What Is Mohs Surgery?
Mohs micrographic surgery (MMS) is the gold standard for removing certain types of skin cancer, particularly basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). It involves removing thin layers of cancer-containing skin and examining each layer under a microscope until only cancer-free tissue remains.
This technique achieves the highest cure rates (up to 99% for new cancers) while preserving as much healthy tissue as possible. However, even with maximal tissue preservation, Mohs surgery can leave significant defects — particularly on the face, where skin cancer is most common due to sun exposure.
Facial reconstruction after Mohs surgery is a specialized field that requires deep understanding of facial anatomy, aesthetic subunits, and advanced reconstructive techniques. Dr. Chaiyasate's dual fellowship training in craniofacial surgery and reconstructive microsurgery makes him uniquely qualified to handle even the most complex post-Mohs defects.
Why choose a plastic surgeon for Mohs reconstruction? While dermatologists perform Mohs surgery to remove the cancer, a fellowship-trained plastic surgeon like Dr. Chaiyasate brings specialized expertise in facial anatomy, aesthetic principles, and advanced reconstructive techniques to achieve the best possible functional and cosmetic outcomes.
Facial Areas We Reconstruct
Skin cancer can occur anywhere on the face. Each area presents unique reconstructive challenges that require specialized techniques to maintain both appearance and function.
Nose
The most common site for facial skin cancer. Reconstruction must address skin coverage, structural support (cartilage), and nasal lining. Techniques range from local flaps for small defects to the paramedian forehead flap — the gold standard for large nasal reconstruction.
Common Techniques:
Lips & Perioral Region
Lip reconstruction must preserve oral competence (the ability to eat, drink, and speak). The orbicularis oris muscle must be carefully reconstructed. Special techniques maintain the vermillion border and natural lip contour.
Common Techniques:
Eyelids & Periorbital Area
Eyelid reconstruction is critical for protecting the eye. Even small defects can affect lid closure and tear drainage. Reconstruction must restore both the anterior (skin/muscle) and posterior (tarsal plate/conjunctiva) layers.
Common Techniques:
Cheek
The cheek's large surface area and relative skin laxity allow for various flap options. However, proximity to the facial nerve, eye, nose, and mouth requires careful planning to avoid distortion of adjacent structures.
Common Techniques:
Forehead & Scalp
The forehead has limited skin laxity, making reconstruction challenging for larger defects. Hair-bearing areas require special consideration to maintain natural hairline and minimize visible scarring.
Common Techniques:
Ears
Ear reconstruction after skin cancer removal must address the complex three-dimensional anatomy of the ear. Cartilage framework may need to be rebuilt to maintain ear shape and projection.
Common Techniques:
Treatment Options
Dr. Chaiyasate selects the optimal reconstruction technique based on the defect's size, location, depth, and the patient's individual needs. The goal is always to achieve the best functional and aesthetic outcome.
Primary (Linear) Closure
The simplest reconstruction method, where the wound edges are brought together and sutured directly. This works best for small, linear defects in areas with sufficient skin laxity. Dr. Chaiyasate carefully plans the closure along natural skin tension lines and facial creases to minimize visible scarring.
Skin Grafts
Skin grafts involve transplanting skin from a donor site to cover the defect. Full-thickness skin grafts (FTSG) provide better color and texture match and are preferred for facial reconstruction. Common donor sites include the preauricular area (in front of the ear), postauricular area (behind the ear), and supraclavicular region (above the collarbone), which provide excellent color match for facial skin.
Split-thickness skin grafts (STSG) are thinner and may be used for larger defects or as a temporary measure. They heal more reliably but may have less ideal color and texture match.
Local Flaps
Local flaps use adjacent tissue to reconstruct the defect, providing the best color and texture match since the tissue comes from the same facial region. This is the most commonly used technique for moderate facial defects. Types include:
Advancement Flaps
Tissue is slid forward to cover the defect. Includes V-Y advancement and A-T closure techniques. Ideal for forehead, cheek, and lip defects.
Rotation Flaps
A semicircular flap is rotated to fill the defect. Excellent for cheek and scalp reconstruction where tissue can be recruited from a wide arc.
Transposition Flaps
Tissue is moved over intervening skin to reach the defect. Includes rhombic (Limberg) flaps, bilobed flaps, and Z-plasty techniques.
Nasolabial Flap
Uses tissue from the nasolabial fold (smile line) to reconstruct nasal ala, upper lip, and lower eyelid defects. Scar hides in the natural crease.
