contracted.  Even if there is a portion of the graft that did not take, which is another possbility, it is best to leave the graft in place and undisturbed.  Please speak with your surgeon regarding your options.