The week six dip: why a good repair looks worse before it looks right

The stitches come out at a week and everyone is pleased. The line is flat, the color is settling, and the patient goes home thinking the hard part is finished. Four weeks later they are back on the phone, upset, describing a lump. The repair has become firm. It sits proud of the skin around it. On the nose or the cheek it may have developed a distinct rounded quality, as though something has been packed underneath it.

Nothing has gone wrong. What has happened is the most predictable event in the entire recovery, and it is the one nobody warns anyone about, which is why the phone call happens at all.

The original element in this piece is a three checkpoint appearance curve for facial Mohs repairs, giving the expected finding at each checkpoint, the specific deviation at each that is genuinely abnormal, and the reason revision decisions are deferred until after the curve has run. The underlying scar biology and the management of the specific deformity that produces the bulge are both documented in the surgical literature. The version that tells a patient which week they are in and what they should be seeing has not been written, and its absence generates an enormous amount of unnecessary worry.

Why the dip exists at all. A healing wound does not simply seal and stop. After the wound closes, the body lays down new collagen in a disorganised mass, and it lays down far more than it will eventually keep. New blood vessels proliferate to supply that activity, which is the source of the redness. Only later does the remodelling phase begin, in which the excess collagen is broken down, reorganised along lines of tension, and the vascularity regresses. That remodelling phase runs for many months after the wound has closed, long after the point most people assume healing is finished (StatPearls, Wound Healing Phases).

The peak of collagen deposition and vascular proliferation therefore comes weeks after the wound looked finished. The scar is at its firmest, reddest and most raised in the middle of that phase, not at the start of it.

Flaps add a second mechanism. A flap is tissue that has been cut around and moved, which means its lymphatic drainage has been interrupted along most of its border. Fluid that would normally leave the tissue has nowhere convenient to go. The result is a persistent swelling within the flap itself, contained by the circular scar around it, which pushes the tissue up and out. This is trapdoor deformity, also called pincushioning, and it is common enough that its management is a subject in its own right (Aesthetic Plast Surg 2025). It is most conspicuous where the repair is round or curved and where the skin is thick, which is why the nose is the classic site.

Checkpoint one, the two week mark. Expect a line or a flap outline that is pink to red, flat or nearly so, possibly with some bruising still resolving and some crusting at the suture points. There may be a numb patch extending beyond the repair. Mild tightness is normal.

The deviations that matter here are the ones that suggest something acute rather than something evolving. Increasing pain rather than decreasing, spreading redness that extends well past the repair, warmth, discharge, or fever are infection until proven otherwise and want a same week phone call, not a wait and see. A flap or graft that is going dusky, grey or black in part or in whole is a perfusion problem and is urgent, and it is the reason the signs of infection after Mohs are worth reading before you need them rather than after.

Checkpoint two, the four to eight week window. This is the dip. Expect the repair to be firmer than it was, often noticeably so. Expect it to be raised. Expect redness that may be more intense than at week two rather than less. On a flap, expect a rounded fullness that makes the repaired area sit above the surrounding skin. Expect it to feel tethered when you make an expression, and expect the numbness to still be there.

Almost none of that is a reason to intervene. It is a reason to be told in advance that it is coming. The single most useful thing a patient can do in this window is take a photograph in consistent light, so that the comparison at checkpoint three is against an image rather than against a memory that has been colored by six weeks of anxiety.

The deviations that do matter in this window are different from the acute ones. A repair that is progressively enlarging rather than plateauing, a new firm nodule that is distinct from the general firmness, ulceration or breakdown of the skin over the repair, or bleeding from an area that had healed all warrant a look. So does an eyelid that is being pulled downward or a nostril rim that is being pulled up, because a scar that is distorting a mobile free margin is a functional problem and its timing is not the same as a cosmetic one.

Checkpoint three, six to twelve months. Expect the firmness to have substantially settled, the redness to have faded toward the surrounding skin tone or toward pale, and the raised quality to have flattened considerably. Expect residual numbness in some cases, expect the scar to remain visible, and expect it to look better under overhead lighting than it did in month two.

This is the checkpoint at which a revision conversation is a reasonable conversation. Almost everything that looked like it needed fixing at week six has fixed itself by here, and operating in the middle of the dip means operating on tissue that is actively remodelling, which reliably produces a worse result than waiting.

What the studies do not tell you. There is no published cohort that photographed a large series of Mohs repairs at fixed intervals and reported the proportion showing firmness, elevation and erythema at each one. The curve described here is assembled from the biology of wound remodelling, from the recognised natural history of trapdoor deformity, and from clinical practice. It is a description of the typical, not a probability. Individual variation is wide, thick sebaceous skin behaves differently from thin skin, and second intention healing follows a different course from a flap.

There is also no trial establishing the right moment to intervene. The convention of waiting six to twelve months before revising is exactly that, a convention, grounded in the observation that scars improve on their own and that the improvement is not finished early. Some specific problems, particularly a margin being distorted, are handled sooner, and that judgement belongs to the surgeon rather than to a calendar.

The practical instruction. At the stitch removal appointment, ask one question. What should this look like at six weeks. If the answer includes the words firmer and redder, you have been told the truth, and the phone call in month two never has to happen. Add a photograph at each checkpoint in the same light, and by the time you get to the point where scar care and recovery genuinely start to matter, you will be judging your repair against evidence rather than against dread. The tissue is doing exactly what it is supposed to do, and the only intervention required for most of the curve is patience and sun protection over a healing scar, which does more for the final color than anything else available.