Mohs surgery and reconstruction of Skin Cancer on the face

A diagnosis of skin cancer especially on the face can lead to anxiety; what does this mean for the future? How will the scars look? How big will the wound be? Fortunately, most non-melanoma skin cancers (NMSC) have a high cure rate when treated promptly. 

There are many ways to treat skin cancer on the face but the two most common methods are a wide local excision (WLE) or Mohs procedure (named after Fred Mohs, the inventor of the technique). 

Most facial plastic surgeons will recommend undergoing a Mohs procedure to remove smaller skin cancers, especially in cosmetically sensitive areas around the eyelids, lips or nose. This is why it is critical not only to have a regular appointment with a dermatologist, but if there is an area of concern, undergo a biopsy to catch them early when treatment is much easier. Dermatologists specially trained to remove skin cancers using Mohs technique will perform this procedure in the office and read the pathology at the time of the removal. This will allow the dermatologist and the reconstructive surgeon to know the cancer has been fully removed. 

The other option is wide local excision, either under local anesthetic or general anesthetic. In these cases, a surgeon will remove the lesion with a margin of normal appearing tissue, anywhere from a ¼’ to ½”. This allows an estimate of the area that should be uninvolved by tumor. The removed tissue is then sent to a pathologist who will look at the edges and make sure the cancer is fully removed. The downside to this process is that if further cancer is found, the patient would need to undergo an additional procedure to remove the extra tissue. The reconstructive surgeon, in many cases the same surgeon, can then reconstruct once it is known that all the cancer has been removed. 

In either case, the resulting wound that is left is closed using any number of techniques. Facial plastic surgeons often find Mohs reconstruction to be one of the most satisfying and challenging of the reconstructive procedures. This is because the wound is never known ahead of time and requires a great deal of experience and thinking “outside-the-box” in order to result in a good scar outcome. 

Mohs reconstructions may be done the same day as the removal or the next day. They can be done under local anesthetic or general anesthetic in the operating room, depending on the extent of reconstruction. Options to close facial wounds include skin grafts, rearrangement of tissue around the wound, or creating other local “flaps” of tissue to move into the wound. The goal is to reconstruct all aspects of the normal tissue, as well as create scars in a way that will minimize the appearance of them in the future. All surgery will result in scars, but if the scar are thin, flat, soft and hidden in a pre-existing or normal site for a wrinkle or fold, they are often not visible. 

In cases where we have time prior to the removal to meet the patient, it is my personal preference to have a consultation with them to discuss the particular lesion they are going to have removed, the options for reconstruction and even drawing for them the types of scars they may be able to expect. This eases some of the anxiety in many cases and makes the next steps more predictable. 

Regardless of the method of removal, it is critical to find new skin cancers early by starting annual dermatology skin checks. Paying attention to areas on your own face or body that are concerning to you is also important-you can request a biopsy if you feel particularly worried about a changing or growing lesion. If this issue is ever one you are facing, take heart in knowing the plastic surgeons at the Emory Aesthetic Center have years of experience and find joy in treating patients with these complex issues. Don’t forget: use sunscreen!

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Anita Sethna, MD, FACS is double board certified in Head and Neck surgery and facial plastic and reconstructive surgery, with a passion for helping her patients to achieve their most confident, empowered, and youthful selves. To schedule your private consultation, please give our Atlanta office a call at 360.223.7530 or fill out our online contact form and we will get in touch with you right away.


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