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O RIGINAL A RTICLE

Facial Reconstruction After Mohs Surgery: A Critical Review of Defects Involving the Cheek, Forehead, and Perioral Region

Anna R. Johnson, MPH, Sabine A. Egeler, MD, Winona W. Wu, BA, Alexandra Bucknor, MBBS, MRCS, y Ahmed M.S. Ibrahim, MD, PhD, and Samuel J. Lin, MD, MBA

T he advent of Mohs surgery and its association with increased tissue preservation and higher cure rates has changed the landscape for treatment of facial cutaneous malignancies. 1 Coupled with an increasing incidence of skin cancer, the demand for Mohs surgery is projected to continue to rise. 1,2 The frequently smaller sized defects left after Mohs surgery may necessitate a different reconstructive approach compared to those arising from wide local excision. 2 Facial defects can be associated with psychologic, emo tional, and social consequences. 3 The impact of a facial lesion is related to its perceived visibility, with central defects being associ ated with increased reported feelings of disfigurement compared to laterally located defects. 3 This underscores the need to obtain and evaluate patient-reported outcome measures for the Mohs surgical population. Examination of reconstruction after Mohs surgery of the nose has received significant attention in the literature. 4–10 Other centrally prominent aesthetic facial units including the forehead, cheek, and perioral region are also affected by cutaneous malignancies, yet have received less attention in the literature. This emphasizes a need to revisit current reconstruction techniques for these areas following tumor removal. The primary aim of this study is to review the current surgical experience of reconstruction of these areas following Mohs surgery and examine frequently used approaches based on the available literature. The secondary aim is to detail surgical and patient-reported outcomes of these studies. Literature Search A comprehensive electronic search strategy was designed with a medical research librarian using PubMed, EMBASE, and Web of Science to identify all original citations. There were no restrictions made based on language, publication year, or publication status. The search included articles from database inception until October 4, 2017. The search terms are listed in Table 1 and the search strategy is listed in Table 2. The medical subject headings and text words were modified according to the results yielded in each database search as an iterative process. In addition, a manual reference check was performed on all articles meeting inclusion criteria to capture additional references not yielded in the initial search strategy. METHODS

Abstract: Facial defects following Mohs surgery can cause signifi cant functional, cosmetic, and psychologic sequelae. Various tech niques for nasal reconstruction after Mohs surgery have been analyzed in the medical literature, yet there has been less attention given to procedures for other crucial facial aesthetic regions. A literature search using PubMed, EMBASE, and ISI Web of Science for studies assessing reconstructive techniques of the forehead, cheek, and perioral regions after Mohs surgery was performed. No limitations on date or language were imposed. Studies meeting inclusion criteria consisted of an entirely post-Mohs population, specified technique for aesthetic unit reconstruction, and detailed complications. The initial search yielded 2177 citations. Applica tion of the author’s inclusion and exclusion criteria resulted in 21 relevant studies. Linear closure was highlighted as the predominant technique when possible in all 3 aesthetic zones. Local flaps remained the workhorse option for cheek and forehead defects. Cheek and perioral reconstruction were associated with higher complication rates. Eighty-one percent of studies did not include patient-reported outcomes or standardized outcome measurement assessments. Mohs surgery has become a valuable approach for treatment of skin malignancies of the face. This review has identi fied significant study heterogeneity in methodology, design, and outcome assessment. Currently, there is no evidence-based litera ture to support an algorithm to guide surgeon choice of treatment in these 3 central areas. Recommendations are provided to improve the quality of future studies to better inform appropriate surgical technique for each facial unit analyzed.

KeyWords: Facial reconstruction, Mohs surgery, patient-reported outcomes

( J Craniofac Surg 2019;30: 400–407)

From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and y Department of Plastic Surgery, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. Received June 28, 2018. Accepted for publication August 21, 2018. Address correspondence and reprint requests to Samuel J. Lin, MD, MBA, 110 Francis St, Suite 5A, Boston, MA 02215; E-mail: sjlin@bidmc.harvard.edu

TABLE 1. Search Terms

‘‘Mohs surgery,’’ ‘‘cheek/surgery,’’ ‘‘lip/surgery,’’ ‘‘forehead/surgery,’’ ‘‘facial neoplasms/surgery,’’ ‘‘head and neck neoplasms surgery,’’ ‘‘skin neoplasms surgery,’’ ‘‘plastic surgery,’’ ‘‘esthetics,’’ ‘‘surgical wound infection,’’ ‘‘graft rejection,’’ ‘‘graft survival,’’ ‘‘patient satisfaction,’’ ‘‘treatment outcome,’’ ‘‘reconstructive surgical procedures,’’ ‘‘postoperative complications,’’ and ‘‘wound closure techniques.’’

The authors report no conflicts of interest. Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000005074

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range was not reported, it was calculated directly by the authors whenever possible.

