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Facial and Eyelid Reconstruction After Mohs Surgery

There are many types of surgery to repair the wound from your Mohs surgery. The best choice depends on the size, depth and location of the wound. This handout will review the most common options after Mohs surgery on the face and eyelid. 

Your surgeon will discuss all of the options with you. The goal is to give you the best outcome to cover the wound (and make sure you breathe well if you had Mohs surgery on the nose). For some wounds, you may not need this type of surgery; the wound will heal over time on its own. 

Full Thickness Skin Graft (FTSG)

Skin from another part of the body is used to cover the wound after Mohs surgery. It might be the skin in front of or behind your ear, or skin from your neck above the collar bone. (See image below.) 

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This is called a full thickness skin graft. You will have a cut where the skin was removed. 

Stitches are used to close the wound. These will dissolve on their own or will be removed at your first visit after surgery.

Local Skin Flap 

Skin next to the Mohs wound is moved to cover the wound. This is called a local flap. Local flaps are a great option because the skin is very much alike in color and thickness. (A piece of cartilage can be placed under the flap to support your nose if needed.) This is often done in one stage.

The figures below show a local flap. This is called a bilobed flap. Skin on the upper nose is moved to cover the open wound. Excess skin is trimmed. Stitches are used to close the wound.

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Interpolated (Pedicled) Flaps

If your Mohs wound is larger, you may need an interpolated paramedian forehead flap or melolabial cheek flap. This is like a local skin flap, except tissue is taken from a little further away such as the forehead or cheek. In the first surgery, the flap is left attached to its original blood supply. The blood vessels in the skin are called a “pedicle”. A second surgery between 2-4 weeks later is needed to divide the pedicle after a new blood supply has formed.

Paramedian Forehead Flap First Stage Your surgeon will take a piece of skin from your forehead off the center (paramedian). This skin is moved down to cover the wound on your nose. (Cartilage can be used to support or rebuild the shape of your nose.) 

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(Forehead flap planned; the nose is prepared. Extra skin may be removed.)

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(Flap of tissue is brought down from forehead to cover the wound.)

The pedicle is left in place for 3-4 weeks. A gauze dressing is wrapped around the pedicle for the first week. 

Paramedian Forehead Flap Second Stage

After the blood supply to the nose has formed, you will have a second surgery. Your surgeon will “divide” the pedicle and “inset” the skin to re-create the inner eyebrow. The shape of your nose will also be refined. You may need a third surgery later if more refining is needed.

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Melolabial Cheek Flap

Your surgeon will take a piece of skin from your cheek-lip crease (melolabial) and move it to cover the wound on your nose, often around the nostril. (Cartilage may be used to support or rebuild the shape of your nose.) 

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(Wound on the lower nose after Mohs surgery.)

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(Melolabial cheek flap with ear cartilage if needed to support the nose structure.)

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(Ear cartilage can be taken through a small incision.)

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(You will have a small pedicle of tissue from your cheek to the nose.)

A gauze dressing may be placed around the pedicle for the first week.

Melolabial Cheek Flap Second Stage 

This pedicle is left in place for 2-3 weeks. Then you will have a second surgery. The pedicle will be “divided”, and the shape of your nose refined.

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Eyelid Reconstruction

Local skin flaps are often the best for wounds of the eyelid. You may have a cut in the normal eyelid crease or below the lower eyelid lashes. If a skin graft is needed, skin from your other upper eyelid may be used. If the tear drainage system was involved, you may need a silicone tube placed in the tear duct. This tube is usually removed several months later in the office.

When the wound involves part of the edge of the eyelid, the main goal of surgery is to remake an eyelid that works well and will protect the eye. Some of the surgery options are explained below.

Semicircular Advancement Flap (Tenzel)

When there is a small wound in the edge of the eyelid, the two edges can be sewn together. In larger wounds, a semicircular advancement flap may be used. Your surgeon will take skin from the outer corner of the eye and move it over to become the new outer part of the eyelid.

Tarsoconjunctival Flap (Hughes)

To repair larger wounds of the lower eyelid, a tarsoconjunctival flap may be used. Tissue from the back surface of the upper eyelid is taken with its blood supply and brought down into the wound of the lower eyelid. A full thickness skin graft is then placed over the lower eyelid flap. Your eyelids are sewn together for several weeks until the lower eyelid blood supply has formed. A second surgery is done 4-8 weeks later to divide the flap and allow the eyelids to open again.

Wound Care Instructions

Swelling and Bruising 

Swelling and bruising are common and should go away in 2-3 weeks. To help with swelling and bruising:

  • Sleep with your head raised on 2 or 3 pillows the first week after surgery. 

  • Avoid bending with your head below your heart level for 1 week.

  • Do not apply ice packs to your surgery site unless your surgeon has told you to. Ice can decrease blood flow to the skin.

It is normal for your local flap or skin graft to feel numb. This should get better over the first few weeks to months after surgery. Expect your nose to be stuffy for up to 3 months if you had surgery on your nose.

Incision Care

Keep your incision(s) dry for 2 days after surgery. After 2 days you may shower and let water run over the incisions and gently pat dry. Wash your face incisions gently at the sink with warm soapy water twice a day. Do not soak or scrub the incisions. 

