Delayed Versus Immediate Reconstruction After Mohs Surgery for Skin Cancer

How Waiting Can Lead to Better Outcomes

Mohs micrographic surgery is considered the gold standard treatment for removing certain common skin cancers, like basal cell carcinoma and squamous cell carcinoma. This highly effective technique involves surgically removing cancerous tissue layer by layer, examining each layer under a microscope until only cancer-free tissue remains.

Once the cancer is fully excised, reconstructive surgery is generally performed right away to close the surgical wound. However, in some cases, the reconstructive surgery may be delayed anywhere from several days to weeks after the initial Mohs procedure. 

This article explores the reasons for and benefits of undergoing delayed reconstruction following Mohs surgery for skin cancer.

What Is Delayed Mohs Surgery?

Delayed Mohs surgery refers to cases where the reconstructive surgery to repair the skin after Mohs excision is postponed for a certain period rather than being done the same day. Typically, the reconstructive surgery is delayed for 5 to 20 days after the original Mohs procedure that removed the skin cancer.

There are several potential reasons why a surgeon may recommend waiting to reconstruct the wound site:

• Allow more time for detailed examination of surgical margins: Delaying gives the surgeon time to thoroughly analyze the excised tissue to confirm all cancerous cells have been eliminated before closing the wound.
• Wait for pathology results: Tissue samples may need to be assessed by a pathologist before the surgeon can definitively confirm the cancer is fully gone. Delaying reconstruction allows time for this analysis.
• Improve surgical planning: The surgeon has an opportunity to carefully consider all reconstruction options and decide on the optimal approach based on the final defect size and location.
• Enhance wound healing: Waiting a few days enables the surgical site to begin healing and form granulation tissue, which can provide a better foundation for grafting or other reconstructive techniques.

Learn more about the benefits of delaying Mohs surgery reconstruction and schedule a consultation to discuss your personalized treatment plan.

What Are the Benefits of Delayed Mohs Reconstruction?

Multiple studies have shown that delaying the reconstructive surgery after Mohs excision can lead to reduced complications and improved outcomes compared to immediate reconstruction done the same day.

Some of the benefits associated with postponing the reconstructive procedure include:

Benefit	Description
Lower risk of graft failure	Delaying reconstruction allows time for the wound bed to become revascularized before grafting, improving survival of the skin graft.
Reduced incidence of postoperative bleeding and infections	Waiting for initial healing helps minimize risks like bleeding and infections after reconstructive surgery.
Decreased scarring	Delayed reconstruction may lead to less scarring and better cosmetic results.
Better wound surface for grafting	After a few days, granulation tissue forms in the wound, providing a more ideal grafting surface.
Allows swelling and bruising to subside	Postponing reconstruction gives time for post-op swelling and bruising to resolve, providing the surgeon with better operative visibility.
More accurate assessment of defect	As the surgical site starts healing, the skin defect dimensions become more defined, facilitating optimal repair.
Flexibility in surgical planning	The surgeon can take time to consider all repair options and decide on the best approach based on the unique location and size of each patient’s defect.
Potentially shorter procedures	Patients may require less complex reconstructions since delaying surgery can prevent cancer recurrence at the wound edges.

When Is Delayed Mohs Reconstruction Recommended?

There are no definitive guidelines on the optimal timing for reconstruction after Mohs surgery. It depends on each patient's unique circumstances and considerations like the size and site of the surgical defect. However, research has shown delayed repair may be ideal in certain situations:

For larger defects

Postponing reconstruction for larger skin defects allows more time for surgical planning to ensure the best functional and cosmetic repair.

When the wound location makes flap options challenging

Certain delicate or high-tension areas like around the eyes or lips may benefit from delayed repair.

For patients with multiple skin cancers

Staged surgery with delayed reconstruction for each site allows treatment of all growths for patients with multiple skin cancers.

To reduce graft failure risks

Waiting 5 days or more has been shown to improve skin graft integration for reconstructive flaps and grafts.

To avoid unplanned extensive repairs

Delaying surgery prevents potential cancer recurrence at wound edges, avoiding more complex repairs.