TABLE 2. Search Terminology

Data Extraction and Analysis All identified citations were imported into EndNote X8.0.1 (Thomas Reuters, New York, NY). Included titles were subjected to a full-text screen. Inclusion and exclusion criteria are detailed in Table 3. Screening and data extraction were completed indepen dently by 2 authors (ARJ, SAE), and any disputes were resolved by discussion. If consensus could not be reached, a 3rd author was consulted for adjudication (WWW). Included articles were then classified into 3 categories according to main facial aesthetic unit of involvement. Criteria used to define each category are provided in Table 4. Data extracted included: study design, sample size, defect size and location, reconstructive technique, complications, follow up period, and patient-reported outcomes. If mean defect size or Human subjects only Entirely post-Mohs surgical population Post-Mohs reconstruction of defects involving the cheek, forehead and/or perioral region Full-text available Exclusion criteria Case studies Studies lacking complication information Studies not specifying complications per aesthetic zone involved Animal studies Technical studies detailing surgical techniques PubMed (1137 results) ((‘‘Mohs Surgery/methods’’[Mesh] OR ‘‘MOHS’’[tw] OR MOHs’[tw])) AND (((((((((‘‘Esthetics’’[Mesh]) OR (‘‘Surgical Wound Infection/analysis’’[Mesh] OR ‘‘Surgical Wound Infection/etiology’’[Mesh] OR ‘‘Surgical Wound Infection/ prevention and control’’[Mesh])) OR ‘‘Graft Rejection’’[Mesh]) OR ‘‘Graft Survival’’[Mesh]) OR ‘‘Ectropion/etiology’’[Mesh]) OR ‘‘Patient Satisfaction’’[Mesh]) OR ‘‘Treatment Outcome’’[Mesh]) OR (‘‘Reconstructive Surgical Procedures/adverse effects’’[Mesh] OR ‘‘Reconstructive Surgical Procedures/complications’’[Mesh] OR ‘‘Reconstructive Surgical Procedures/ methods’’[Mesh] OR ‘‘Reconstructive Surgical Procedures/therapeutic use’’[Mesh])) OR ‘‘Postoperative Complications’’[Mesh]) AND (‘‘Cheek/ surgery’’[Mesh] OR ‘‘Lip/surgery’’[Mesh] OR ‘‘Forehead/surgery’’[Mesh] OR ‘‘Facial neoplasms/surgery’’[Mesh] OR ‘‘Head and Neck Neoplasms/ Surgery’’[Mesh] OR ‘‘Skin neoplasms/surgery’’[Mesh] OR ‘‘Surgery, plastic/ methods’’[Mesh] OR ‘‘Wound closure techniques’’[Mesh])) EMBASE (519 results) ((("mohs micrographic surgery’’/exp OR mohs OR "micrographic surgical technique’’) AND ("face’’/exp OR facial OR cheek OR lip OR forehead OR perioral)) NOT (((‘‘mohs micrographic surgery’’/exp OR mohs OR ‘‘micrographic surgical technique’’) AND (‘‘face’’/exp OR facial OR cheek OR lip OR forehead OR perioral)) AND ‘‘case study’’/de)) AND ‘‘article’’/it AND ‘‘human’’/de Web of Science (521 results) (TS ¼ (Mohs) OR TS ¼ (Micrographic surgery)) AND (TS ¼ (Esthetics) OR TS ¼ (Surgical Wound Infection) OR TS ¼ (Graft Rejection) OR TS ¼ (Graft Survival) OR TS ¼ (Ectropion) OR TS ¼ (Patient Satisfaction) OR TS ¼ (Treatment Outcome) OR TS ¼ (Reconstructive Surgical Procedures) OR TS ¼ (Postoperative Complications)) TABLE 3. Inclusion and Exclusion Criteria Inclusion criteria

RESULTS

Study Characteristics Initial searches yielded 2177 citations. After title and abstract screening, 52 full-text articles were reviewed. Of these, 31 studies did not meet inclusion criteria. The main reason for article exclusion was a heterogeneous patient cohort which included non-Mohs surgical patients. Ultimately, 21 articles met the above-mentioned criteria (Fig. 1). Cheek: Overview of Studies Articles meeting inclusion criteria for cheek reconstruction included 8 retrospective reviews and 1 case series (Table 5). The average sample size was 113 patients. Mean defect size was 11.27 cm 2 . Patient follow-up information was reported in 44% of studies. The most frequently used reconstructive procedure for cheek defects was a cervicofacial advancement (CFA) flap. Direct linear closure, healing by secondary intention, other local flaps, and skin grafts were also described. Complications occurred in 7 of 9 studies and are detailed in Table 5. Patient satisfaction measures were described in 1 study. Cheek: Reconstructive Techniques Direct linear closure was the preferred reconstructive technique in all areas of the cheek. This approach was frequently used in combination with a postoperative scar management program for defects up to 4 cm in diameter. 17 Healing by secondary intention was described in 1 study for defects averaging 5.87 cm 2 . 13 TheCFA flaps were described in 50% of studies for closure of medium to larger-sized defects (mean ¼ 21.35 cm 2 , standard deviation 17.95) or defects spanning multiple aesthetic subunits. 16,18,20 Studies describing the CFA differed in their plane of dissection and placement of incision. 11,16,18,20 Inferiorly based rotation flaps

TABLE 4. Definitions of Aesthetic Subunits

Cheek : The cheek was defined by the pre-auricular crease laterally, the nasolabial fold medially, the zygomatic arch superiorly, and the mandible inferiorly. 11 Forehead : The forehead was defined by the temporal grooves laterally, the frontonasal groove inferiorly, and the hairline superiorly. 12 Perioral region : The perioral region was defined by the nasal base superiorly, the mental crease inferiorly, and the melolabial creases laterally. 3

FIGURE 1. Flow diagram of studies included and excluded from analysis.

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TABLE 5. Summary of Cheek Study Characteristics Study Study Design Total Patients, n Defect Location Defect Size Reconstructive Technique Complications Follow-up Period Inclusion of PROM Becker et al (1998) 13 RR 132 Cheek 5.87 cm 2 (mean) Secondary intention Wound retraction Persistent ectropion Poor scar cosmesis 2.8 y (mean) No Rustad et al (1998) 14 RR 109 Melolabial crease 3.50 cm 2 (mean) Subcutaneous pedicle flap Secondary debulking procedures (required for 1/3 of flaps > 4 cm 2 ) NS No Fader et al (2002) 15 RR 14 Middle cheek 5.46 cm 2 (mean) Z -plasty transposition flap Superficial tip necrosis (n ¼ 1) Revision surgery (n ¼ 1) NS No Austen et al (2009) 16 RR 32 Cheek 41.76 cm 2 (mean) CFA Flap necrosis (n ¼ 3) Persistent ectropion (n ¼ 1) Hematoma (n ¼ 2) NS No Soliman et al (2010) 17 RR 186 Cheek 4 cm (maximum diameter) Direct linear closure None reported 3 y (mean) No NS No

