What Is A Skin Flap On The Forehead After Skin Cancer Removal

If This Tree Could Talk! Every scar tells a story. What's yours? Photo: Getty Images

If yous have a scar, congratulations! Think of it equally a badge of courage and healing. Our expert dermatologists tell how to nurture a new scar to get the best outcome — and, if needed, how to fix an older scar to make information technology expect better.

Almost no i gets through life without a few scars. You can probably trace some milestones with a bout of your own skin: the chicken pox you couldn't end scratching when you were 7, the time you fell off your cycle, that acne that tormented you lot in high school or when you had a C-section along with your bundle of joy.

If you've been diagnosed with pare cancer and are going in for treatment, good for you. That's much ameliorate than if information technology stayed undiagnosed and continued to abound. If it's treated when it'southward small, you may not even take a scar. If yous need surgery to remove information technology, you probably volition cease up with some kind of scar to add to your drove. Yous may or may not be worried about that. Either way, we want to reassure yous that a scar demonstrates the healing power of your own skin. We asked two expert physicians to share their expertise on everything you need to know to be scar-savvy, from wound care to scar repair.

Whatis a scar, exactly?

A scar is your pare's natural style of knitting itself back together after it'south been hurt. Healing is a multipart process, and the science behind it is complex. Dermatologic surgeon Mary-Margaret Kober, Dr., who practices in the Denver area, helps explicate it in simple terms. Wherever in that location'south been an injury, she says, the first thing that happens is that claret cells called platelets gather together and form a clot to cease the bleeding and seal the wound. Your immune system kicks in and creates inflammation, which helps fight infection and commencement the healing. Later, cells chosen fibroblasts make collagen, growth factors and other substances to help mend and rebuild the skin. A few days later, the tissue starts to contract and make a scar. It can accept upwards to a twelvemonth for a scar to fully heal and reveal its final result. Even when healed, scar tissue is never completely like normal skin. "Information technology's not quite every bit potent or as elastic, the color and texture may be different and it doesn't produce pilus, oil or sweat," Dr. Kober says.

Practise skin cancers always demand surgery?

Non ever. The two most mutual types of skin cancer are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the major nonmelanoma peel cancers. Treatment options are based on the size and location of the cancer, and may include topical medications, scraping and burning, freezing, radiation, light-based treatments like lasers and photodynamic therapy, and excision or Mohs surgery.

Excision means the physician surgically removes the tumor with a scalpel, then sends it to a lab for later analysis of the margins. In Mohs surgery, which is recommended for some BCCs and SCCs and requires special preparation, the Mohs surgeon removes the visible tumor and a very minor margin and analyzes the processed tissue in an on-site lab while the patient waits. If whatever cancer cells remain, they are pinpointed and removed. The surgeon repeats this until there is no testify of cancer. This technique has a high cure charge per unit and achieves the smallest possible scar, says Dr. Kober, who has extensive training and feel in Mohs surgery.

In rare cases, a BCC or SCC may become advanced and require boosted treatment with medications.

Melanomas, which are far less mutual than BCCs and SCCs, can exist more unsafe. Surgery is the near common treatment. Some surgeons are using Mohs surgery successfully on certain cases of melanoma, merely this requires additional training. Patients with more advanced melanomas may require additional treatments, such every bit radiation or medications, including immunotherapies and targeted therapies.

"Most patients underestimate the length of their scar before skin cancer surgery. Public education almost this is crucial."

How much do patients worry about scars?

When doctors tell patients they need pare cancer surgery, they hear a wide range of reactions, says Dr. Kober. "I have some patients who say, 'I don't intendance nigh the scar, Doc. I don't have a modeling career. But get the cancer out.' That'due south i extreme." There are as well patients on the other side of the spectrum, she says, who are very concerned virtually the scar and its cosmetic appearance.

Hooman Khorasani, MD, former chief of the Partition of Dermatologic & Cosmetic Surgery at Mount Sinai Medical Eye in New York Urban center, sees the full gamut of reactions in his private practice on the Upper East Side of Manhattan every bit well. That includes glory patients who know an unsightly scar could hurt their career. Dr. Khorasani, who is quadruple lath-certified in dermatology, Mohs surgery, corrective surgery and facial cosmetic surgery, spends virtually fifty percent of his time doing Mohs surgery and says he's careful to reassure patients likewise as manage their expectations. Most cases are BCCs and SCCs. When detected early on, they're almost e'er curable. "I explain to patients that these are very mutual skin cancers and that they're not alone," he says. "We're definitely going to take care of it and get rid of the cancer. That's the most of import thing." He knows the importance of a good corrective outcome, besides. In fact, he's done extensive inquiry on minimal scar wound repair.

