Skin cancer that is visible on the skin is only the tip of the iceberg. Consequently, the surgeon must remove the cancer deep below the skin’s surface to achieve a cure. The goal in cancer surgery is to completely remove the cancerous cells while conserving as much healthy, normal tissue as possible. Many cancerous lesions can be treated with Mohs Micrographic Surgery (Mohs).
Mohs is beneficial because:
- It spares normal healthy tissues, particularly where there is not a lot of tissue to work with.
- It offers the best cure rate for skin cancer.
- Special care is taken to minimize the size of the defect so that there is smaller wound which improves healing.
After Mohs surgery the surgeon may use a graft or flap to repair the defect, if needed, or allow the surgical site to heal on its won without further treatment.
However, for patients with large lesions or recurrent skin cancer, removal of the lesion may be by Mohs surgery or general excision surgery, and will require reconstruction of the wound created by surgical removal of the tumor. This is especially true where the defect is larger than expected, involves a critical structure or is very complex.
Reconstructive surgery is the repair of the wound produced after the malignant cells are removed. It can be done immediately after skin cancer removal or delayed. The goal of reconstructive surgery is to camouflage the reconstruction and restore function and appearance.
Reconstructive surgery options include local tissue rearrangement with flaps, and skin grafts. If muscle, bone or cartilage is removed during surgery, these tissues will also be reconstructed to achieve balance and symmetry. The area where the skin is taken is called the donor site.
The donor graft or flap is chosen based on:
- how closely it matches the skin color and texture in the area of the wound
- How visible the scar will be at the donor site, and
- How close the donor site is to the wound
Skin Grafts and Flaps
Grafts and flaps may be needed where the wound is too large to heal on its own. Skin Grafts and Flaps are made of the same tissue type but the flap has its own blood supply and the graft does not. When a graft is unlikely to survive in the new location, a flap is chosen because it has its own blood supply,
Skin Grafts (Adjacent Tissue Transfer)
Repair of defects created with Mohs surgery frequently use skin grafts from adjacent healthy skin to repair damaged or missing skin. Skin grafts involve the transplanting of adjacent skin over the wound to improve the function and appearance of the area. The graft may be a thin layer of healthy tissue, or a full thickness skin graft. Grafts do not have an intact blood supply, rather they get their blood supply from the underlying wound that is prepared to accept the graft, and within 3-4 days’ new blood vessels form and communicate with the new skin.
A flap is fatter pieces of tissue, made of healthy skin and tissue and retains its blood supply. Flaps are used to cover exposed bone, tendons, major blood vessels, and organs. Flaps can contain skin and fat, or skin, fat and muscle.
Types of flaps
- Local flap or pedicle flap. This type is never fully detached from its location, and remains fastened to its own blood supply. The tissue is freed and rotated or moved from an adjacent location to cover the defect.
- Free flap. A free flap is completely freed from the surrounding tissues. Using the patient’s own tissue, an area of tissue with its blood supply, is removed from the donor site and transplanted to the site of the defect and the flap’s blood supply is surgically reconnected to the vessels near the wound.
Scarring after skin cancer reconstruction is always designed to place the scars in the natural creases and wrinkle lines, when possible. However, your genetics also determine how you heal and scar. At Advantage Dermatology in Jacksonville, Florida our surgeons do everything possible to minimize scarring.