NS No

Lewin et al (2015) 19 CS 20 Medial/Infraorbital Cheek 4.68 cm 2 (mean) Inferiorly-based rotation flap None reported 2 mo-2 y (range) No VanOnna et al (2016) 20 RR 41 Infraorbital/Zygomatic Cheek 8.00 cm 2 (mean) CFA Early: (1-wk post-op) Ectropion (n ¼ 3) Hematoma (n ¼ 2) Late: (6–8 wks post-op) Sensory neuropathy (n ¼ 17) Color mismatch (n ¼ 12) Numbness (n ¼ 11) Contracture/tension (n ¼ 11) 1 y (minimum) Yes

Wound healing difficulty (n ¼ 7) CFA:(n ¼ 4), PCAF:(n ¼ 1), Linear closure: (n ¼ 1), FTSG: (n ¼ 1) Ectropion (n ¼ 7) CFA (n ¼ 5), Free flap (n ¼ 2)

Flap necrosis (n ¼ 24) SC Ectropion

Flap necrosis (n ¼ 2) CFA:(n ¼ 2)

(n ¼ 3) SC Hypertrophic scarring (n ¼ 2) SC

dissection plane (22%)

Linear closure (53%) CFA (19%) PCAF (8%) FTSG (8%)

V-Y advancement flap (2%) Free flap (1%) Other (9%)

Rapstine et al (2012) 11 RR 400 Cheek < 2 cm 2 (36%) 2–4 cm 2 (20%) 4–6 cm 2 (10%) 6–8 cm 2 (8%) 8–10 cm 2 (6%) > 10 cm 2 (20%)

Jacono et al (2014) 18 RR 88 Cheek 14.30 cm 2 (mean) CFA-SC plane (78%) CFA-deep

CFA, cervicofacial advancement flap; CS, case series; FTSG, full-thickness skin graft; NS, not stated; PCAF, perialar crescenteric advancement flap; PROM, patient-reported outcome measure; RR, retrospective review; SC, subcutaneous plane dissection was used.

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mean defect size was 11.24 cm 2 . Follow-up information was reported in 40% of studies. The most common reconstructive technique was direct linear closure. Healing by secondary intention was described in 1 study for forehead defects, including presence of exposed bone. Other approaches included local flaps and full thickness skin grafts (FTSGs). Complications occurred in 2 studies (Table 6). Patient satisfaction outcomes were detailed in 1 study. Forehead: Reconstructive Techniques Direct linear closure was used in over 50% of patients. 12,17 Healing by secondary intention was used in 1 study for large defects (mean ¼ 14.79 cm 2 ), including those with bone exposure. 21 The double-opposing rotation advancement flap (DORAF) was described as an appropriate closure modality for small defects in the temple, described by the authors as < 10 cm 2 , and medium-to large defects between 20 and 30 cm 2 in the central forehead. 22 The contralateral subgaleal sliding (CLASS) flap was used for large, lateral forehead defects (mean ¼ 8.68 cm 2 ), located near the hair line. 23 In 1 study, modified Burow’s advancement flaps were commonly used for coverage of mid-lateral and supra-brow defects, accounting for 51.7% and 62.5% of all reconstructions, respec tively. 12 Additionally, FTSGs were infrequently used to achieve closure for defects > 5 cm 2 located in the central, lateral, mid forehead, and supra-brow region. In contrast, defects > 4 cm 2 located near the hairline were closed using rotation flaps or A to-T advancement flaps (Fig. 2B). 12 Forehead: Surgical Outcomes and Patient Satisfaction Healing by direct linear closure had no reported complica tions. 13 Furthermore, with a mean epithelialization time of 5.7 weeks, healing by secondary intention was also associated with no immediate postoperative complications. However, Becker et al did describe incidences of scar depression and hypopigmentation using this technique. 21 The 2 studies employing the DORAF and CLASS flaps were associated with 1 episode of infection each, both

FIGURE 2. (A) Aesthetic subunits of the cheek. (B) Aesthetic subunits of the forehead. (C) Aesthetic subunits of the perioral region.

and subcutaneous pedicle flaps were described for medial defects abutting the nose and lateral cheek defects involving the melolabial crease, respectively. 14,19 The Z -plasty transposition flap was used for defects not amenable to linear closure in all cheek regions 15 (Fig. 2A).

Cheek: Surgical Outcomes and Patient Satisfaction

Surgical outcomes were described in studies using direct linear closure, and authors reported a 0% complication rate. 11,17 Themost common cheek reconstruction complication was observed in studies using the CFA. In all studies using the CFA, there were a total of 29 episodes of flap necrosis, 4 episodes of ectropion, and 4 postopera tive hematomas. 11,16,18,20 In contrast, the subcutaneous pedicle flap and Z -plasty transposition flap were associated with a lower com plication rate. 15,16 Patient satisfaction was reported in 1 study involving the CFA. 20 Forehead: Overview of Studies Five retrospective review articles were included for the forehead region (Table 6). The average sample size was 103 patients. The

TABLE 6. Summary of Forehead Study Characteristics

Study Design

Total Patients, n

Defect Location

Reconstructive Technique

Follow-up Time

Inclusion of PROM

Defect Size

Complications

Becker et al (1999) 21

14.79 cm 2 (mean)

Forehead bone exposure

RR 132

Secondary intention None reported

1.1 y (mean)

Soliman et al (2010) 17

RR 125

Forehead

3.6 cm (maximum diameter)

Direct linear closure (77%)

None reported

Ransom et al (2012) 22

18 cm 2 (mean)