What should patients expect well-nigh the size of a pare cancer surgery wound and the resulting scar?

It'south of import to know that the wound that will be created during surgery on a BCC or SCC will be bigger than yous might accept guessed in accelerate, says Dr. Khorasani. For one thing, while your peel cancer may accept looked like a small red spot when diagnosed, that can be just the tip of the iceberg. At that place may exist extensions, or "roots," of the cancer that are not visible from the surface that will be discovered during surgery, requiring the removal of more tissue.

basal cell carcinoma excision and scar

Dr. Kober explains how a circular wound becomes a directly-line scar. "If yous endeavor to bring that circumvolve together, the two ends pucker upward and become raised," she says. To correct for that, the surgeon has to remove those piffling puckers on either stop. So before the wound is airtight, the surgeon shapes the wound and so information technology looks more than like a football game than a baseball (doctors call this shape an "ellipse"). "Information technology does lengthen the scar, but it means that the scar lies flat and will wait its best."

The ratio between the diameter of the circle to the length of the ellipse is one to 3, Dr. Khorasani explains. Therefore, if yous exercise the math, the length of the scar volition exist nigh six times the diameter of the original lesion. "The 10 fellows whom I taught Mohs surgery call this 'The Khorasani i to 6 Scar Rule,'" he says. "They all still employ it to brainwash their patients."

Public teaching about this is crucial, he stresses, every bit a 2020 report in JAMA Dermatology reported that when patients scheduled for Mohs surgery for skin cancer on their face were asked nearly their expectations before their surgery, more than 80 percentage underestimated the length of their resulting scar by about half.

Dr. Kober says that nearly of the time, Mohs surgeons are able to clear the roots of a tumor by removing just i or two layers of tissue. "Merely every one time in a while, both the patient and I are surprised at how far those roots have traveled. That's the do good of Mohs surgery; nosotros can expect at 100 percent of the margin and make certain that the skin cancer is out and won't come back." She always reassures patients that she volition do everything she can to keep the scar as small as possible. "Surgeons also do their best to hide the scar in the normal folds of the skin, or in smile lines," she says. "The vast majority of the fourth dimension it heals well and you barely notice it. Merely if the patient is not completely happy with a scar, there are techniques to improve its appearance."

Because melanoma is more than likely to spread than nonmelanoma pare cancers, surgical guidelines require the doctor to remove a larger safe margin of healthy tissue. Dr. Khorasani says that on average, the wounds from melanoma surgery, and thus the scars, are about twice as large as those from other pare cancers.

What should people know about surgical techniques?

With any surgical process, it's important to wait for a doctor who is well-trained, up on the latest techniques and has performed the procedure many times.

When he was didactics medical students about surgical technique and how to handle the tissue, Dr. Khorasani says, "I would tell residents they must treat the epidermis, the top layer of the skin, as if it is the most delicate blossom. I would teach them to use a hook to grab the skin rather than a forceps, which can pinch the skin and traumatize that frail flower of epidermis. I would also tell them that to give the scar an even finish, they have to brand sure every edge they're suturing together is as even every bit a door on a spaceship."

Larger pare cancers may need reconstruction using what is called a flap from neighboring skin or sometimes a skin graft from another area of the torso.

Are some people just naturally good healers?

Having a expert blood supply to the area of the surgery is the number ane issue in healing, says Dr. Khorasani. In full general, when yous're younger, you have a greater blood supply, then younger people tend to heal well. Notwithstanding, he says he has seen many elderly patients who naturally heal well, also. "I call back that just means they accept good regenerative mechanism. I always ask them what their secret is, especially those over xc who are super sharp mentally. Some people are simply genetically blessed and heal actually well — similar Wolverine!"

What habits can nosotros larn from good healers?

A salubrious diet is very of import, says Dr. Khorasani. "And stress hormones can inhibit the wound-healing process, so finding ways to reduce stress, such as meditation, also helps healing."

Smoking slows down the healing process, and it makes the scars worse, Dr. Kober says. "So delight don't smoke."

