Facial Skin Lesion Removal and Reconstruction in Hampshire: Excision, Local Flaps and Scar-Conscious Repair
- 3 days ago
- 10 min read
Written by Mr Tim Biggs, Consultant ENT Surgeon and Rhinologist. Mr Biggs is an RCS-certified cosmetic nasal surgeon and performs functional, cosmetic and revision rhinoplasty in Hampshire.
Quick summary: Facial skin lesions, whether benign moles, cysts, or suspected skin cancers, often need surgical excision rather than just a biopsy. On the face, and especially on the nose, removing a lesion safely is only half the job; closing the resulting defect without distorting the surrounding features is the harder half. Mr Tim Biggs, Consultant ENT Surgeon, Rhinologist and Facial Plastic Surgeon, treats facial lesions and reconstructs the defects that follow using local flap techniques drawn directly from his background in dorsal preservation and Piezo rhinoplasty. He sees patients for this at Adnova Clinic in Fareham, Medicana Hospital in Winchester, and Nuffield Health Wessex Hospital in Eastleigh.
What counts as a facial skin lesion?
“Lesion” is simply the clinical term for any abnormal area of skin. On the face, the lesions that prompt a surgical opinion generally fall into two groups.
Benign lesions are not cancerous but are often removed for comfort, recurrent irritation, or cosmetic reasons:
• Dermal and compound naevi (moles)
• Seborrhoeic keratoses
• Epidermoid and pilar cysts
• Skin tags and fibroepithelial polyps
• Viral warts and papillomas
• Milia
• Lipomas presenting in the subcutaneous facial plane
Malignant and premalignant lesions need a more structured pathway, because the priority shifts from cosmetic preference to complete removal with clear margins:
• Basal cell carcinoma (BCC), by far the most common skin cancer on the face, particularly the nose, nasolabial fold and periorbital region
• Squamous cell carcinoma (SCC)
• Melanoma
• Actinic (solar) keratosis, a premalignant change that can sometimes be managed non-surgically but is monitored closely
The face carries a disproportionate share of skin cancer because of lifetime sun exposure, and the nose is the single most common site for BCC. This is precisely where the reconstructive side of this article matters most.
When should a facial lesion be checked?
A lesion should be assessed promptly if it shows any of the following:
• New growth, or a change in size, shape, colour, or border of an existing mole (the
ABCDE rule: Asymmetry, irregular Border, multiple Colours, Diameter over 6mm, Evolving)
• Bleeding, crusting, or ulceration that does not heal
• A lesion that is tender, itchy, or recurrently inflamed
• A pearly, translucent nodule with visible surface blood vessels (classic for BCC)
• A scaly, rough patch that persists or thickens
If a GP suspects skin cancer, referral usually goes through the NHS two-week-wait pathway. Many patients also choose to see a specialist privately for a faster opinion, particularly for lesions that are causing anxiety.
How facial lesions are diagnosed
Most lesions are assessed clinically, often with dermoscopy to examine the surface pattern in more detail. Where the diagnosis is uncertain, or the lesion is suspicious enough to need histological confirmation before definitive treatment, a biopsy is taken first:
• Shave biopsy: removes a superficial sample, suited to raised, low-suspicion lesions
• Punch biopsy: a small full-thickness core, useful for flat or pigmented lesions
• Incisional biopsy: removes part of a larger lesion when full excision is not yet appropriate
• Excisional biopsy: removes the entire lesion with a margin of normal skin, providing both diagnosis and, if margins are clear, treatment in one step
For most facial lesions where surgery is already the planned treatment, excisional biopsy is the most efficient route: one procedure, one healing process, one scar.
Treatment options for facial lesions
• Excision with primary closure or flap repair: the mainstay for both benign lesions being removed for good and for skin cancers needing clear margins
• Wide local excision: used for confirmed skin cancers, with a margin dictated by lesion type, size and depth
• Mohs micrographic surgery: a staged technique, usually carried out by a dermatological surgeon, in which tissue is examined layer by layer until margins are clear.
This is frequently followed by referral for reconstruction of the resulting defect, which is where a facial plastic surgeon's flap expertise is most valuable
• Curettage and cautery: suitable for selected low-risk, superficial lesions
• Cryotherapy or topical treatment: an option for some premalignant actinic keratoses, not generally appropriate for confirmed skin cancer or for lesions in cosmetically critical areas
The right option depends on the lesion's behaviour, depth, and location, which is assessed at consultation rather than guessed from a description alone.
Why facial reconstruction is not “just stitching it up”
Skin on the face does not behave uniformly. Laxity, thickness, colour and texture vary sharply between the forehead, cheek, nose, lip and eyelid, and the face is conventionally divided into aesthetic subunits, regions bordered by natural shadows, creases and contour changes (the nasal tip, ala, dorsum, sidewall and columella are themselves subunits of the nose alone). A repair that ignores subunit boundaries can leave a result that heals well but still looks “wrong,” because it distorts a free margin (eyelid, lip, nostril rim) or sits across a junction the eye expects to see.
