Plastic Micrographic Surgery
As your doctor likely discussed with you following surgery during the discussion about the treatment options available for the wound, many wounds will heal if left alone. Most wounds left to heal on their own heal will do so with worse scarring than if they are surgically closed immediately - however the forehead is one of the few areas that does tend to do ok and in some cases does brilliantly. The longer a wound remains open, typically, the worse the scarring. We know that wounds that have not healed by 21 days tend on average to heal with thicker scarring than those that heal before that (we know this from the burn literature). Smoking, nutrition and general health all affect wound healing.
In addition to an unpredictable cosmetic outcome, secondary intent healing is limited by inconvenience to the patient (long time to heal); infection is very, very rare in such wounds on the face.
Most of the doctors who perform the Mohs procedure are dermatologists and many do great work. There are seven of us worldwide (myself included) who are formally trained in Mohs surgery and are also board certified plastic surgeons; the advantage is the highest cure rate from Mohs, followed by immediate cosmetic reconstruction. I prefer to close wounds since I feel the result is predictably better when I surgically limit the number of factors/hurdles I am asking the wound to overcome.
That being said, I wasn't there for your cancer removal so I can't comment on the depth or what your doctor had in mind. I would trust your doctor (you chose to go to them in the first place) and know they have a plan in mind to ensure the wound heals in an optimal cosmetic fashion; I would certainly encourage you to contact them with any apprehension or concerns that you have; I would give them the benefit of a doubt that they would want to know of your thoughts and concerns and it would likely help you both to discuss it.
An unsightly scar after secondary intent can typically be addressed down the road to make it look better as well and a suboptimal result doesn't mean anything was done wrong - sometimes it takes a few steps to get to the final result. The wound healing cascade takes 9-12 months during which scars tend to soften, lighten and become flatter and more supple so patience is also a virtue.
Repairing Mohs Surgical Wounds
Although the wound will eventually heal itself, the scar will be worse and why would anyone want to walk around with a "hole in their head" requiring daily wound care when it can be closed immediately?? Closure of a Mohs defect depends on the location, size and shape of the wound.. If it is small it closed primarily. If too large for that (e.g the size for example the size of a silver dollar as in your case then a flap, that is attached nearby is rotated in to fill the defect, or occasionally a skin graft can be used. Often times if you have redundant skin the final scar can be placed in a normal crease line in the forehead. See a board certified plastic surgeon or facial plastic surgeon that has a special interest in Mohs closures.
There are several options with respect to reconstruction following Mohs surgery.
One can have the wound repaired immediately following Mohs surgery, they can allow it to heal in completely without having any reconstruction, or the wound can be allowed to heal to some extent so that it is made smaller before having reconstruction done. The main advantage to allowing it to heal in some on its own first are that it will likely necessitate a small flap/graft.
Secondly, there are many times in which the cosmetic result from allowing a wound to heal in by itself completely can be superior to that achieved from a flap/graft (ie. this is often seen on the nose, depending on how deep the wound is). The down side is that there are times in which the cosmetic result is not as acceptable because the scar appears as a faint white patch that can be less appealing than a series of lines that can be strategically placed to mininize their appearance. Another main disadvantage is that it often takes a long time for the wound to heal in by itself, even partially and will likely require a larger bandage for a longer period of time.
Depending on the size of the wound, your Mohs surgeon may want you to be on antibiotics during a portion of the healing process. It is important to take your lifestyle needs into account (can you accept a larger bandage for a longer period of time, decreased physical activity for a longer period of time) when making this decision. Basically, allowing the wound to heal in first some stretches the whole process by some time, however, it could have a great impact in decreasing the overall size and improving the appearance of the final size.
How to Repair Mohs Surgery Wound?
Thank you for your
question. Good news, there are multiple options available to close your wound.
I recommend that you make an appointment with a board certified plastic surgeon
to discuss your surgical options.
Repair after Mohs surgery
Most repairs are performed on the day of the Mohs surgery. I tend to perform all necessary repairs on the ssame day. Some doctors like to allow the wound to heal for a period of time before applying a skin graft. This allows the base of the wound to fill in somewhat so there is less of a depression on the grafted skin. In my mind there isn't really any benefit to allowing a wound to heal before performing a flap repair. By the way many areas will heal well if allowed to heal by themselves. This is called secondary intention healing and is most useful on the concave areas of the temples, ears, eyes, and nose.
Reconstructive surgery after Mohs micrographic surgery
Ideally, reconstructive surgery repair should take place immediately after eradiation of tumor with Mohs micrographic surgery. If you choose to have a plastic surgeon to do the repair, reconstruction should take place that afternoon or the very next morning to minimize risk of infection. Certain wounds along concavity such as inside of the ears may be amenable to self-granulation without further repair assuming one is consistent with emollient application after Mohs surgery.
The first option in many cases is to close the wound by your Mohs surgeon that day. If the defect is large and the skin tight, sometimes you can allow for healing slowly over 4-6 weeks to close the area. This then can be later closed if needed as the wound will be at least 20% smaller if not more. This requires patience on your part. Sometimes it heals so good on its own that revision is not even needed but this may be more true in other areas rather than the mid forehead. A skin graft on the forehead is almost always a poor choice for cosmetic outcome and so a local flap or linear closure is often used in these cases. Since you did not send a picture, just keep checking in with your Mohs surgeon and come up with a plan that makes the most sense as you see how it heals on its own over time.
Is time critical for closure for forehead mohs defect
I would recommend getting the defect closed sooner as opposed to later. Here is the thing...yes you can take a chance and let it granulate (heal) in and see what it looks like. Most of the time it will be fine but sometimes it doesn't turn out well. At that point, If you don't like it you can have a surgeon do a scar revision which would be cosmetic. However, if a surgeon closes it after it will reduce the risk of a cosmetically unacceptable result and reduce the chance you would have to later on pay for a cosmetic procedure. Some insurances may cover scar revisions but not in my area of New Jersey as far as I know.
Mohs surgery and reconstruction
The location and size of the defect on the forehead really dictates the best approach to closure. I have seen all approaches including flaps, grafts, primary closure , and secondary intention result in excellent cosmetic results. I typically prefer closing the defect the same day as the Mohs surgery.
The answer to your question depends entirely where on the forehead your wound is. I would not recommend a skin graft -- it is very difficult to get an exact color match and will look very obvious. If the wound heals by itself, it will take some time (3-6 weeks) and it will feel like nothing is happening for the first 2 weeks and then all of a sudden it will start to heal from underneath and around the sides. If a wound heals on its own, it will shrink down to 1/3 the size of the wound.
It is sometimes easier to undergo a scar revision after it has healed by second intention because the resultant scar will be smaller. Otherwise, repair directly after Mohs is advised but it really depends on the area of the forehead as to whether you should have a flap or a linear repair done. If you go to an experienced Mohs surgeon (fellowship-trained and Mohs college certified) or a plastic surgeon you will be able to get the right advice based on your current wound.
Best of luck,