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Use of Local Skin Flaps May Lead to Reduced Risk of Scarring Following Mohs Surgery


Three methods of cosmetic surgery—local skin flap, full thickness skin graft, and secondary intention—were evaluated for their scarring risk following Mohs microscopic surgery on the distal third of the nose.

Lowest scores on the Vancouver Scar Scale (VSS), an objective scar measurement, were seen when the local skin flap method of cosmetic surgery was used immediately following Mohs microscopic surgery (MMS) for basal cell carcinoma (BCC) on the distal third of the nose, according to new study results published in The Journal of Clinical and Aesthetic Dermatology.

The method was compared against full thickness skin graft (FTSG) and secondary intention (SI; leaving the area to heal on its own), both used in combination with MMS. This retrospective chart review of patients’ electronic medical record covered 66 adults (18 years and older) who underwent MMS for BCC at Bay Dermatology and Cosmetic Surgery in Largo, Florida, between June 2019 and June 2020.

The original cohort comprised 77 patients, but 11 were lost to follow-up. Following 1-week and 6-month evaluations post MSS, patients were stratified by VSS score into 3 groups, with lower scores indicating optimal scar healing, satisfactory surgical outcomes, and less scarring: 0 to 3, low: 4 to 6, medium; and 7 to 13, high. The VSS scale incorporated measures of skin pigmentation, vascularity, pliability, and height.

“Repair of nasal structures is particularly challenging due to the unique anatomy of the area, varying degrees of convexity and concavity in close proximity, and the relative paucity of redundant skin to utilize,” the authors wrote. “The goal of this study is to identify if there is a measurable difference in surgical outcomes, as determined by the VSS, between closures using a local skin flap, FTSG, or SI. There is no algorithmic process to assist in the decision.”

Most of the patients in their analysis had low VSS (77.61%), followed by medium (16.42%) and high (4.48%). Further, a majority of the patients in the low-VSS group had local flap surgery (76.92%); just 3 healed via SI.

Among the patients who had medium VSS, most had undergone FTSG (81.82%). No patients in the medium group underwent SI, and the remaining 2 (18.15%) had local flap reconstruction.

All patients in the high VSS group underwent FTSG.

Clinical images of defects and postoperative scars at the 1-week and 6-month evaluations were used to classify the patients into these groups. There were 38 male and 39 female patients, 95% were White and 5% were Hispanic, and the mean (SD) age was 70 (10.7) years.

The BCC histologic subtypes identified in this analysis were nodular (48.05%), infiltrative (23.38%), mixed subtype (16.88%), and superficial (11.69%). Local skin flap was the most common overall cosmetic surgery following MMS, at 62.34%, and SI was the least common, at 3.90%. These malignancies were most frequently found on the nasal ala (51.5%), followed by the supratip (25.8%) and the infratip (22.7%). The most common depth of final defect in each group was the dermis (42.31%, low; 54.55%, medium; 66.67%, high).

Severe adverse events, including excessive postoperative bleeding and surgical site infection, were not reported. Scar revisions were not required in any cases.

The investigators used bivariate analysis to determination associations between post-MMS surgery and VSS, and they found that repair type had a significant association with 6-month VSS (P < .0001). Age, sex, ethnicity, BCC location, histologic subtype, depth of final defect, total stages needed to clear tumor, preoperative size, defect size prior to repair, and sebaceous skin quality were not associated with this outcome.

They stressed that the clinical importance of their findings are that they “support current research indicating local skin flaps provide better surgical and cosmetic outcomes compared with FTSG. The key benefit of a local flap is the ability to more effectively match color, texture and thickness, commonly using tissue reservoir from the same cosmetic subunit to close the surgical defect.”

Still, they encourage further study and more data to confirm their findings. This should include evaluations of how much vascularity, pigmentation, pliability, and height contribute to scar formation, as well as possible influences from body mass index, smoking history, diabetes, and cardiovascular disease on surgeon’s choice of optimal closure.


Fronek LF, Dorton D. Surgical outcomes following Mohs microscopic surgery for basal cell carcinoma on the distal third of the nose. J Clin Aesthet Dermatol. 2022;15(6):32-36.

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