Cellulitis (n ¼ 1) Scar edema

RR 16

Forehead

Double-opposing rotation

requiring steroid injection (n ¼ 2) Scar revision (n ¼ 1)

advancement flap

Hussain (2013) 23

8.68 cm 2 (mean)

Infection (n ¼ 1)

RR 16

Lateral forehead

Subgaleal sliding single-stage flap Primary closure (56%)

4 wks (minimum) Yes

Quatrano et al (2016) 12

3.42 cm 2 (mean)

None reported

RR 227

Forehead

Modified Burow’s (34%) A to T advancement flap (6%) Rotation flap (1%)

FTSG (1%) Other (2%)

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of which resolved with antibiotic therapy. 22,23 Only 1 study described patient-reported outcomes using a modified Likert scale. 23 Perioral Region: Overview of Studies Two case series and 7 retrospective review articles were included for the perioral region (Table 7). The average sample size was 30 patients. Mean defect size was the smallest reviewed at 2.41 cm 2 . Follow-up information was included in 67% of studies. Location and extension of defects in this region varied (Table 4). The most common reconstructive technique involved local and/or advancement flaps. The most common postoperative complication

was hypertrophic scarring, which occurred in 33% of all studies. Patient-reported outcomes were assessed in 2 studies.

Perioral Region: Reconstructive Techniques Direct linear closure was described less frequently for perioral reconstruction. It was used in 1 study for 73% of upper and lower lip defects measuring up to 3 cm in diameter. 17 Another study described an approach involving linear closure after composite resection for partial to full thickness defects involving up to 1/3 of the upper lip. 25 For small, partial thickness defects (mean ¼ 0.9 cm 2 ), simple vertical excision with primary closure was described. In this same study, excision of adjacent normal tissue followed by

TABLE 7. Summary of Perioral Study Characteristics

Study Design

Total Patients, n Defect Size

Defect Location

Reconstructive Technique

Follow-up Period

Inclusion of PROM

Study

Complications

3.05 cm 2 (mean)

Island pedicle flap Eclabium (n ¼ 1) Hypertrophic scarring requiring dermabrasion (n ¼ 3) Trapdooring

1–5 mo (range) No

Kaufman et al (1996) 24

RR 4

Philtrum

requiring steroid injection (n ¼ 2) Numbness (n ¼ 2) Misalignment of white roll requiring revision surgery (n ¼ 1)

Godek et al (1998) 25

1.70 cm 2 (mean)

164 d (mean)

Yes

RR 12

Composite resection and linear closure

Gloster et al (2002) 26

2.50 cm 2 (mean)

UL: (n ¼ 2)

RR 13

Secondary intention Deformation of the vermilion border (n ¼ 1) LL TZ-transposition flap None reported

6 mo (mean)

Yes

LL: (n ¼ 11)

Trokel et al (2006) 27

RR 11

Central and lateral LL

3 mo (minimum) No

2.60 cm 2 (mean)

FTSG (n ¼ 4)

Housman et al (2008) 28

Philtrum

Pigmentary

3–49 mo (range) No

Island pedicle flap (n ¼ 2) Advancement flap (n ¼ 1)

discrepancy (n ¼ 1) FTSG Eclabium (n ¼ 1) FTSG Scarring requiring dermabrasion (n ¼ 3) FTSG reaction (n ¼ 6): CFA-S: (n ¼ 5), CFA-M: (n ¼ 1) Hypertrophic scarring (n ¼ 22): CFA-S: (n ¼ 14), CFA-M: (n ¼ 8) Pyogenic granuloma (n ¼ 2) CFA-S (n ¼ 1), CFA-M (n ¼ 1):

RR 138

3cm

UL and LL

Direct linear closure (73%)

None

Soliman et al (2009) 17

(maximum diameter)

1–3 cm 2 (range)

CFA-S (n ¼ 16)

Johanson-Johangir et al (2012) 29

RR 33

Central UL

Foreign body

CFA-M (n ¼ 17)

Huilgol et al (2014) 30

2.30 cm 2 (mean)

UL: (n ¼ 8)

Double island

Hypertrophic scarring

LL: (n ¼ 2)

pedicled flap

(n ¼ 2) UL þ LL Postoperative

bleed requiring flap takedown (n ¼ 1) LL Vermilionectomy (n ¼ 1) LL

Jacono

RR 7

1.2–2.1 cm

Central UL

Bilateral

None

8 mo (mean)

et al (2015) 31

(range of diameter)

transposition flap

CFA, cervicofacial advancement flap; CFA-M, modified cervicofacial advancement flap; CFA-S, unmodified cervicofacial advancement flap; CS, case series; FTSG, full thickness skin graft; LL, lower lip; NS, not stated; PCAF, perialar crescenteric advancement flap; PROM, patient-reported outcome measure; RR, retrospective review; SC, subcutaneous plane dissection was used; UL, upper lip.

