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Original Investigation Research

Complication Rates in Delayed Mohs Reconstruction Surgery

S kin cancer is the most common malignant neoplasm, withmore than 5.4million cases diagnosed annually in theUnited States. 1 Treatment tends to vary based on the type, location, and primary vs recurrent lesions, but surgical resection remains the main treatment modality. Mohs micro- graphic surgery (MMS) is a commonly used technique for ex- cision because it allows dermatologic surgeons to precisely re- move cancers while offering the highest cure rates with maximal preservation of surrounding tissue. Repairs of MMS defects are typically done the same day when performed by the resecting Mohs dermatologic sur- geon. Ideally, all reconstructions would be performed imme- diately after MMS, but delayed (non–same-day) reconstruc- tions are often performed when a separate reconstructive surgeon repairs the wound. Timing of reconstruction de- pends on the complexity and location of the MMS defect, pa- tient anxiety and pain tolerance, and scheduling or availabil- ity of the reconstructive surgeon. There is a perception of a theoretical increased risk of infection if closure is not per- formed immediately, because wounds are left open and may be exposed to contamination if not properly cared for. How- ever, delayed closure allows for more flexibility if additional time is needed to confirm clear tumor margins and is espe- cially helpful when the resection and reconstruction are per- formed by separate surgical services. It can also allow recon- structive surgeons greater opportunity toplananddiscuss their method of closurewithpatients, which canbe useful whenop- timal repair may involve more complex methods of repair. Patients referred for delayed reconstruction often have larger ormore complex defects; higher complication ratesmay be expected in this patient population. In 1990, Mordick et al 2 reported the only study of complications associated with de- layed head and neck MMS reconstruction. They demon- strated a 5.5%complication rate—2 patients with cellulitis and 1 with skin graft loss—in a small cohort of 55 cases. To our knowledge, there are no recent studies describing the inci- dence of complications solely in patients who have under- gone delayed MMS head and neck reconstruction. Thus, the goals of our study are todescribe the complication rates among patients who underwent delayed MMS reconstruction of the head and neck and to identify risk factors associated with the occurrence of complications. We performed a retrospective cohort study using pooled data from 2 institutions: University of Washington Medical Center and Virginia Mason Medical Center. The institutional review boards of both institutions approved this retrospective re- view and granted us waiver of written informed consent. The analysis was performed from June 2014 to March 2016. The study population included patients who underwent MMS re- construction in the head and neck from February 1, 1989, to December 31, 2012. These patients were identified based on billed reconstructiveCurrent Procedural Terminology code.We excluded patients with incomplete medical records that did Methods Study Design and Participants

not provide adequatemedical history,wounddetails, andpost- operative follow-up. Patients who had same-day reconstruc- tionwere also excluded. Deidentified patient informationwas then pooled for final analysis. Data Collection and Main Outcome Measures A standard database was used for abstraction to collect pa- tient characteristics, comorbidities, medications, previous ra- diation treatment at the defect site, recurrent disease, char- acteristics of the MMS defect, reconstructive modality, complexity of reconstruction (ie, was for >1 technique used) and complications. Defects were classified by location based on facial subunits. Those that involved more than 1 subunit were designated as composite defects. Large defects were de- fined as those 2.0 cm or greater, and 1.5 cm or greater if lo- cated on the nose. Reconstructive modalities included com- plex primary closure, full-thickness skin graft, adjacent tissue transfer local flap, interpolated local flap (ie, paramedian fore- head or melolabial flap), composite graft, and free tissue flap. A composite graft was defined as any graft that included both cartilage and soft tissue, such as an auricular helical rim graft for alar defects. Many cases required greater than 1 type of re- constructive method. The primary outcome measures were immediate and de- layed postoperative complications. Immediate complica- tions occurredwithin 24 hours of surgery, while delayed com- plications occurred more than 24 hours after surgery. Any immediate complication was recorded, including wound- related or systemic issues. Delayed complications included hemorrhage, hematoma, infection, skin necrosis, wound de- hiscence, and others, such as vestibular stenosis, saddle de- formity, or septal perforation. Hemorrhage was defined as bleeding requiring intervention. Hematoma was defined by clinical examination and incision or drainage confirming the diagnosis. Wound dehiscence was defined as any noted sepa- ration along the suture line. Necrosis was defined as any skin flap or graft loss. Infection was defined as presence of ery- thema, purulence, increased tenderness, and/or induration; if there was concern about infection, antibiotics were pre- scribed.Wound cultureswere not routinely performed to con- firm presence of infection. Wound Management All patients underwent MMS using standard surgical tech- niques. The wounds were kept dressed until reconstruction was performed. At the time of reconstruction, all wounds were examined and prepared with Betadine. The wound bed was debrided of nonviable tissue. If a full-thickness skin graft was planned, debridement was minimized. All patients received 7 days of prophylactic postoperative antibiotics, and cephalexin was prescribed if the patient had no medica- tion allergy. Follow-up was conducted by the reconstructive surgeon, initially 1 week after surgery with the aim of a total 1-year follow-up. Statistical Analysis Both institutions used a standard database for abstraction to collect clinical outcomes data. Descriptive statistics were cal-

(Reprinted) JAMA Facial Plastic Surgery September/October 2016 Volume 18, Number 5

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