Skin cancer reconstruction on the face

Australia has among the highest rates of skin cancer in the world. On the face, that fact becomes a reconstructive problem as well as an oncological one. A basal-cell carcinoma on the alar rim, a squamous-cell carcinoma on the ear, or a melanoma on the cheek is not only a tumour to be removed. It is a hole that will sit next to an eyelid, a nostril, a lip or a hairline, where a few millimetres of pull can change how a person blinks, breathes or is read in a room. The cancer operation comes first. The reconstruction is how the hole is made liveable. Those are sequential duties, not a menu.

This is a science editor’s explainer, not a treatment recommendation. Check practitioners on the Ahpra register. Neighbouring essays live in the reconstructive hub, including reconstructive plastic surgery beyond cosmetics and scar revision, realistic expectations.

BCC, SCC and melanoma, in general terms

Basal-cell carcinoma (BCC) is the most common. It rarely spreads to distant organs. It can, if left, burrow through the tissues of the nose, eyelid or ear in a way that makes a later reconstruction much larger than an earlier one would have been. Some BCCs are well defined; some are morphoeic or infiltrative and extend further than the surface suggests. That is why a “small pearly bump” is not sized by the patient’s photograph.

Squamous-cell carcinoma (SCC) is the next most common on sun-damaged Australian skin. It can spread to lymph nodes, particularly when it is large, poorly differentiated, on the ear or lip, or arising in a suppressed immune system — transplant recipients are a special-risk group. An SCC is not a BCC with a different name. The margin, the follow-up and the threshold to involve a head-and-neck or melanoma-and-surgical-oncology meeting change.

Melanoma is less common than the keratinocyte cancers and more dangerous at equivalent depth. Management is guided by published Australian and international pathways: excision with a margin that depends on the measured thickness, and, where indicated, discussion of sentinel-node biopsy and systemic treatment. Reconstruction of a melanoma defect has to wait on that oncological plan. A flap that would be elegant for a BCC can be the wrong first move if it rearranges lymphatics or delays a wider excision.

This journal will not turn those sentences into a self-diagnosis chart. A changing lesion on the face belongs with a GP or a dermatologist, not with a comparison of your own photos. Pathology is the name of the disease, not the look of the crust.

Margins are a bargain between tumour and face

A surgical margin is the rim of apparently normal tissue taken with the tumour. Guidelines quote millimetres that vary by tumour type, subtype and site. On the back, those millimetres are cheap. On the eyelid margin or the nostril sill, they are expensive. The bargain is not “take less so it looks better”. The bargain is: take enough that the pathologist can say the examined edge is clear, then reconstruct what that requires. Incomplete excision is how people return for a second, larger hole.

Frozen-section checking in a main theatre, and Mohs micrographic surgery in a dermatology setting, are two ways of reading the edge before the reconstruction is committed. They are not available for every tumour or in every town. When they are not, the team may reconstruct immediately on clinical grounds, or dress the wound and wait for paraffin pathology before the second stage. Waiting with a dressed defect is unglamorous and sometimes the more precise medicine. Building a flap over an incomplete excision is how tumours are buried.

Margins are also not magic. A report of “clear” means no tumour was seen at the edges that were examined, in the planes that were sampled. Some tumours skip. Some recurrences appear years later. Follow-up — and a low threshold to re-biopsy a scar that changes — is part of the operation’s life, not an optional extra.

Flaps and grafts are tools, not trophies

Once the hole exists, there are a few honest ways to close it. Direct closure, in a line that follows a wrinkle or a junction of facial units, is the first choice when it will not pull an eyelid down, a nostril across or a lip into a whistle. When it will, the next tools are local flaps and skin grafts.

A local flap borrows neighbouring skin, still attached by a blood supply, and rotates, advances or transposes it into the defect. The names — bilobed, forehead, nasolabial, V-to-Y — matter to surgeons and should be translated for patients: where the extra scar will sit, what will look swollen for weeks, and which expression might feel tight. A flap on the nose can leave a padded, bulky look that later needs a tidy. A flap near the eye can, if misjudged, threaten the lid margin. Blood supply can fail; a flap can partly die. That is a named risk, not a rarity so small it can be skipped in consent.

