Repair (reconstruction) after procedures to remove cancer or to fix wounds from an external cause is done with many techniques since open wounds come in many forms. Wounds can be accidental from a sudden trauma, slowly degenerative from mild repetitive trauma over time, from chronic pressure on an area not relieved by movement and thus deprived of oxygen, surgically induced by efforts to rid someone of a disease such as cancer or an abscess, infectious or from tissues that die from infection, failure of migrating tissues in the fetus in the uterus to migrate to their pre-programmed location resulting in birth defects, etc. The goal is to restore the tissues to their former function and appearance as closely as possible, knowing that perfection is a difficult goal to achieve. Patients may have unrealistic expectations as to result.

In order to achieve repairs, several things are needed. Any dead or dying tissue needs to be removed completely to avoid infection and worsening of the situation. The patient must have adequate health with respect to oxygen in the tissues, adequate protein and iron, adequate supplements like vitamins, especially zinc and vitamin C, and control of problems with various disease processes known as comorbidities.

Any state of health short of perfect will frequently yield an imperfect or even worse result. Examples of chronically compromised health states are in diabetics with poor wound healing, those with a smoking habit, obesity, those unable to comply fully with physician recommendations, oral cortisone use, etc.

In an attempt to close defects in skin, muscle and other tissues, the preferred method is to use identical tissue which is close nearby, as seen in direct primary (side-to-side) closure with stitches or with flaps of nearby tissue that still maintain their blood supply by remaining partially attached to the patient. This is called “replacing like with like.”

Some very superficial wounds can simply be allowed to heal by secondary intention, that is, the tissues deeper down will produce blood vessels that will then move up and repopulate the area. Then the surrounding skin will migrate directly across that healing platform which supports those tissues (skin or a skin graft) with oxygen.

Sometimes, vacuum assisted sterile foam helps in that scenario. The vacuum pulls out fluids, bacteria and fungi, and induces the more rapid migration of new blood vessels into overlying skin or skin grafts. This phenomenon reduces the potential for infection and increases the potential for skin graft survival.

Absent this possibility, other tissues from further out on another part of the body are certainly desirable. These can take the form of skin grafts of a split- or full-thickness nature, with or without additional tissues including cartilage and/or fascia and/or muscle and/or nerves and/or vessels and/or other specialized structures, either attached to its original blood supply as in a pedicled flap (visualize a long reaching construction crane) or freed up entirely and moved to a blood supply near the wound on the same patient as in a free tissue transfer.

Use of high pressure oxygen chambers for brief periods (hyperbaric oxygen) similar to what divers use when coming up from the ocean floor aids in wound healing. This puts maximum oxygen onto the surface of the red blood cells and saturates the liquid plasma in which the blood cells float. Wounds heal much more effectively in this way.

In other situations, as a temporary or permanent measure, tissue can be taken from other humans and/or other primates. Now, with improved methods of softening the body’s immunologic attack on other humans’ tissues, full transplantation of major organs such as kidneys are routinely transferred from living or deceased donors. Even more recently, transplantation of multi-tissue organs from a recently deceased person, such as a face, an arm or a hand, is becoming more common.

We Maximize Keeping Normal Skin Undisturbed During Mohs Surgery

Because skin cancer cells do not stick well together, they can be gently scraped after an equally gentle numbing process is used. The removal of the first layer of skin is very thin and allows preparation of a pathology slide for the surgeon to review in search of remaining cells. Only if more cells are seen under the microscope is another thin layer removed. Thus, tissue is not unnecessarily removed.

Skin cancer cells do not stick well together. This is because the connections between the cells, called desmosomes, are bonded together weakly, unlike regular skin, in which the cells are bonded together strongly. The human experience is one of having a shrink wrap protection for our body. This prevents leakage of protein-rich fluids and salts and prevention of the entry of bacteria, all of which maintain our health.

The process of removing the cancer starts after a typically well-tolerated numbing process with very gentle scraping with a half dull, tiny, slotted-spoon-shaped device called a curette. What is first produced is a small amount of a mush which represents the cancer cells. This mush is continuously swept aside until a resistant layer of skin is seen and felt.

What remains is mostly normal skin, which is where the process starts for the exploratory removal of one or more thin layers in less than three minutes for each layer. The removal of the first layer of skin (and possibly any remnants of tumor) is followed by preparation by a specialized tissue technician of a glass slide that is then studied under the microscope by the surgeon.

This removal is akin to an archaeologist placing strings for orientation over a pottery burial site and then slowly thinning down the soil in the search for more pottery. The strings are ways of marking zones on the ground, similar to Mohs surgeons making maps on paper and labeling them in a clock face or grid pattern. Once there’s no more pottery, then the process stops and the site is declared to be cleared.

This is similar to what Mohs surgeons do, until they find no more cancer under the microscope. Thus only the tiniest amount of skin is removed but with a high level of assurance that the cancer is gone. In order to qualify to be labeled as a Mohs surgery, the doctor reading the slide must also be the same doctor doing the tumor removal. Otherwise, the process is not qualified to be called Mohs surgery and cannot be represented to the patient or billed as such.

All this time, an hour or so, the patient who is still numb (for about three hours or so), waits nearby and has a snack and a drink and reads a book or chats in our reception area with another patient undergoing the same process.