Use a cotton swab to apply a thin coat of Vaseline ointment to your incision(s) twice a day until your follow up visit. Do not use antibiotic ointment unless prescribed by your doctor. It may harm the skin for some patients. Do not apply any makeup or other lotions to your incisions the first week after surgery. You may cover your wound with a clean bandage or leave it open to air. 

Some stitches dissolve on their own. Stitches that need to be removed will come out at the first visit. 

You may start to apply a silicone gel or sheet to the incisions in 2-3 weeks.

Special Instructions After Pedicled Flaps

If you had a paramedian flap or melolabial flap, the pedicle may ooze blood for the first few days after surgery. 

A gauze dressing, often a yellow gauze called Xeroform™, may be wrapped around the pedicle. Twice a day, apply Vaseline ointment directly to the entire gauze dressing and incision until your follow-up visit. The gauze dressing will be removed in clinic. After this point, continue to apply Vaseline.

After a paramedian flap, it will be hard to wear glasses after the first stage of forehead surgery. Glasses should not rest or put pressure on the flap.

You may feel nervous or uncomfortable about how you look after the first stage of the surgery. Keep in mind that this only lasts for a short time until the pedicle is divided, and the skin is sewed back in place. 

Eye Care

If you have a pressure patch on the eyelids, you can remove this at home. Your surgeon will tell you when to remove the patch. You should then start to apply ointment as directed by your surgeon. Cold wet compresses can help with swelling of the eyelids.

Apply eye ointment and eye drops as you are directed. The ointment may melt into the eyes and cause temporary blurry vision; this will go away once the ointment is stopped.

Ear Care

If you have an incision on your ear: Use a cotton swab to wash it gently with soap and water. You may gently clean off any dry blood. Rinse it gently with water. Apply a thin coat of Vaseline ointment to the ear incision 2 to 3 times daily for 1 week. There may be gauze sewn to your ear called a bolster. Do not try to remove this gauze. This will be removed at your first clinic visit. 

Pain 

Pain may be mild to moderate. Pain may last 3 to 7 days. We will give you a prescription for opioid pain medicine to use as needed at home. If you use opioid pain medicine, take a stool softener to prevent constipation. Do not drive or drink alcohol while taking opioid pain medicine.

Acetaminophen (Tylenol®) will help with pain. Your surgeon will tell you if you can take anti-inflammatory pain medicine such as ibuprofen (Advil®, Motrin®) or naproxen (Aleve®). 

Do not take aspirin for 1 week before or after surgery, as it can cause bleeding (unless you have been told not to stop your aspirin). 

Activity 

  • Light activity only for 2 weeks after each surgery. No jogging, exercise classes or contact sports. 

  • You may walk carefully after the first 48 hours.

  • No swimming or putting your head underwater for 2 weeks or until after your second surgery if you are having a 2-stage surgery.

  • Avoid lifting more than 15 pounds for 2 weeks after each surgery.

  • You may drive 48 hours after surgery as long as you are not taking opioid pain medicine.

  • Plan to take a week off work. You may need longer, but it will depend on the type of work you do. 

Smoking

Smoking and nicotine can make it harder for you to heal. Do not smoke or use a nicotine replacement for at least 2 weeks before and 4 weeks after surgery.

Sun Protection

You must protect your skin from the sun! Make sun shielding or sunscreen a part of your daily routine. Clothes protect against UV rays. When using clothes for sun shielding, wear a wide-brimmed hat to shield your face. 

Sunscreens are products that absorb sun rays. They protect against scarring and pigment color changes. The best way to choose a sunscreen is to check the SPF, or Sun Protection Factor number. Use one with an SPF number of 30 or more. For best results, you must apply a sunscreen 30 – 60 minutes before going out into the sun. Apply a good amount of sunscreen. Choose a sunscreen that is waterproof if you sweat a lot or will be swimming. Apply sunscreens as often as the label tells you to. 

Medicines can make skin more likely to sunburn. Some antibiotics, water pills, and birth control pills make the skin more sensitive to UV light. Check with your doctor or pharmacist if you are taking any medicine. 

When to Call 

If you have any of these symptoms, please call your doctor or clinic nurse:

  • Bleeding that soaks the dressing in 10 minutes or less.

  • Any sign of infection:

    • Spreading redness.

    • Increased pain, warmth or swelling at the surgery site.

    • Cloudy pus like drainage.

    • Fever over 100.5°F on 2 readings 4 hours apart.

  • Change in color: Your flap or graft may look pink or purplish in color, this is normal. Call if the flap color becomes pale white, gray or black. 

  • Pain is not controlled with pain medicine.

Who to Call

Monday-Friday from 8:00 am – 5:00 pm:

If you received your care at the: 

  • ENT Clinic at UW Hospital, call (608) 263-6190 or (800) 323-8942.

  • Transformations Clinic, call the Transformations Clinic (608) 836-9990 or (866) 477-9990.

  • Plastic Surgery Clinic at UW Hospital, call (608) 263-7502.

  • University Station Eye Clinic, call (608) 263-7171. 

After 5:00 pm or weekends, the clinic numbers are answered by the paging operator. Ask for the ENT doctor on-call. Leave your name, area code and phone number. The doctor will call you back.

If you are a patient receiving care at UnityPoint – Meriter, Swedish American or a health system outside of UW Health, please use the phone numbers provided in your discharge instructions for any questions or concerns.