Why Would a Mohs Surgeon Choose to Use a Skin Graft on the Nose when an Uncomplicated Flap is an Option?

Nasal reconstruction can be accomplished well with either flaps or skin grafts.  Flaps do NOT always lead to far superior aesthetic outcome compared to skin grafts and there are many instances when a skin graft is superior to a flap.  Flaps have the advantage of matching skin color, texture, and thickness, but lead to further scars on the nose, which may be more noticeable than the defect.  Both flaps and skin grafts often need secondary interventions to improve their appearance, such as steroid injections, dermabrasion, or peels.  

No, a skin graft is absolutely not easier, for the repair, the healing, etc.. A flap is preferable as long as the tension lines, skin, and area allow for it.

Thank you for your question. This is a difficult question to answer definitively, as every surgical case and patient is different. These decisions are typically made between both the patient and the surgeon, as sometimes local tissue flaps do indeed provide superior closures. However, sometimes a graft proves to be a better option cosmetically, depending on the size of the defect, patient preference, and other factors. Often times, a surgeon may not be able to predict the end size of a defect depending on the aggressiveness of the tumor, and this too may prove to be a factor in closure decisions. I hope this helps.

This is a very good question. A flap is tissue that brings its own blood supply with it. It can be a random flap which has a more unreliable blood supply or it can have a blood vessel running in the flap called and axial flap that has a more robust blood supply and thus more reliable.

A graft is a piece of skin that is thin and taken free form the body and sewn into place on the defect. Blood supply grows into this tissue from the bed. It may be more difficult for blood supply to grow into the graft for many reason. (bad recipient site, smoking, infection, sheer forces. etc.)

One problem with small flaps on the face is swelling of the flaps called pin- cushioning. A classic example is the bilobed flap. Looks great in the books and when the flap is initially performed but the final result is often "puffy" and often requires revision.

Although I prefer flaps on the face to close Mohs defects, the nasal side wall is actually a very reasonable site for a full thickness skin graft and would likely be high on my selection list as well. A skin graft is not necessarily faster either because of donor site closure and bolster placement. (A bolster holds the graft down to the wound bed.)

I hope that you did well and that this helps answer your question.

Skin that is adjacent to the wound has the best match of texture, color, and thickness.  Adjacent flaps can be used and/or grafts from  adjacent tissue can be used.  There are other fancy tricks such as the Canon purse string flap.  There are literally dozens of options available.  The best choices are based on size and location of the wound, elasticity of adjacent tissue, blood supply, extent of sun damage and precancerous condition of donor sites, health of the patient,  experience and training of the surgeon, etc.

 An experienced, well trained, Board Certified Plastic Reconstructive Surgeon is usually your best chance for the most options.  Some dermatologists performing Mohs are taking on wounds that are beyond their capabilities, not because they are bad doctors, but because they are medical specialists, focusing on a sub-specialty of pathology.  In todays world, no specialist will master his own specialty in his entire lifetime. The knowledge base is too big and outpacing us every day.  It would be unfair to expect a dermatologist to master the art of surgery and plastic reconstructive surgery.  The prudent patient will arrange for a plastic surgeon to  repair the defect after the Mohs dermatologist has removed the cancer.  This is logistically inconvenient, but in the patient's best interest as a general rule.

As one of a  few Plastic Reconstructive Surgeons performing Mohs, we provide both services in house to simplify logistics.

Best wishes. Knowledge is power.  Luis F. Villar MD FACS