Certain supplements, such as garlic, gingko, vitamin C, fish oil and vitamin E, or medications that thin the blood, such as aspirin, Coumadin or Plavix, can make you more predisposed to haemorrhage complications that can affect scar healing, says Dr. Kober. It's important to tell your md in accelerate if you're taking any of those and get advice on whether y'all should terminate them before or after surgery.

Scar Repair. Left: Dr. Khorasani used a flap of pare from the cheek to cover a wound from Mohs surgery on the nose. Right: The scar afterwards dermabrasion and laser resurfacing.

After surgery, what tin patients do for a ameliorate scar outcome?

Follow your md's instructions for post-op care. Dr. Kober says that after a surgery, she applies ointment to keep the wound moist and a pressure dressing that stays on for 48 hours. "This helps to immobilize the wound and facilitate the healing process. The pressure also helps to forestall any oozing that might occur after surgery."

Since Dr. Khorasani now mostly uses internal sutures and rarely uses external sutures, he prefers a special medical glue combined with Steri-Strips (butterfly bandages) for added support. "This makes a kind of external patch that helps protect the wound and simplifies wound intendance," he says.

Limit activity and then you don't stretch the wound site. For almost two weeks after surgery, Dr. Khorasani says, the wound has only a fraction of its original strength, so any motility can stretch the scar and affect the fashion it will heal. This tin be catchy if your wound is on the back of your paw, for instance, or on your lower leg. But if you really desire a good outcome, Dr. Khorasani advises, have information technology easy.

Keep the wound moist with ointment. "Dry wounds heal slower and tend to scar more than," says Dr. Kober. After 48 hours, she recommends that patients remove the dressing, wash the wound gently with plain soap and water and then keep it covered with ointment and a cast each day until they return to see the doctor, normally in about a week. "We prefer they use a neutral ointment and non an antibiotic ointment considering many people develop contact allergies to those," she explains.

Protect your scar from the sun. New scars tend to darken and discolor when exposed to ultraviolet (UV) low-cal. While you should exist protecting your skin from the sun anyway to help forestall future pare cancers, both doctors say that for improve scars it is crucial to use sunscreen religiously and keep the expanse covered if possible. "I advise it for at least the commencement six months to a twelvemonth later on surgery," says Dr. Kober.

"Surgeons exercise their best to hibernate the scar in the normal folds of the skin, or in grin lines."

Consider trying a silicone patch or gel. Silicone has been shown to reduce the thickness of some scars, says Dr. Khorasani. After the stitches have been removed, patients can apply an over-the-counter silicone canvas as directed. In that location's also a silicone gel with sunscreen in it that dries to class a kind of waterproof shield. Both doctors often recommend silicone for patients who want a minimal scar. "Try the silicone sheets for two months or longer," says Dr. Kober. "Several silicone gel products go on clear, allowing information technology to be hidden under makeup. Patients often utilize these products for three to six months."

What are the signs of trouble in a healing scar?

Haemorrhage: Dr. Kober tells patients that if they notice a bit of blood oozing after surgery, "hold firm force per unit area for 20 minutes on the area — without peeking. If you peek, you release the pressure and have to start the clock over again," she says. "Most of the time that will solve the problem." All the same, for patients who are on blood thinners and don't clot too, that may non stop the oozing. "If that's the case," Dr. Kober says, "I tell patients to give us a telephone call. Nosotros can talk it through, get a sense of how much bleeding there is and, if needed, follow up in the office."

Infection: Typically, infections are very cerise, hot and tender, says Dr. Kober. "If it's a prominent infection, y'all might run into a little yellowy-greenish substance. Just sometimes it's more subtle." In that location'southward always a lilliputian redness associated with the healing procedure. "Simply if redness is growing around the wound, or if you have what I describe as pain out of proportion to what you would expect for the normal healing process, call your doctor," says Dr. Kober. "Most of the fourth dimension information technology'due south nothing, but it's always good to put your heed at ease."

"It'southward of import for patients to know that infections rarely happen earlier twenty-four hour period v afterwards surgery," says Dr. Khorasani. "Redness and oozing before 24-hour interval five are often related to allergic reactions."

If someone doesn't like a scar, what can be done to improve information technology?

