Tight and Lopsided Skin Flap Reconstruction Results

Most patients look pretty gruesome shortly after reconstruction of a defect left by Moh's micrographic surgery of the nose. Most of the time, the result improves dramatically. This, however, takes time. Too often surgeons get involved with manipulation of the wound healing process and create a bigger problem. Steroid injections and various adjustments should be done rarely.

A local tissue flap can affect adjacent tissue.  Most of the cases will resolve once swelling subsides.  Make sure you express your concerns with your surgeon to prevent any longterm problems. Raffy Karamanoukian, Los Angeles

The skin is surprisingly resilient and even the tightest wound closing after skin flap repair will loosen up nicely over time. Work with your dermatologic surgeon or plastic surgeon and start scar massage after agreed upon time after suture removal. Cortisone injection for hypertrophic changes or additional scar revision may be seldomly performed as needed.

I appreciate your concern and worry regarding the pulled appearance after Mohs surgery. You should rest assured that it is not uncommon for nearby anatomical structures (lips, nose, ear, eyes) to look a bit pulled after reconstruction. Such effects generally settle out within 90 days or so. If it is persisting beyond 90 days, you should return to your surgeon for a re-evaluation.

Asymmetry after reconstruction can be a temporary or permanent situation. When a flap is created it is basically borrowing tissue from one area to move it to another area that lacks adequate tissue (i.e. the surgical defect). It is very important that the person designing and executing this repair be an individual with training and experience in facial reconstruction. If the design and execution are performed correctly then the problem will likely improve over time (although perhaps not completely since again there is limited loose tissue from which to borrow on the nose). It takes 6-12 months to get the final cosmetic result following reconstructive surgery. Follow up with the plastic surgeon who performed the repair, and if you're not comfortable and satisfied with the care of that doctor, see another doctor, perhaps a fellowship-trained Mohs surgeon, for a second opinion.

I am assuming that you have seen a fellowship trained Mohs surgeon and a board certified plastic or facial plastic surgeon.  All flaps do take time to "mature" and in trained hands will most often yield lovely results.  The early healing phase requires some patience and faith on your part.  If you have concerns with your plastic surgeons work, you need to ask them about it. Getting advice online will not help you since we cannot see the work and your surgeon will know better than anyone what was done and whether this is a normal good outcome or whether there are some issues that need to be addressed. Call them and find out today. Good luck.

Nasal reconstruction after Mohs surgery is tricky; the goal is for excellent functional and cosmetic results for years to come - not just for the first few days or weeks.

Sometimes, in order to get good long term results, reconstruction is more involved (ie, flaps and or cartilage grafts) than one might imagine (ie, simple sutures or skin grafts). The healing from these more involved repairs may take several months, but the long term results are worth it.

Give it time - follow up with your reconstructive surgeon as he recommends. If you are still dissatisfied at 1 year, revision may be appropriate.

Good luck!

Mike Nayak, MD

It will take time for your scar tissue to soften. However, sometimes a surgical lid ectropion occurs after repairing a skin cancer defect close to the eye. This should be followed and repaired by an oculo plastic surgeon if it is bothersome.

Without a photograph it is impossible to respond to you except in generalities. Reconstructing the nose with a flap (an island of tissue borrowed from next door and turned to cover the hole left by the cancer removal) is associated with swelling. Your surgeon fully understands these subtleties and I am sure that he considered post op swelling and tension when he/she performed the operation. Once the swelling subsides you will be pleasantly surprised.

It is not uncommon to have some pulling on a flap after reconstruction. All wounds are different and reconstruction can be a challenge. Most flaps will look better and settle down over time. A flap can take as long as 6-12 months to fully mature. You best bet is to discuss this with the plastic surgeon and insure that he/she follows you closely to make sure you get the best result possible.