A skin graft is a piece of skin detached from a donor site — often the neck, the area in front of the ear, or, for a full-thickness graft, another facial leftover — and sewn onto the defect. It survives by drinking from the wound bed. It will not take on bare cartilage without help, which is why nasal and ear reconstructions sometimes need more than a stamp of skin. Grafts can be pale, depressed or shiny. They can fail if the bed is mobile or if a haematoma lifts them. They avoid rearranging the neighbourhood, which is sometimes the point.

Secondary intention — letting a carefully chosen wound granulate — still has a place, particularly at the inner canthus or on concave surfaces, in people who can manage dressings. It is not neglect. It is a decision.

Complex reconstructions — more than one flap, cartilage grafts for a nostril, a staged forehead flap — are how larger defects of the nose and eyelid are rebuilt. They take more than one operation. Anyone offering a single-visit restoration of a major nasal defect is describing a hope, not a standard pathway.

Mohs collaboration is a relay, not a rivalry

Mohs micrographic surgery maps the tumour in horizontal layers and reads the entire margin before the patient leaves the dermatology chair. For certain BCCs and SCCs in high-risk facial sites, Australian dermatological practice treats it as a precise way to spare tissue while still clearing the edge. The hole that remains may then be reconstructed by the same clinician, or by a plastic surgeon later the same day or later in the week.

That relay needs planning. The reconstructive surgeon wants to know the true defect, not the pre-Mohs estimate, because Mohs holes are often larger than the surface lesion. The patient needs to know whether they will go home with a dressing and a second appointment, and who is responsible after hours if a flap or graft misbehaves. None of this is a turf war when it is done well. It is two specialist registrations working on two halves of one problem.

Not every facial skin cancer needs Mohs. Many are appropriately treated by a GP with surgical interest, a general surgeon, a plastic surgeon or a dermatologist using standard excision and pathology. Rural and regional Australia cannot pretend that every town has a Mohs service. Tele-dermatology and visiting specialists close some of that gap; they do not close all of it. A delayed reconstruction after a dressed excision is sometimes how a regional patient gets both an adequate margin and a considered closure.

Sun protection is aftercare and prevention

A reconstruction on the face is a reconstruction on an organ that will be sunned again. Grafts and fresh scars burn easily. Pigment can darken or bleach. The next BCC is statistically not a surprise in an Australian face that has already grown one. Broad-brim hats, clothing, shade, and a sunscreen that the person will actually wear are the dull, durable half of the operation. This is not a product endorsement. It is why follow-up clinics ask about the cricket, the boat and the farm.

Smoking impairs flap and graft blood supply. People who can stop around the time of surgery give those tissues a better chance. Immunosuppression, including transplant medicines, changes both the cancer risk and the healing. Those facts belong in the history, not in a footnote.

Scar maturation on the face takes months. Redness is not a verdict at week three. Massage, silicone and time are the usual first measures; steroid injections and revision are later, selective tools, covered in our scar-revision essay. This journal does not publish before-and-after photographs and will not describe a “typical” nose. Variation is the medicine. A good reconstruction is one that protects a function — blinking, breathing, oral competence — and that the person can live with in the mirror. It is not a return to an unmarked face.

How to use the appointments

Ask what the biopsy showed, and what margin the guidelines suggest for that subtype at that site. Ask whether the reconstruction will happen the same day or after pathology. Ask whether Mohs is being considered, and if not, why not — distance and tumour type are legitimate answers. Ask where a flap’s extra scar will sit, or where a graft will be taken from. Ask how to protect a graft in the first week, and which symptoms — bleeding, a dusky flap, a fever, a sudden swelling — warrant same-day review.

If the lesion is a melanoma, ask how the reconstruction sits beside the wider-excision and node discussion. Do not let a desire for a small scar drive a smaller cancer operation.

Skin-cancer reconstruction on the face is ordinary Australian hospital and rooms practice, and it is still easy to underestimate. The tumour sets the hole. The hole sets the tool. Sun sets the next appointment. Treat it as reconstructive medicine, not as cosmetic advertising, and let function lead the design.