For high-risk wounds

Immunocompromised patients or surgical sites prone to poor healing may warrant waiting to allow surgical margins to stabilize.

For wider excisions

Larger Mohs defects removed over multiple stages are better reconstructed after a delay when the final size is definitive.

Ultimately, the Mohs surgeon will evaluate each patient and defect independently to decide if immediate or delayed reconstruction is most appropriate.

Contact us to schedule a consultation and determine if delayed Mohs surgery reconstruction is the right option for you.

Preparing for Delayed Mohs Surgery

If your doctor recommends postponing reconstructive surgery after your Mohs procedure, here are some tips to prepare for the delayed reconstruction:

1. Follow postoperative wound care instructions provided to support healing of the initial surgical site before the reconstructive surgery. Keep the area clean and watch for signs of infection.
2. Be diligent about taking prescribed antibiotics as directed to prevent infection leading up to the second surgery.
3. Continue avoiding blood thinners like aspirin, NSAIDs, and certain supplements to minimize bleeding risks for the delayed reconstructive procedure.
4. Make sure you have arranged the appropriate amount of time off work or other responsibilities to accommodate the two separate surgeries.
5. Set up transportation for both the initial Mohs surgery day and the second delayed reconstructive surgery. You will need someone to drive you home after both procedures.
6. Ask your surgeon when you need to stop eating and drinking before the delayed reconstructive surgery, as this may differ from instructions for the first Mohs surgery.
7. Voice any questions or concerns you have about the delayed repair process so your surgical team can provide reassurance and education.

Following your doctor’s pre- and postoperative instructions closely can help ensure you heal properly after each stage of surgery. Be diligent about wound care and avoiding infection in preparation for your second reconstructive procedure.

What to Expect After Delayed Mohs Surgery

Undergoing a planned postponed reconstructive surgery after your initial Mohs procedure involves some unique aspects to be aware of:

1	Time for the original Mohs surgical site to heal before the second surgery. This allows the wound to form granulation tissue to help the reconstructive graft, flap or stitches integrate and take.
2	Potential need for interim wound care like changing bandages to facilitate proper healing leading up to the reconstruction surgery.
3	A second round of postoperative wound care and recovery after the reconstructive procedure. This is necessary for protecting the repaired surgical site.
4	Possible temporary cosmetic changes like a concave divot appearance as the Mohs wound heals in preparation for surgical repair.
5	Excellent long-term cosmetic results from the reconstructed skin defect performed after a deliberate delay to allow for optimal surgical planning and wound bed preparation.
6	Reduced risk of surgical complications like graft failure, poor healing, bleeding, and infection thanks to staged procedures.

While being patient through 2 recovery periods and additional time off can require perseverance, allowing a gap between your cancer removal and reconstructive surgery facilitates the best possible aesthetic and functional outcome.

Consult an Experienced Mohs Surgeon About Reconstruction Timing

The decision of whether to pursue immediate or delayed reconstruction following Mohs surgery for skin cancer is a complex one, depending on your unique case. That is why it is crucial to have a thoughtful in-depth discussion with your Mohs surgeon regarding the options and optimal timing for repairing your skin defect after cancer removal.

Here at Dermatology and Skin Health, Dr. Gary Mendese is a fellowship-trained Mohs specialist with extensive experience performing cancer excisions and both immediate and delayed reconstructive procedures. He will carefully evaluate your case and provide expert recommendations tailored to your needs regarding timing of your Mohs reconstruction.

With offices across southern New Hampshire and northern Massachusetts, we offer exceptional surgical care and comprehensive dermatology services. From skin cancer treatments to aesthetic rejuvenation, our patient-first practice strives to optimize the health, wellness and beauty of your skin.

To learn more about Mohs surgery and reconstructive procedures, book a consultation with Dr. Mendese online or call our offices near you. 

Dover - (603) 742-5556

Newington - (603) 742-5556

Peabody - (978) 525-0100

Londonderry - (603) 742-5556

Bedford - (603) 742-5556

Discover individualized treatment to achieve the best possible results from your skin cancer removal and repair.