Surgeons also work with relaxed skin tension lines (RSTLs), the lines along which skin naturally folds, to plan incisions and closures that settle into existing creases rather than fighting against them. The smaller the defect relative to local skin laxity, the more closure options exist; the larger or more centrally placed the defect, particularly on the nose, the more a flap or graft becomes necessary rather than optional.
Reconstructive options after facial lesion excision
Primary closure
Where the defect is small relative to surrounding skin laxity, direct closure along the RSTLs gives the simplest scar and the most predictable healing. This is the default whenever it is achievable without distorting a nearby feature.
Skin grafts
When local tissue cannot be mobilised, a full-thickness skin graft (commonly harvested from behind the ear or the supraclavicular area) can resurface the defect. Grafts are reliable but rely on the wound bed for their blood supply during the take period, and colour or texture match is sometimes less precise than a local flap from adjacent skin.
Local flaps
A local flap moves adjacent skin, complete with its own blood supply, into the defect, rather than relying on a graft to “take.” Because the donor skin usually matches the defect closely in colour, thickness and texture, flaps generally give the most natural result on visible facial areas, at the cost of a more deliberately planned incision pattern. The main types used on the face include:
• Advancement flaps: skin is moved in a straight line to close the defect, commonly used on the forehead, cheek and upper lip
• Rotation flaps: a curved incision allows skin to pivot into the defect, useful for larger cheek, temple or scalp defects where there is enough surrounding laxity to recruit
• Transposition flaps: skin is lifted and moved over intervening tissue into a defect at a different point. The bilobed flap is the classic example for small to medium nasal tip and ala defects, recruiting laxity from higher up the nose or glabella in two stages of movement. The rhomboid (Limberg) flap is a workhorse for cheek and temple defects
• Nasolabial flap: recruits skin from the nasolabial fold to resurface defects of the nasal ala and sidewall, taking advantage of a natural crease as the donor scar line
• Glabellar flap: rotates or advances skin from between the eyebrows, useful for defects of the medial canthus and upper nasal sidewall
• Paramedian forehead flap: a staged, pedicled flap bringing forehead skin down onto the nose, typically reserved for larger or full-thickness nasal defects where local nasal skin alone cannot cover the area, often used after Mohs surgery for more extensive skin cancers
Flap choice is rarely arbitrary. It follows the defect's size, depth and subunit location, the donor skin available, and the patient's healing factors, decided at consultation rather than from a generic protocol.
Nasal reconstruction: a particular area of focus
The nose is both the most common site for facial skin cancer and the least forgiving area to reconstruct, because there is little spare skin, the surface is highly contoured, and the airway and structural support sit just beneath the skin envelope. This is the same territory Mr Biggs works in for dorsal preservation and Piezo ultrasonic rhinoplasty, where preserving and respecting the nose's underlying framework while reshaping the surface is the entire discipline. That same anatomical familiarity, with the vascular supply, subunit boundaries and structural support of the nose, carries directly across into planning bilobed, nasolabial, glabellar and forehead flap reconstructions after lesion excision, rather than treating nasal skin cancer repair as a separate, unrelated skill.
Anaesthesia, setting and where treatment takes place
Most isolated lesion excisions with primary closure or a straightforward local flap are comfortably done under local anaesthetic in a clinic procedure room. Larger excisions, multiple lesions in one sitting, more extensive flap reconstruction, or patient preference for sedation or general anaesthetic are better suited to a day-case hospital setting with full theatre support.
• Adnova Clinic, Fareham: Mr Biggs' self-pay facial plastic surgery base, suited to lesion excision and local flap reconstruction performed under local anaesthetic in a dedicated clinic setting.
• Medicana Hospital, Winchester: the base for Mr Biggs' broader ENT and insured practice, with day-case theatre facilities for excisions and flap reconstructions better suited to general anaesthetic or sedation, alongside sinus and nasal airway surgery.
• Nuffield Health Wessex Hospital, Eastleigh: a CQC-rated “Good” private hospital in Chandlers Ford with full theatre and inpatient support, an option for more complex reconstructive cases or where a patient's insurer directs care to this site.
NHS experience and surgical volume for lesion work of all kinds is built at Queen Alexandra Hospital, Portsmouth.
Recovery and aftercare
• Sutures on the face are typically removed at five to seven days, slightly later for flaps under more tension
• Keep the wound clean and follow the specific wound care advice given for your procedure
• Avoid unnecessary facial movement or strain near the repair in the first one to two weeks
• Sun protection over the scar is important for at least twelve months, since early scars pigment more readily in UV light
• Scars mature over twelve to eighteen months; an early pink, slightly raised scar is normal and almost always settles
• Where a lesion is excised for diagnostic or cancer reasons, histology results and any further treatment plan are discussed at a dedicated follow-up appointment
Costs
Costs for facial lesion excision and reconstruction vary considerably depending on the number and size of lesions, whether closure is straightforward or requires a local flap or graft, and whether the procedure is done under local or general anaesthetic. A personalised quote is provided after consultation and examination. Self-pay and insured pathways are both available at Medicana Hospital, Winchester and Nuffield Health Wessex Hospital; Adnova Clinic operates on a self-pay basis.