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complications, including a 7% rate of ectropion and a 41% rate of sensory neuropathy. 20 This highlights the need for adequate postoperative follow-up and monitoring. Of note, only 50% of studies using the CFA documented patient follow-up period, further emphasizing the potential for an incomplete understand ing of complications. A variation of this flap, the deep CFA (DCFA) flap is an axial pattern flap dissected below the superficial muscular aponeurotic system (SMAS). This deeper plane of dissection confers increased tissue mobility while preserving adequate blood supply. Prior studies have shown decreased rates of edge necrosis in this sub group. 38–40 However, it has been criticized due to its technical difficulty, risk of iatrogenic nerve injury, longer dissection time, and increased risk of ectropion. 16,37,41 Although the majority of flaps reviewed in this series were dissected in the subcutaneous plane, it must be noted that there were no episodes of flap edge necrosis or ectropion when the DCFA was used, including in higher-risk smoking populations. This emphasizes the clinical versatility and potential applicability of the DCFA for reconstruc tion of larger-sized defects and for smokers. Other local flaps including the subcutaneous tissue-island pedi cled flap, V-Y advancement flap, and inferiorly-based rotation flap have been described for reconstruction of defects of the medial cheek. 3,19 This is consistent with available literature that highlights the ability of these flaps to exploit available redundant skin in the jowl for defect closure. The inferiorly based rotation flap, although studied in a small sample size, reported no complications including ectropion or flap necrosis. It does not require extensive tissue dissection and can be fashioned so that incision scars are camouflaged along the nasolabial folds and relaxed skin tension lines. 41 The minimal amount of tissue needed to raise the flap and recent success in a patient population on chronic anticoagulation support warrant further inves tigation of its application as an alternative to the traditional CFA. 39 Similar to the cheek, closure by direct linear repair was the preferred technique whenever possible for closure of small forehead defects. Available literature has emphasized the orientation of closure in certain forehead regions to optimize cosmesis. 17,42 The glabella is a forehead subunit which merits special attention due to its aesthetically prominent location, relative paucity of surrounding tissue for reconstruction, and anatomic proximity to the brows and eyelids. 43 Vertical closure was described for defects in this region, as it was less likely to cause hairline and brow distortion. 12 Rotation advancement flaps have also been detailed for this special zone. The periglabellar advancement flap has been described as a reconstructive approach for central forehead defects ( < 5 cm) that employs superiorly and inferiorly placed Burow’s triangles to facilitate skin rotation into the defect, providing aes thetically pleasing results. However, its applicability to an entirely post-Mohs surgical population has not yet been assessed. 43 Local flaps were more frequently used for larger-sized and lateral forehead defects. A common theme among the flaps reviewed in this series was the optimization of nearby tissue for closure. Advancement flaps facilitate mobilization of large amounts of neighboring tissue for reconstruction. Although reported in the literature, this review did not identify any complications associated with extensive tissue under mining in this region, including sensory deficits. 44,45 A promising technique for paramedian and lateral forehead defects is the contra lateral subgaleal sliding flap. Although described in a low-powered study, it offers an alternative approach for defects in forehead regions with less tissue mobility. 23 It requires less dissection compared to other described flaps. Additionally, it is often performed under local anesthesia, conferring potential financial benefits given the low complication rate documented in the study. The perioral region had the smallest mean defect size; how ever, reconstruction of defects in this region can have significant

perialar crescent excision and lateral cheek advancement was used for larger, full-thickness defects (mean ¼ 2.6 cm 2 ). 25 Healing by secondary intention was described in 1 study for defects of the upper and lower lip with vermilion and mucosal involvement. 26 Local flaps were the preferred reconstructive option for the perioral region and were described in 67% of studies, irrespective of involved subunit. 24,27–30 Mucosal advancement flaps and island based pedicle flaps were used for defects involving the mucosa, vermilion border, and inferior aspect of the philtrum. 28 Bilateral transposition flaps were described for single-stage reconstruction of central defects involving Cupid’s bow and the philtral column, partial thickness defects, and for defects with vermilion and red lip involvement (Fig. 2C). 31 Perioral reconstruction had varying complication rates based on subunit involvement and reconstructive technique. Upper lip recon struction was associated with more complications than lower lip reconstruction, with incidences of upper lip hypertrophic scarring, misalignment of the white roll, and deformation of the vermilion border (Table 7). 25,28,29 These complications were not described in lower lip reconstruction. Philtral reconstruction was associated with eclabium, hypertrophic scarring, and development of pyogenic granulomas. 24,28 Hypertrophic scarring was observed in 3 studies that all used local flaps for reconstruction of philtral and upper lip defects. 24,29,30 Two studies included patient-reported outcomes by using modified Likert scales. 25,26 DISCUSSION Mohs surgery has changed the landscape for defect reconstruction after facial cutaneous malignancy extirpation. This technique is associated with increased tissue preservation and higher cure rates. 32,33 It has emerged as an increasingly popular alternative approach to traditional wide-local excision. 1,2 The aim of this study was to identify common reconstructive approaches for 3 central aesthetically prominent facial locations. Although multiple recon structive techniques for each aesthetic subunit were identified, direct linear closure was still a valued technique particularly for smaller lesions, with minimal complications reported. Healing by secondary intention was used less frequently due to factors includ ing unpredictability of clinical outcome and unfavorable ultimate cosmesis. 12,34,35 Scar contracture may also be a significant factor. 36 For larger defects and in defects located in topographically complex areas, it is necessary to apply the concept of the reconstructive ladder for closure. The increased complication rate associated with more complex reconstructions should be justified by better aesthetic results and more predictable closure. Although linear closure was commonly described for defects in the cheek, flaps were the preferred closure method in two-thirds of all studies. Soliman et al championed direct linear repair over local flaps for closure of larger-sized defects (up to 4 cm in width) due to the cheek’s tissue laxity, rich sub-dermal vascularity, and ability to generously undermine the tissue. 17 Despite having the highest complication rate, the CFA was the most common technique for larger cheek defects averaging 21 cm 2 in this review. Historically, the CFA flap has served as a mainstay for cheek reconstruction. Traditionally, the CFA is dissected in the subcu taneous plane, provides good color and texture matching, and can be used for defects located in various areas of the cheek. 3,16 However, its utility can be limited due to factors, including unpredictable vasculature, decreased flap mobility, inconsistent blood supply, and increased frequency of distal edge necrosis. 37 One study in this review described a high incidence of late-onset Perioral Region: Surgical Outcomes and Patient Satisfaction

