I had a biopsy and the results are that I have a squamous cell on the tip on my nose, very small area. Using a Mohs Surgeon how will he/she determine if the procedure will be conducted with stitches or left to heal by itself. Please advise. thank you.
Mohs Surgery on Nose - Stitches or Left to Heal by Itself?
Doctor Answers 6
Repair or Secondary Intention Healing
When we allowa wound to heal by itself we refer to it as secondary intention healing. This tends to work best in concave areas including the temple and depressed contours of the nose, eyes and ears; however, other factors may come into play. Very superficial defects may also heal very well by secondary intention healing. Overall, the best answer is to talk to your doctor, and ask why he or she is performing a particular repair or allowing the wound to heal by secondary intention.
The need for stitches depends on the size of the cancer
If the cancer is small and is removed with the first layer (stage) of the Mohs procedure then there is a good chance we can let the body heal naturally and stitches will not be needed. However, if the cancer is larger, and the defect is wider or deeper after the cancer is removed, then a repair with stiches is often recommended for the best cosmetic results.
Reconstruction for the nasal tip after Mohs surgery
Normally, nasal tip defects are reconstructed by either a skin flap which involves movement of adjacent skin to cover the area, or a skin graft which is a patch of skin removed from a separate area such as behind or in front of the ear, side of the neck or other donor areas from the same patient. Otherwise, nasal defects on such a convex area of the tip of the nose typically do not heal with appropriate aesthetic outcomes. The underlying cartilage may be too noticable as bumps and the scar tissue may be too thin. All of this depends on the depth of the wound as it is possible to consider healing without stitches if the wound is shallow.
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Squamous cell on nose tip repair options
First of all, are you seeing a board certified and fellowship-trained Mohs surgeon. You can tell by going to Mohscollege.org and look up your doctor. Next, you should know that this surgical decision can only be determined after the Mohs layers show no residual cancer cells and the depth of the area is known. Sometimes these "small" cancers can be tiny or be just the tip of the iceberg. Lastly, your fellowship-trained Mohs surgeon is required for certification to have extensive experience with reconstruction. So they will be able to tell you if a skin graft , a local flap, a linear closure , or healing without stitches is best. In general, the nose tip is rounded and is not prone to ideal healing without stitches whereas the creases of the nose would do much better without stitches. Rest assured, that if stitching is needed this will cut down your healing time by up to 3 weeks as compared to leaving it open to heal on its own. Lastly, be aware that every wound can and will heal without any stitches, but if ideal cosmetic outcome is of concern then discuss this with your Mohs surgeon.
Secondary intention healing without sutures
Your surgeon should be able to advise you based upon what area and how large of a defect are involved after removal of your skin cancer. Typically the best areas for secondary intention healing (without sutures) are those that are found on concave areas of the face such as nasal ala creases.
There are several factors that determine a repair
First off, kudos to you for using a Mohs surgeon to treat a skin cancer on a cosemtically sensitive area. As stated before, make sure that you are using a fellowship-trained Mohs surgeon.
Personally, I do not like to leave defects on the nasal tip to heal by secondary intention. I feel that this leaves an unacceptable scar. There are other locations were secondary intention healing is acceptable (concha of ear, small medial canthal defects), but I do not consider the nasal tip one of these.
Depending on the size of your final defect, there are several repair options. If your defect is midline on the nasal tip, your surgeon may be able to close it primarily (in a straight line). If that is not feasible, then you are looking at a skin flap (moving around adajcent skin) or a skin graft. I am not a big fan of grafts on the nasal tip unless it is really small and shallow.