Thinking in facial units
The face is made of units, the nose, cheeks, eyelids, lips, chin and ears, each with its own color, texture and borders. A repair that respects those borders, placing scars where one unit meets another, disappears far better than a patch in the middle of a unit. When a wound takes up most of a small unit, such as the side of the nose, surgeons sometimes enlarge it to the edges of the unit and rebuild the whole unit, which looks more natural than a small patch.
Timing is flexible.
Repair on the same day as the excision is the norm after Mohs surgery, and saves a second anesthetic. A delay of a few days is safe while waiting for pathology after standard excision, and a study of 320 grafts after Mohs surgery found that grafts placed more than six days later had fewer complications, perhaps because the wound bed had begun to form new blood vessels. For a traveler, the plan is set before arrival so that each day of the stay is used.
Delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications.
Study of 320 grafts after Mohs surgery, JAMA Facial Plastic Surgery, 2019
How are the nose, eyelids, lips and ears rebuilt?
1
Forehead flap, first stage
For large defects of the nose, skin from the forehead is turned down on a narrow stalk that keeps its blood supply and stitched into the nose.
2
Three weeks later
Once the flap has grown into its new site, the stalk is divided in a second, short operation and the forehead closed.
3
Refinement
A third, smaller stage some weeks later thins and shapes the flap when needed. Cartilage grafts from the ear support the nostril rim if the cancer removed it.
The nose
The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts.
Study of graft reconstruction timing, JAMA Facial Plastic Surgery, 2019
- The size and depth of the wound, and whether cartilage or lining was removed.
- Its position on the face, the facial units it involves and how close it sits to the eyelid margin, the nostril rim or the red border of the lip, where even a small pull distorts.
- The color and thickness of the surrounding skin.
- Smoking, diabetes and blood thinners, which slow healing.
- Whether radiation is planned after surgery.
Eyelids, lips and ears
Eyelid repairs must protect the eye, so they restore both the outer skin and the inner lining and support, sometimes in stages, together with an eyelid specialist when the margin is involved. On the lips the surgeon aligns the border of the red lip to the millimeter. A step shows. Ear defects heal well with grafts and local flaps, and cartilage from the other ear rebuilds the rim when needed.
Safety
Skin cancer surgery under local anesthesia carries little risk, and the largest study of Mohs surgery confirmed it.
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Adverse events in 20,821 Mohs procedures at 23 centers
| Event |
Share of all adverse events |
| Infection |
61.1 percent |
| Wound opening or loss of skin |
20.1 percent |
| Bleeding or blood collection |
15.4 percent |
| All adverse events, per procedure |
0.72 percent |
| Serious events, per procedure |
0.02 percent |
Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate.
Multicenter prospective cohort, JAMA Dermatology, 2013
How many days in Istanbul, and what decides the cost?
- The biopsy report, and slides or blocks if the pathologist should review them.
- Close-up photographs of the lesion with a ruler beside it, and a wider photograph of the face.
- Any previous treatment of the same spot, and your medicines, especially blood thinners.
Warning signs after surgery
Bleeding that does not stop after twenty minutes of firm pressure, spreading redness, fever, a graft or flap that turns dark, or, after eyelid surgery, pain in the eye or loss of vision need the surgeon the same day.
Most trips take a week.
Plan five to ten days in Istanbul. Mohs surgery and a same-day repair need a week, with the stitches out on day five to seven. When standard excision waits for the pathology report, add two to four days, spent resting, since the dressing stays on and the face needs no care beyond keeping it dry. A forehead flap for the nose needs a second trip after three weeks. Flying is safe the day after a repair under local anesthesia. Many patients still wait until the stitches come out. A flap on the nose or eyelid swells less if you keep the head raised and avoid bending forward in the first days, including on the plane.
Cost depends on the size and number of tumors, the method of margin control, the type of repair, the anesthesia and the pathology. Your own figure follows the free review of your file.
Your coordinator replies on WhatsApp from the first question. The visa invitation letter goes out ten days before you travel, a driver meets you at the airport, and a hotel near the hospital is booked for you and a companion. The team works in seven languages, with interpreters for any other. Meals come halal, vegetarian or diabetic, the prayer room is open, and a female doctor is assigned on request when the schedule allows. Back home, send photographs of the scar at one, three and six months, and keep regular skin checks with your dermatologist for life, since people who have had one skin cancer are at risk of another.
Skin cancer reconstruction FAQ
Why is the reconstruction done after the cancer is removed?
Because the edges must be confirmed free of cancer first. A repair over a tumor left behind would hide its return.
What is Mohs surgery?
A method in which the tumor is removed in thin layers and every edge is examined under the microscope the same day, until no cancer remains. It spares healthy skin and lowers recurrence.
Will I have a visible scar?
Every repair leaves a scar, and placing it along natural lines and between facial units makes it hard to see once it has matured over a year.
Is a flap better than a skin graft?
Flaps match color and thickness better, while grafts suit shallow wounds and some sites such as the ear and eyelid. The surgeon chooses by site and depth.
How long do I need to stay in Istanbul?
Five to ten days in most cases, and a second visit after three weeks for a forehead flap.
Can my family come with me?
Yes. A companion stays with you at the hotel we arrange.
References
- van Loo E, Mosterd K, Krekels GA, et al. Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up. European Journal of Cancer. 2014;50(17):3011-3020.
- Rowe DE, Carroll RJ, Day CL. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. Journal of Dermatologic Surgery and Oncology. 1989;15(3):315-328.
- Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatology. 2013;149(12):1378-1385.
- Sladden MJ, Balch C, Barzilai DA, et al. Surgical excision margins for primary cutaneous melanoma. Cochrane Database of Systematic Reviews. 2009, issue 4, CD004835.
- David AP, Miller MQ, Park SS, Christophel JJ. Comparison of Outcomes of Early vs Delayed Graft Reconstruction of Mohs Micrographic Surgery Defects. JAMA Facial Plastic Surgery. 2019;21(2):89-94.