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significant study heterogeneity in methodology, design, and out come assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. In addition, there is a notable absence of patient centered outcome instruments included in studies. Future efforts may be directed toward identification of a validated instrument to contour selection of reconstructive strategy. REFERENCES 1. Asgari MM, Olson JM, Alam M. Needs assessment for Mohs micrographic surgery. Dermatol Clin 2012;30:167–175 2. Valent´ın-nogueras SM, Broadland DG, Zitelli JA, et al. Mohs micrographic surgery using Mart-1 immunostains in the treatment of invasive melanoma and melanoma in situ. Dermatol Surg 2016;42:733–744 3. Pepper JP, Baker SR. Local flaps: cheek and lip reconstruction. JAMA Facial Plast Surg 2013;15:374–382 4. Rohrich RJ, Griffin JR, Ansari M, et al. Nasal reconstruction - beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405–1416 5. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239–247 6. Park SS. Reconstruction of nasal defects larger than 1.5 centimeters in diameter. Laryngoscope 2000;110:1241–1250 7. Guo L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local flaps: a simple algorithm for management of small defects. Plast Reconstr Surg 2008;122:130e–139e 8. Zitelli JA, Fazio MJ. Reconstruction of the nose with local flaps. J Dermatol Surg Oncol 1991;17:184–189 9. Jacobs MA, Christenson LJ, Weaver AL, et al. Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose. Dermatol Surg 2010;36:23–30 10. Mohs FE, Snow SN, Larson PO. Mohs micrographic surgery fixed tissue technique for melanoma of the nose. J Dermatol Surg Oncol 1990;16:1111–1120 11. Rapstine ED, Knaus WJ, Thornton JF. Simplifying cheek reconstruction: a review of over 400 cases. Plast Reconstr Surg 2012;129:1291–1299 12. Quatrano N, Dawli T, Park A, et al. Simplifying forehead reconstruction: a review of more than 200 cases. Facial Plast Surg 2016;32:309–314 13. Becker GD, Adams LA, Levin BC. Spontaneous healing of Mohs wounds of the cheek: a cosmetic assessment. Dermatol Surg 1998;24:1375–1382 14. Rustad TJ, Hartshorn DO, Clevens R, et al. The subcutaneous pedicle flap in melolabial reconstruction. Arch Otolaryngol Head Neck Surg 1998;124:1163–1166 15. Fader DJ, Wang TS, Johnson TM. The Z-plasty transposition flap for reconstruction of the middle cheek. J Am Acad Dermatol 2002;46:738–742 16. Austen WG Jr, Parrett BM, Taghinia A, et al. The subcutaneous cervicofacial flap revisited. Ann Plast Surg 2009;62:149–153 17. Soliman S, Hatef DA, Hollier LHJ, et al. The rationale for direct linear closure of facial Mohs’ defects. Plast Reconstr Surg 2011;127:142–149 18. Jacono AA, Rousso JJ, Lavin TJ. Comparing rates of distal edge necrosis in deep-plane vs subcutaneous cervicofacial rotation advancement flaps for facial cutaneous Mohs defects. JAMA Facial Plast Surg 2014;16:31–35 19. Lewin JM, Sclafani AP, Carucci JA. An inferiorly based rotation flap for defects involving the lower eyelid and medial cheek. Facial Plast Surg 2015;31:411–416 20. van Onna MA, Haj M, Smit JM, et al. Long-term outcome of the cheek advancement flap, a report of 41 cases. J Plast Surg Hand Surg 2016;50:354–358 21. Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg 1999;121:751–754 22. Ransom ER, Jacono AA. Double-opposing rotation-advancement flaps for closure of forehead defects. Arch Facial Plast Surg 2012;14:342–345

cosmetic ramifications by distorting important anatomic bound aries and relationships. 3,46 Despite many studies highlighting flap closure as preferable in this region, direct linear closure has been described as an appropriate mode of closure for small, cutaneous defects of the upper and lower lip. 47 In this review, direct linear repair was used as the predominant mode of closure in one study to close defects spanning 40% the width of the upper lip and 50% of the lower lip with favorable cosmesis. 17 Additionally, although maximizing the quantity of available tissue for closure may seem intuitive, Huilgol et al demonstrated excellent functional and aesthetic outcomes through composite defect excision and repair by direct linear closure. 30 Lower lip closure has been described as less technically challenging. In this review, there was a lower incidence of complications in this region compared to the upper lip (see Table 7). 17,30 The central lip and philtrum have been described as more technically challenging due to the need to respect anatomic landmarks to restore anatomy. 48 Defects with more soft tissue extension and greater diameter were associ ated with a higher rate of postoperative complications. 25,26,28 Past surgical experience of lip defect closure has included frequent use of techniques such as the Abbe´ flap, Gillies flap, and Karapandzic flap. 49–54 Their use was not identified in this review, perhaps reflecting a decline in their utility in the post-Mohs population. This could be attributed to smaller defect size observed in this review or lack of studies detailing reconstruction of lesions with commissure involvement. There was a lack of consensus regard ing the use of full-thickness skin grafts across these studies. Concerns for its application included contraction, poor skin matching, and resulting deformity in an aesthetically sensitive area. 3,30 This review has revealed a lack of patient-reported outcomes. Only 19% of studies included some measure of patient reported satisfaction using a modified Likert scale to assess outcome vari ables including cosmesis and function. No study assessed psycho logic outcomes or social function after facial reconstruction. Moreover, the majority of studies (81%) either did not include patient outcomes or reported surgeon/author outcome assessments. These analyses have the potential to introduce bias into studies, as authors may tend to report only positive outcome results. This is concerning, as central facial defects are associated with a particu larly high social penalty. 55–57 A lack of patient-reported outcome information could inappropriately result in performance of surgical techniques that do not optimize patient satisfaction. Future studies should routinely include validated outcome instruments to mini mize these risks. 58–60 Limitations This present study has notable limitations. The quality of available literature influenced our review, as studies were either retrospective analyses or cases series. This introduces the possibil ity of selection bias. The heterogeneity of included studies limited our ability to synthesize data across studies. For example, many studies did not report mean defect size and depth, involvement of underlying structures, or follow-up time. We attempted to address this by calculating mean defect size and average follow-up time whenever possible through available study data. We also did not extract data regarding malignancy type or cancer recurrence, which may have influenced modality of closure selected. Additionally, the inconsistent, or lack of follow-up times reported in studies may not have captured complication profiles of certain techniques. CONCLUSION Mohs surgery has become a valuable surgical approach for treat ment of facial skin malignancies. This review has identified

