The Bottom Line

A local flap repair uses a section of skin adjacent to a surgical wound to fill in the defect. Unlike a skin graft (which transplants skin from a distant site), local flaps keep their original blood supply intact and blend seamlessly with surrounding skin in color and texture. Local flaps are the preferred reconstruction option after Mohs surgery on the face and other cosmetically important areas. The repair is done the same day as the cancer surgery, and with careful technique the resulting scar is often well-hidden in natural skin lines or facial expression folds.

What Is a Local Flap?

A local flap is a rearrangement of the skin and underlying tissue immediately adjacent to a wound. The surgeon lifts or rotates a section of nearby skin while keeping it attached at one end (the pedicle), which preserves the blood vessels supplying it. This attached base ensures the flap survives without needing to grow a new blood supply from the wound bed — unlike a skin graft, which must revascularize from scratch.

Because the flap tissue comes from the area immediately around the wound, it matches the local skin in color, thickness, and texture better than any graft harvested from a distant site. This is especially valuable on the face, where color mismatches are most visible.

Why Is a Local Flap Chosen Instead of Simple Closure or a Graft?

Your surgeon chooses the reconstruction technique based on the size and location of the wound, the availability of adjacent skin, the need to avoid distorting nearby structures (such as the eyelid, nostril, or lip), and the expected cosmetic outcome:

  • Simple closure: Best for small defects with sufficient lax adjacent skin. The wound edges are pulled together and sutured directly. Quick and produces a thin linear scar.
  • Local flap: Used when the wound is too large for simple closure without distorting nearby structures, or when hiding the scar in a natural fold or hairline produces a better cosmetic result.
  • Skin graft: Used when no sufficient local tissue is available, or when the wound needs to be visible for recurrence surveillance.
  • Second-intention (open) healing: Some locations — like the inner corner of the eye, the temple, and the concavities of the ear — actually heal with excellent cosmetic results when left open, avoiding any reconstruction at all.

Types of Local Flaps Used After Mohs Surgery

There are many local flap designs, and your surgeon will choose the one best suited to your wound’s geometry, location, and the available skin. Some common types include:

  • Advancement flap: A rectangle or triangle of skin next to the wound is stretched (advanced) directly into the defect. The simplest type of flap.
  • Rotation flap: A curved segment of skin is pivoted around a central point to fill a triangular defect. Common on the scalp and cheek.
  • Transposition flap: A skin segment is moved laterally across a bridge of intact skin to reach the defect. Examples include the rhombic flap and the Z-plasty.
  • Island pedicle flap: A small section of skin is freed from its surroundings on all sides but one, keeping only the deep pedicle (blood supply) intact, and tunneled or moved to the defect.
  • Interpolation flap: A flap is moved over or under intact skin to reach the defect, requiring a second procedure to divide the bridge after the flap heals. Used for larger nose and lip defects (paramedian forehead flap, nasolabial flap).

What Happens During the Repair?

Local flap repair is performed the same day as Mohs surgery, once all cancer margins are confirmed clear. It is done under local anesthesia in the same outpatient setting:

  • Design: The surgeon marks the flap geometry carefully, taking into account the natural skin tension lines and facial landmarks.
  • Additional anesthesia: More local anesthetic is injected into the donor site where the flap will come from.
  • Incisions and undermining: The surgeon makes incisions around the planned flap and lifts the skin from the underlying fat layer, freeing it to move while preserving blood vessels.
  • Transfer: The flap is moved into position over the defect.
  • Closure: The flap is sutured into place and the donor site (where the flap came from) is also closed, creating a new scar in a less visible location.
  • Duration: Flap repair adds 30–90 minutes to the procedure, depending on the flap type and wound size.