While many surgeons used to suggest waiting 6 months or longer to let a scar heal earlier having treatment to improve the way it looks, Dr. Khorasani says recent studies have shown that early on scar treatment tin can be more benign. "It is now becoming more widely accepted that early scars are more receptive to alter," he says. He recommends starting scar treatments half-dozen weeks after surgery for cosmetically sensitive areas of the face, for example. Scars that are older can also benefit from some treatments.

Redness: "Redness means blood vessels formed to heal the wound, and they're all the same engorged with claret," says Dr. Khorasani. "We have certain lasers we tin can treat those vessels with to reduce the redness of a scar."

Irregularity: "The only thing that really takes care of surface irregularity in a scar is dermabrasion, which is kind of similar polishing your skin to even it out," says Dr. Khorasani. "Don't worry; it doesn't injure."

Atrophic scars: Some scars are atrophic, which means they are sunken or pitted. "If the depression is as well deep, the best option is to practise a scar revision and excise the scar. For more shallow depressions, nosotros might also inject fat or a semipermanent filler, such as Bellafill, to help even out atrophic scars," says Dr. Khorasani.

Texture: The texture of scar tissue is not like the texture of normal skin. "This is because in scar tissue, the collagen fibers are oriented parallel to each other as opposed to normal skin, where collagen fibers are woven together in a basket-weave blueprint," he explains. In club to reverse this, Dr. Khorasani, who completed a yearlong fellowship on this topic, can employ a resurfacing laser, like a CO_ii laser, to brand microscopic wounds. "As these tiny wounds heal, they restore the collagen compages back to that normal basket-weave pattern."

Dr. Kober adds, "Particularly on the olfactory organ where sebaceous (oil) glands are more prominent, laser resurfacing is a great option. The laser smooths the scar and blends it into the surrounding peel, making it less visible."

Scars and skin of color: Light amplification by stimulated emission of radiation resurfacing with CO_two is non an option for darker peel tones because of the risk of loss of pigmentation, or peel color. Dr. Khorasani says another type of laser, using what is called Pico applied science, may exist helpful for treatment of scars in skin of colour. An effective alternative to lasers, he says, is to use microneedling combined with platelet rich plasma, or PRP. This technique uses microscopic needles to create zones of micro injury within the scar. The growth factors from the platelets help abound new healthy collagen. He as well uses microneedling devices that emit radiofrequency heat to stimulate collagen production.

Hypertrophic scars: Sure people may be decumbent to hypertrophic scars, which are thick and raised, or keloids, where the scar tissue extends outside of the original injury and grows and becomes hard. "We inject steroids to flatten these scars," says Dr. Kober. "It ofttimes takes more than one treatment." Doctors have as well started to add the topical treatment 5-fluourouracil (aka 5-FU) to the steroid mix in gild to avoid steroid-induced side effects and thinning of the surrounding tissue, adds Dr. Khorasani.

dermabrasion and CO2 laser combination to treat scar

Scar repair before and afterwards: Dr. Khorasani used a combination of dermabrasion and partial ablative CO2 laser to better the appearance of this scar above the lip.

Combination: Dr. Khorasani says he tries to look at the whole area surrounding a scar earlier determining the best handling. "We routinely do a combination treatment," he says. "For example, if nosotros're going to exist lasering a scar on ane cheek, why non consider treating the acne scarring on the other cheek, and make it all even?"

"At that place is as well a synergistic do good of combining different scar modalities," he says. "For instance, we routinely combine dermabrasion with CO₂ light amplification by stimulated emission of radiation resurfacing." Dermabrasion helps with surface irregularities and removes the acme layer of peel to allow the CO₂ laser to penetrate a scrap deeper into the dermis. And since dermabrasion can crusade some bleeding, combining it with CO₂ laser handling helps stop the haemorrhage.

On the horizon: Dr. Khorasani says that using substances that stimulate collagen product in scars that have resisted other treatments is promising. These include PDO threading (sutures that dissolve and turn into collagen) and injectables similar Sculptra.

He also led a report published in the Periodical of the American Academy of Dermatology in 2021, which treated brow scars with injections of botulinum toxin (Botox) versus placebo after Mohs surgery. The patients who received Botox injections into the forehead muscles after the repair of the wound on the forehead had a better overall scar outcome.

Photos courtesy of Hooman Khorasani, MD.

*An before version of this article was featured in The Peel Cancer Foundation Journal 2017.