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The Journal of Craniofacial Surgery Volume 30, Number 2, March 2019

Facial Reconstruction After Mohs Surgery

23. Hussain W. The contralateral subgaleal sliding flap for the single-stage reconstruction of large defects of the temple and lateral forehead. Br J Dermatol 2014;170:952–955 24. Kaufman AJ, Grekin RC. Repair of central upper lip (philtral) surgical defects with island pedicle flaps. Dermatol Surg 1996;22:1003–1007 25. Godek CP, Weinzweig J, Bartlett SP. Lip reconstruction following Mohs’ surgery: the role for composite resection and primary closure. Plast Reconstr Surg 2000;106:798–804 26. Gloster HM. The use of second-intention healing for partial-thickness Mohs defects involving the vermilion and/or mucosal surfaces of the lip. J Am Acad Dermatol 2002;47:893–897 27. Trokel Y, Finn R. TZ-transposition flap: an alternate method of lower lip reconstruction for partial thickness defects. J Oral Maxillofac Surg 2006;64:1381–1384 28. Housman TS, Berg D, Most SP, et al. Repair of the philtrum: an illustrative case series. J Cutan Med Surg 2008;12:288–294 29. Johnson-Jahangir H, Stevenson M, Ratner D, et al. Modified flap design for symmetric reconstruction of the apical triangle of the upper lip. Dermatol Surg 2012;38:905–911 30. Huilgol SC, Ma JH, Hills RJ. Double island pedicle or VY flap repair for partial-thickness combined defects of the cutaneous and mucosal lip. J Am Acad Dermatol 2014;71:1198–1203 31. Jacono AA, Bassiri M, Talei B. Bilateral transposition lip flaps: a novel single-stage reconstruction of central upper lip defects involving cupid’s bow. JAMA Facial Plast Surg 2015;17:219–223 32. Merritt BG, Lee NY, Brodland DG, et al. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol 2012;67:1302–1309 33. Chuang GS, Leach BC, Wheless L, et al. Preoperative expectations and values of patients undergoing Mohs micrographic surgery. Dermatol Surg 2011;37:311–319 34. Patel SA, Liu JJ, Murakami CS, et al. Complication rates in delayed reconstruction of the head and neck after mohs micrographic surgery. JAMA Facial Plast Surg 2016;18:340–346 35. Donaldson MR, Coldiron BM. Scars after second intention healing. Facial Plast Surgery 2012;28:497–503 36. Van der Eerden PA, Lohuis PJ, Hart AA, et al. Secondary intention healing after excision of nonmelanoma skin cancer of the head and neck: statistical evaluation of prognostic values of wound characteristics and final cosmetic results. Plast Reconstr Surg 2008;122:1747–1755 37. Vuyk HD. Forehead, temple and scalp reconstruction. In: Vuyk HD, Lohuis PJFM, eds. Cutaneous Flaps in Head and Neck Reconstruction. London, UK: Hodder Arnold Publication; 2006 38. Cole EL, Sanchez ER, Ortiz DA, et al. Expanded indications for the deep plane cervicofacial flap: aesthetic reconstruction of large combined temporofrontal and brow defects. Ann Plast Surg 2015;74:543–548 39. Delay E, Lucas R, Jorquera F, et al. Composite cervicofacial flap for reconstruction of complex cheek defects. Ann Plast Surg 1999;43:347–353 40. Tan ST, Swee T, MacKinnon CA. Deep plane cervicofacial flap: a useful and versatile technique in head and neck surgery. Head Neck 2006;28:46–55 41. Kroll SS, Reece GP, Robb G, et al. Deep-plane cervicofacial rotation advancement flap for reconstruction of large cheek defects. Plast Reconstr Surg 1994;94:88–93