Recovery After Local Flap Repair

  • Swelling: Expect significant swelling, especially around the eyes or nose, for 1–2 weeks. Cold compresses (not directly on the wound) can help.
  • Bruising: Common, especially on the face. It typically resolves in 2–3 weeks.
  • Wound care: Daily cleaning with mild soap and water, followed by petroleum jelly and a fresh bandage, is standard until the wound is fully closed.
  • Suture removal: Face sutures are typically removed at 5–7 days; elsewhere at 7–14 days.
  • Activity: Avoid bending over, heavy lifting, or strenuous exercise for 2–4 weeks to reduce swelling and protect the repair.
  • Eating: If the repair is near the mouth, soft foods for the first few days may be more comfortable.
  • Sun protection: All scars should be protected from UV exposure for 12 months to prevent darkening.

What Will the Scar Look Like?

Because local flap repairs involve multiple incision lines (the main closure plus the donor site), the scar pattern is more complex than a simple linear scar. However, skilled surgeons design flaps so that:

  • Incision lines fall along natural skin creases, expression lines, and hairline borders where they are least visible
  • The color and texture of the repaired area blends naturally with surrounding skin
  • Any visible scar can be refined later with laser treatment or scar revision if needed

Initial appearance is often surprisingly good — and continues to improve over 12–18 months as the scar matures and swelling fully resolves.

When to See a Dermatologist

  • You have been told a local flap will be needed after your Mohs surgery and want to understand what is involved
  • Your wound after Mohs surgery is larger than expected and simple closure is not possible
  • You notice the flap looks pale, cold, or dark in the days after surgery (possible vascular compromise — contact your surgeon promptly)
  • Your wound shows signs of infection (increasing redness, warmth, swelling, discharge, or fever)
  • You are unhappy with your scar appearance at 6–12 months and want to discuss laser or scar revision options

Frequently Asked Questions

Does a local flap repair hurt more than simple closure?

A flap repair involves a larger area of local anesthesia and more tissue movement, so there may be slightly more soreness for 2–3 days after surgery. Most patients manage well with acetaminophen. The pain level is still well within what can be managed with over-the-counter medications. Because the entire procedure is done under local anesthesia, there is no general anesthesia recovery involved.

Will I need a second surgery?

Most local flap designs are completed in a single session. However, interpolation flaps (like the paramedian forehead flap used for large nose reconstruction) are staged procedures — a second visit is required 3–4 weeks later to divide the bridging tissue once the flap has established its blood supply at the new location. Your surgeon will explain whether your repair is single-stage or multi-stage before you commit to the procedure.

What if I don’t like the cosmetic result?

Scars continue to improve for up to 18 months. Many features that look concerning early — such as pincushioning (a raised, pillow-like appearance) or redness — resolve on their own over time as swelling subsides and collagen remodels. If you are still unhappy after 12–18 months, laser treatments, dermabrasion, or a formal scar revision can often make significant further improvements. Schedule a follow-up with your surgeon to discuss options.

How do I know if my flap is healing properly?

A healthy flap should look pink and slightly firm in the first few days, not white or dark. After 1–2 weeks, the redness begins to settle and the flap softens. Some firmness and swelling underneath the flap is normal for several weeks. Contact your surgical team promptly if any portion of the flap looks white or grayish (possible ischemia), dark blue or black (possible necrosis), or if there is unusual warmth and pus (infection).

References

  1. Ratner D. Skin flaps. In: Skin Surgery: A Practical Guide. 2019.
  2. Rohrer TE, et al. Flap design for skin cancer reconstruction. Dermatol Clin. 2001;19(1):139-157.
  3. Zitelli JA. Wound healing by secondary intention: a cosmetic appraisal. J Am Acad Dermatol. 1983;9(3):407-415.
  4. Jewett BS. Reconstructive options for head and neck skin cancer. Otolaryngol Clin North Am. 2005;38(2):285-302.

Trusted Resources

Always consult a board-certified dermatologist or Mohs surgeon regarding wound reconstruction options after skin cancer surgery. This article is for educational purposes only and does not replace professional medical advice.