Regional & Interpolated Flaps
For larger or more complex defects, tissue may be borrowed from a nearby — but not immediately adjacent — area. These flaps maintain a blood supply through a pedicle (stalk) that is divided in a second procedure.
Paramedian Forehead Flap
The gold standard for large nasal defects. Forehead skin, supplied by the supratrochlear artery, is rotated down to reconstruct the nose. A 2–3 stage procedure that provides excellent color match and durability.
Abbe (Cross-Lip) Flap
Tissue from one lip is used to reconstruct the other. Particularly useful for philtral and central upper lip defects. The pedicle is divided after 2–3 weeks.
Microvascular Free Tissue Transfer
For the most extensive defects — particularly those involving bone, large areas of soft tissue, or full-thickness loss — microvascular free tissue transfer may be required. This involves transplanting tissue from a distant donor site and reconnecting tiny blood vessels under a microscope.
With over 3,500 microvascular cases and 6 ASRM Best Case and Best Save awards, Dr. Chaiyasate is one of the most experienced microvascular surgeons in the country, capable of handling the most complex reconstructions.
The Facial Subunit Principle
One of the most important concepts in facial reconstruction is the subunit principle. The face is divided into distinct aesthetic regions (subunits) — such as the nasal tip, dorsum, sidewalls, and alar lobules on the nose alone.
When a Mohs defect involves more than 50% of a facial subunit, it is often better to replace the entire subunit rather than just patching the defect. This approach places scars along natural boundaries between subunits, making them far less visible.
Dr. Chaiyasate's fellowship training in craniofacial surgery gives him an intimate understanding of facial subunit anatomy, allowing him to plan reconstructions that respect these natural boundaries and achieve the most natural-looking results.
Nose
Tip, dorsum, columella, sidewalls, alar lobules, soft tissue triangles
Lips
Philtrum, lateral upper lip, lower lip, vermillion, commissures
Cheek
Medial, buccal, lateral, zygomatic
Eyelids
Upper lid, lower lid, medial canthus, lateral canthus
Forehead
Central, lateral, temple, brow
Ears
Helix, antihelix, concha, tragus, lobule
What to Expect
Understanding the reconstruction process helps patients feel prepared and confident about their care.
Timing of Reconstruction
In many cases, reconstruction can be performed the same day as Mohs surgery or within a few days. Dr. Chaiyasate works closely with Mohs surgeons to coordinate care and ensure the best timing for each patient.
For complex cases requiring staged procedures (such as a paramedian forehead flap), the initial reconstruction begins promptly, with subsequent stages planned at appropriate intervals.
Anesthesia Options
Depending on the complexity of the reconstruction, procedures may be performed under:
- Local anesthesia — for simpler closures and small flaps
- Local anesthesia with sedation — for moderate reconstructions
- General anesthesia — for complex or lengthy procedures
Recovery & Healing
Recovery varies based on the reconstruction technique used. Most patients can expect:
- Suture removal in 5–14 days depending on location
- Swelling and bruising that peaks at 48–72 hours
- Return to normal activities within 1–3 weeks
- Scars continue to mature and fade for 6–12 months
- Sun protection is essential during healing
Revision Surgery
In some cases, a secondary revision procedure may be recommended 3–6 months after the initial reconstruction to further refine the result. This may include:
- Scar revision to improve appearance
- Flap thinning or defatting for better contour
- Pedicle division for staged flaps
- Minor adjustments for symmetry
Why Choose Dr. Chaiyasate for Mohs Reconstruction?
Dual Fellowship Training
Fellowship-trained in both craniofacial surgery (Washington University) and reconstructive microsurgery (Ohio State University), providing expertise across the full spectrum of reconstruction.
3,500+ Microsurgery Cases
One of the most experienced microvascular surgeons in the country, capable of handling even the most complex defects requiring free tissue transfer.
6 ASRM Awards
Recognized by the American Society for Reconstructive Microsurgery with 6 Best Case and Best Save awards for excellence in reconstructive surgery.
Facial Anatomy Expertise
Deep understanding of facial subunit anatomy, aesthetic principles, and functional considerations ensures the best possible outcomes for every patient.
Comprehensive Care
Affiliated with Corewell Health, Trinity Oakland, and Children's Hospital at Troy, ensuring access to state-of-the-art facilities and multidisciplinary teams.
Same-Day Coordination
Works closely with Mohs surgeons to coordinate reconstruction timing, often performing reconstruction the same day as cancer removal for patient convenience.
Schedule a Consultation
Dr. Chaiyasate and his team are here to answer your questions and discuss the best treatment options for you or your child.