42. Quatrano NA, Stevenson ML, Scalafani AP, et al. VY advancement flap for defects of the lid–cheek junction. Facial Plast Surg 2017;33:329–333 43. Dabiri G, Tiger J, Anderson H, et al. patient satisfaction after Mohs surgery is not dependent on seeing post-Mohs defect prior to repair. J Clin Aesthet Dermatol 2015;8:33–37 44. Goldberg LH, Silapunt S, Alam M, et al. Surgical repair of temple defects after Mohs micrographic surgery. J Am Acad Dermatol 2005;52:631–636 45. Olson MD, Hamilton GS. Scalp and forehead defects in the post-Mohs surgery patient. Facial Plast Surg Clin North Am 2017;25:365–375 46. Levender MM, Ratner D. Reconstructing complex central facial defects involving multiple cosmetic subunits. Facial Plast Surg 2013;29:394–401 47. Ibrahim AM, Rabie AN, Borud L, et al. Common patterns of reconstruction for Mohs defects in the head and neck. J Craniofac Surg 2014;25:87–92 48. Larrabee YC, Moyer JS. Reconstruction of Mohs defects of the lips and chin. Facial Plast Surg Clin North Am 2017;25:427–442 49. Birgfeld CB, Chang B. The periglabellar flap for closure of central forehead defects. Plast Reconstr Surg 2007;120:130–133 50. Filimon S, Richardson K, Hier MP, et al. The use of a modified abbe´ island flap to reconstruct primary lip defects of over 80%. J Otolaryngol Head Neck Surg 2016;45:35 51. Whang KK, Do MO, Lee S, et al. W-Modification of Abbe flap after Mohs surgery of squamous cell carcinoma on the lower lip. Dermatol Surg 2007;33:485–487 52. Berens AM, Akkina SR, Patel SA. Complications in facial Mohs defect reconstruction. Curr Opin Otolaryngol Head Neck Surg 2017;25:258–264 53. Luce EA. Upper lip reconstruction. Plast Reconstr Surg 2017;140:999–1007 54. Bagatin M, Most SP. The Abbe flap in secondary cleft lip repair. Arch Facial Plast Surg 2002;4:194–197 55. Sclafani AP, Sclafani JA, Sclafani AM. Successes, revisions, and postoperative complications in 446 Mohs defect repairs. Facial Plast Surg 2012;28:358–366 56. Dey JK, Ishii LE, Byrne PJ, et al. The social penalty of facial lesions: new evidence supporting high-quality reconstruction. JAMA Facial Plast Surg 2015;17:90–96 57. Godoy A, Ishii M, Byrne PJ, et al. How facial lesions impact attractiveness and perception: differential effects of size and location. Laryngoscope 2011;121:2542–2547 58. van Leeuwen AC, The A, Moolenburgh SE, et al. A retrospective review of reconstructive options and outcomes of 202 cases large facial Mohs micrographic surgical defects, based on the aesthetic unit involved. J Cutan Med Surg 2015;19:580–587 59. Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol 2011;147:1387–1394 60. Pusic AL, Klassen AF, Scott AM, et al. Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale. ClinPlast Surg 2013;40:249–260

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Research

JAMA Facial Plastic Surgery | Original Investigation

Complication Rates in Delayed Reconstruction of the Head and Neck After Mohs Micrographic Surgery

Sapna A. Patel, MD; Jack J. Liu, MD; Craig S. Murakami, MD; Daniel Berg, MD; Sarah R. Akkina, MD, MS; Amit D. Bhrany, MD

IMPORTANCE Same-day Mohs reconstructive surgery is not always possible owing to patient factors, scheduling, and complexity of defect, but there is hesitancy in delaying closure of such defects.

OBJECTIVE To describe the frequency of and predictors of complications in patients undergoing delayed facial reconstruction after Mohs micrographic surgery (MMS).

DESIGN, SETTING, AND PARTICIPANTS This was a retrospective, multi-institutional cohort study from February 1, 1989, to December 31, 2012. Data were pooled from 2 institutions: University of Washington Medical Center and Virginia Mason Medical Center. All patients who underwent MMS for facial carcinomas with delayed (non–same-day) reconstruction were included. We excluded those with incomplete medical records and no follow-up. The analysis was performed from June 2014 to March 2016. MAIN OUTCOMES AND MEASURES Our main outcome measure was postoperative complication, classified as immediate ( 24 hours after surgery) or delayed (>24 hours after surgery). RESULTS A total of 415 cases in 342 patients were identified. Reconstruction occurred from 1 to 11 days after excision, with 95.4% of repairs occurring within 2 days of MMS. The overall complication rate was 8.2%. The total delayed complication rate was 7.7% (32 of 415 cases). The overall infection rate was 2.4%. In terms of patient characteristics, reconstruction delayed more than 2 days, bone or cartilage exposure, and large defects were associated with complications. In terms of defect location and reconstruction type, complications were associated with composite defects (those that included >1 facial subunit) and use of interpolated flaps with cartilage grafting. We used these variables in a multivariable logistic regression model and found that composite location, use of interpolated flap with cartilage grafting, and reconstruction delayed more than 2 days were associated with postoperative complications. Among the variables in the model, composite location of defects, interpolated flap with cartilage grafting, and delayed reconstruction greater than 2 days were found to have a statistically significant association with a complication (OR, 3.48 [95% CI, 1.16-10.56]; OR, 4.93 [95% CI, 1.44-16.95]; OR, 4.26 [95% CI, 1.24-14.60], respectively). CONCLUSIONS AND RELEVANCE To our knowledge, this is the largest study to report complication rates in delayed reconstruction of MMS defects in the head and neck, noting a rate that is similar to what has been reported in the literature. We noted a statistically significant increased risk of complications when reconstruction is performed for composite defects, if an interpolated flap with cartilage is performed, and if reconstruction is performed after more than 2 days. Downloaded by UCSF Library University of California San Francisco from www.liebertpub.com at 04/08/24. For personal use only.

Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle (Patel, Akkina, Bhrany); Department of Otolaryngology, Kaiser Permanente, Irvine, California (Liu); Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington (Murakami); Seattle Skin Cancer Center, Seattle, Washington (Berg). Corresponding Author: AmitD. Bhrany, MD, Department of Otolaryngology–Head and Neck Surgery, University of Washington, 1959 NE Pacific St, PO Box 356515,

LEVEL OF EVIDENCE 3.

Seattle, WA 98195 (abhrany@uw.edu).

JAMA Facial Plast Surg . 2016;18(5):340-346. doi:10.1001/jamafacial.2016.0363 Published online May 26, 2016. Corrected on September 15, 2016.

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Original Investigation Research

Complication Rates in Delayed Mohs Reconstruction Surgery

S kin cancer is the most common malignant neoplasm, with more than 5.4 million cases diagnosed annually in the United 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 to plan and discuss their method of closure with patients, which can be useful when op timal repair may involve more complex methods of repair. Patients referred for delayed reconstruction often have larger or more complex defects; higher complication rates may 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 to describe 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 reconstructive Current Procedural Terminology code. We excluded patients with incomplete medical records that did Methods Study Design and Participants

not provide adequate medical history, wound details, and post operative follow-up. Patients who had same-day reconstruc tion were also excluded. Deidentified patient information was 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 occurred within 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 cultures were 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

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