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Research Original Investigation

Complication Rates in Delayed Mohs Reconstruction Surgery

did not hold true in our study. 8 Van Leeuwen et al 4 con- ducted a retrospective review of 202 facial reconstructive cases after MMS, with 50% of cases being performed 1 day after MMS and close to 90% completed within 1 week of MMS. Their overall complication rate was 11.9%, with a greater risk associated with nasal and periocular defects. 4 Similarly, Sclafani et al 8 also noted a significantly higher complication with nasal defects. Our series had a higher rate of complications among those requiring an interpolated flap with cartilage grafting, most of which (80%) were completed for nasal defects, but nasal defect location was not associated with a higher rate of complications. Cook and Perone 3 published a prospective study on MMS that assessed the incidence of complications in MMS in a se- ries of 1052 patients who had undergone 1358 reconstruction procedures. Nineteen percent (262 of 1358) of wounds healed by secondary intention. Seventy-five percent (1014 of 1358) were reconstructed immediately, while 6.8% (92 of 1358) were referred to a reconstructive surgeon. How many of the re- ferred reconstructionswere delayedwas not recorded. Among thosewith complete follow-updata, the total complication rate was 1.64% (22 of 1343), most related to bleeding or hematoma formation, and a wound infection rate of 0.07% (1 of 1343) 3 —both lower than in our study. Comparison is difficult because there was no mention of the timing of reconstruc- tion or relation to size or complexity of defects in their study. Some of this discrepancy couldbe due to increaseduse ofmore complex reconstructive techniques in our study because lo- cal flaps, interpolated flaps, composite and skin grafts, as well as a free flap accounted for 82.2% of the reconstructions per- formed in our study. Comparatively, local flaps accounted for 27%of the reconstructions by Cook and Perone, 3 of which less than 1%were interpolated. 3 The use of an interpolated flap as well as exposed cartilage were associated with a significantly higher rate of complication in our study and may explain the overall higher rate of complications we demonstrated. More- over, Cook and Perone 3 used amuchmore rigorous definition for wound infection, requiring wound culture confirmation, whereas our study definedwound infection based on descrip- tion of the wound and/or prescription of additional antibiotic therapy. We chose to include all cases that were clinically sus- picious for a postoperative wound infection based on subjec- tive description of purulent drainage, erythema, and/or ten- derness regardless of culture confirmation. Antibiotics were often started preemptively based on these clinical signs rather than on wound culture confirmation. In cases in which cul- ture was obtained, lack of microbial growth did not preclude inclusion as a wound infection. Thus, the infection rate in our study may be an overestimation of the true rate. Of all the potential head and neck defect locations, com- posite facial defects were the only type to be significantly as- sociatedwith complications in themultivariatemodel. These defects were defined as involvement of multiple facial sub- units, which are inherently larger in size and typically require a more complex reconstruction. Interestingly, although com- posite locationwas linked to complications, dimension of the defect was not statistically significant in the multivariate model. Froma reconstructive aspect, interpolated local flaps,

with cartilage grafting, reconstruction occurring greater than 2 days after MMS, and composite location continued to have a statistically significant associationwith complicationswhen the other factors were controlled. Our total rate of complications, 8.2%, is similar to rates re- ported by others, 2,3,5-8 but it is difficult to generalize and com- pare the results of other studies because most of the studies are retrospective, surgeons do not define wound complica- tions similarly, and defect characteristics may differ between the reporting specialties (ie, dermatology vs separate recon- structive surgery). Although not always the case, it can be pos- tulated that many of the MMS defects referred to be repaired by a reconstructive surgeon may be larger and more complex than those repaired by the Mohs dermatologic surgeon. All patients included in our study underwent a delayed re- construction, whilemost previous reports assessMMS recon- struction in general, rather than specifically in a non–same- day reconstruction setting. The only other report specifically assessing delayed reconstruction of MMS head and neck de- fects is from Mordick et al 2 in 1990. In their series of 55 pa- tients,most of the reconstructionswere skingrafts or local flaps with defect size ranging from 1 to 10 cmwith a median size of 2 to 3 cm. The total complication rate was 5.5% (3 of 55 pa- tients). Twopatients hadwound infections (3.6%), a ratewhich is slightly higher than our rate, and 1 patient (1.8%) had a par- tial loss of a full-thickness skin graft. This did not include 8 pa- tients who underwent repeated surgery for cosmetic rea- sons. Thus, the actual total complication rate may be higher than reported when compared with more recent studies, in- cluding ours. In our study, 67 patients underwent reconstruc- tion with either a full- or split-thickness skin graft; we noted a comparable rate of partial or complete loss of graft with 3.0% (2 of 67). Of note, the timing of reconstruction ranged from 5 to 61 days comparedwith 89%of the patients in our study un- dergoing repair within 2 days of their Mohs resection. Escobar andZide 9 also evaluated complications in 117 head and neck malignant neoplasms that underwent delayed re- construction or healing by secondary intention. The exci- sions, however, were not performed with MMS, and recon- struction was delayed until final pathologic results were available. Three defects (2.6%) closedwith full-thickness skin grafts developed superficial necrosis. Although all reconstruc- tions were delayed about 1 week after excision, andMMS was not used for resection, the study is notable in that there were no reports of infection, despite delayed wound closure. 9 Two more recently published studies on rate of compli- cations afterMMS assessed reconstructions performedbynon- dermatologic specialties. Sclafani et al 8 retrospectively ana- lyzed 446 medical records of patients undergoing MMS, with all reconstructions being performed within 24 hours of MMS, noting a complication rate of 18.7%, higher than in our series. Unlike many other studies including our own, they included scar erythema, tissue contour deformity, telangiectasia, and pin-cushioning that required intervention (eg, steroid injec- tion, scar revision, or laser treatment) as complications, which likely accounts for their higher rate. This increased incidence was associated with being female, younger age, Fitzpatrick 3 skin type, nasal defects, and use of transposition flaps, which

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