The advantages of delayed nasal full-thickness skin grafting after Mohs micrographic surgery

Full-thickness skin grafting following Mohs micrographic surgery (MMS) of the nasal tip and ala provides easy postoperative wound care and avoids functional impairment caused by wound contraction of the nasal ala free margins. Direct comparison of immediate and delayed skin grafting determined which offers greater success and defined factors contributing to success.

To determine if delayed or immediate full-thickness skin grafting results in better graft survival with improved function and appearance, and to identify the recipient bed characteristics, including the size of the wound, the proportion of the wound base having perichondrium, denuded cartilage, and granulation tissue, and graft survival for each technique.

We used a prospective study comparing 200 patients with wounds having a 3-5 cm2 surface area repaired immediately with a full-thickness skin graft (FTSG) to 200 patients with a delayed FTSG. The depth and diameter of the wound of the nasal ala and tip, and characteristics of recipient bed including size (cm2), location, proportion of wound base with perichondrium present, denuded cartilage, granulation tissue, and proportion of graft loss were the main outcomes measured.

Partial graft loss occurred in 11% of those having delayed skin grafts and 30% of those with immediate repair. Delayed grafting was associated with a larger wound surface area (P <.0001), more denuded cartilage (P =.017), greater exposed perichondrium (P <.0001), and less partial graft loss (P <.001). When partial graft loss occurred, the area of loss was smaller with delayed FTSG (P =.036). Contraction of the wound and subsequent nasal valve impairment occurred less often with delayed FTSG (P <.0001). Graft depression was significantly less with delayed FTSG of the ala (P <.0001) and also improved on the nasal tip (P =.47).

This prospective clinical trial of immediate and delayed FTSGs of the nasal tip and ala with denuded cartilage showed improved graft survival in cases where grafting was delayed for 12-14 days. During this period, substantial granulation tissue formed in the wound base. Assessment of the wound base and the presence of granulation tissue are key factors in the success of full-thickness skin grafting.