About Mr Tim Biggs
Mr Tim Biggs is a Consultant ENT Surgeon, Rhinologist and Facial Plastic Surgeon based in Hampshire, holding FRCS (ORL-HNS), a PhD in mucosal immunology, and RCS Board Certification in Cosmetic Nasal Surgery. He is one of a small number of UK surgeons combining Piezo ultrasonic rhinoplasty with dorsal preservation technique, and is College Tutor for Surgery and co-founder of the South East Rhinology Forum. His NHS practice is based at Queen Alexandra Hospital, Portsmouth, referenced here for experience and surgical volume; his private practice for facial lesion excision and reconstruction is based at Adnova Clinic, Medicana Hospital Winchester, and Nuffield Health Wessex Hospital.
More information:
Frequently Asked Questions
Is a facial lesion likely to be cancerous?
Most facial lesions are benign, but the face carries a higher skin cancer risk than most other body sites because of cumulative sun exposure, particularly on the nose. Any lesion that is new, changing, bleeding or not healing should be assessed rather than assumed to be harmless.
What is the difference between an excision biopsy and a shave or punch biopsy?
A shave or punch biopsy samples part of a lesion to confirm a diagnosis before deciding on definitive treatment. An excisional biopsy removes the whole lesion with a margin of healthy skin in one step, providing diagnosis and treatment together when surgery is already the planned route.
Will my wound just be stitched closed, or will I need a flap?
It depends on the size of the defect relative to the surrounding skin's laxity and its location. Small defects with enough local skin slack can usually be closed directly. Larger defects, or those on tighter-skinned areas like the nose, often need a local flap or, less commonly, a skin graft to close without distorting nearby features.
What is a local flap, and how is it different from a skin graft?
A local flap moves nearby skin, with its own blood supply intact, into the defect. A skin graft transfers skin from a separate donor site and relies on the wound bed to supply it with blood while it heals in. Flaps generally give a closer colour and texture match on visible facial skin.
What types of flap are used on the face and nose?
Common options include advancement, rotation and transposition flaps such as the bilobed and rhomboid (Limberg) flaps, along with nasolabial, glabellar and, for larger nasal defects, paramedian forehead flaps. The choice depends on the defect's size, depth and location.
Why does nasal reconstruction need particular expertise?
The nose has very little spare skin, a highly contoured surface, and underlying structural support that must be respected during repair. These are the same anatomical considerations involved in dorsal preservation and Piezo rhinoplasty, which is why a facial plastic surgeon with rhinoplasty experience is well placed to manage nasal skin lesion reconstruction.
Is this done under local or general anaesthetic?
Most single lesion excisions and straightforward local flaps are done under local anaesthetic. Larger or multiple excisions, more extensive flap reconstruction, or patient preference may be better suited to sedation or general anaesthetic in a hospital day-case setting.
How long is recovery, and when do stitches come out?
Facial sutures are typically removed at five to seven days, slightly later for flaps under more tension. Most patients return to normal low-impact activity within a week or two, with full scar maturation over twelve to eighteen months.
Will there be a visible scar?
Any surgical incision leaves a scar, but careful planning along relaxed skin tension lines and aesthetic subunit boundaries aims to make the resulting scar as inconspicuous as possible. Early scars are pink and slightly raised; this settles with time, and sun protection over the area helps the scar fade evenly.
What happens if the histology shows skin cancer after removal?
Results are discussed at a dedicated follow-up appointment. If margins are clear, no further surgery may be needed beyond routine monitoring. If margins are involved or the lesion type warrants it, further excision or onward referral is arranged.
Can this be done on the NHS, or does it have to be private?
Both routes exist. Suspected skin cancer is usually referred through the NHS two-week-wait pathway. Many patients choose a private consultation for a faster opinion or for cosmetically sensitive areas; Mr Biggs sees private patients at Adnova Clinic, Medicana Hospital Winchester, and Nuffield Health Wessex Hospital.
Which of the three locations is right for me?
Adnova Clinic in Fareham is self-pay only and well suited to lesion excision and local flap repair under local anaesthetic. Medicana Hospital in Winchester offers both self-pay and insured day-case care with broader ENT facilities. Nuffield Health Wessex Hospital in Eastleigh is a further insured and self-pay hospital option, particularly for more complex reconstructive cases. This is discussed and confirmed at consultation.
Where to be seen
Adnova Clinic, Fareham
Eagle Point, 1 Little Park Farm Rd, Fareham PO15 5TD
01489 663273 | timbiggssec@adnovaclinic.com
Self-pay only
Medicana Hospital, Winchester
Chilcomb Ln, Winchester SO21 1HU
020 7870 5910 | info@ent-surgeons.uk
Self-pay and insured (Bupa, Aviva, Vitality, Cigna, Allianz, WPA)
Nuffield Health Wessex Hospital, Eastleigh
Winchester Road, Chandlers Ford, Eastleigh SO53 2DW
02380 266 377
Self-pay and insured (Bupa, AXA Health, Vitality, Cigna, Allianz, WPA)
This article is for general information and does not replace a face-to-face clinical assessment. Any new, changing, bleeding or non-healing facial lesion should be reviewed by a doctor.
