xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Original Investigation Research

Complication Rates in Delayed Mohs Reconstruction Surgery

Table 5. Complication Rate Based on Type of Reconstruction and Location of Defect Type of Reconstruction or Location No. of Complications/ No. (%) a

Table 4. Complication Rate–Based Potential Risk Factors

No. of Complications/ No. (%) a

P Value b

Characteristic

P Value b

Sex

.47

Reconstruction

Male

16/170 (9.4) 18/245 (7.3)

Complex closure

2/74 (2.7) 5/67 (7.5) 4/62 (6.4)

.06

Female

Free grafts

>.99

Smoking

.37

FTSG STSG

.80

No Yes

28/360 (7.8) 5/36 (13.9)

0/4 0/1

NA NA

Both FTSG and STSG

Unknown

1/18 (5.6)

Local flap

13/195 (6.7) 12/50 (24.0) 10/31 (32.2)

.37

DM, HIV, immunosuppression

>.99

Interpolated local flap

<.001 <.001

No Yes

30/366 (18.1)

With cartilage

4/49 (8.2)

Composite graft

2/28 (7.1)

>.99

Reconstruction delayed >2 d

.002

Microvascular free flap

No Yes

28/396 (7.1) 6/19 (31.6)

Location Scalp

1/43 (2.3) 4/28 (14.2) 14/185 (7.6) 2/44 (4.5) 4/27 (14.8) 1/40 (2.5)

.23 .27 .72 .56 .26 .23

Recurrent lesion

.75

Forehead

No Yes

28/344 (8.1) 5/50 (10.0)

Eyelid

Nose

Unknown

1/21 (4.8)

Cheek

Bone and/or cartilage exposure

.001

Ear Lip

No Yes

21/338 (6.2) 13/68 (19.1)

0/3 0/5

NA NA

Chin Neck

Large defects (>2 cm; >1.5 cm onnose)

.01

7/23 (30.4) 2/74 (2.7)

.001

No Yes

8/188 (4.2)

Composite

.06

26/227 (11.4)

Abbreviations: FTSG, full-thickness skin graft; NA, not applicable; STSG, split-thickness skin graft. a No. of complications/No. is based on number of Mohs reconstruction cases rather than number of patients. b Either Fisher exact test or χ 2 test was used based on the cell value.

Coumadin

.71

No Yes

22/280 (7.9)

Complications were stratified by patient characteristics, defect location, and reconstructive modality. In terms of pa tient characteristics, delayed reconstruction greater than 2 days, bone or cartilage exposure, and large defects had higher risk of complications ( Table 4 ). In regard to defect location, composite facial defects had a significantly higher rate of com plications ( Table5 ). The use of interpolated flaps in conjunc tion with cartilage grafts was the reconstructive modality with the highest rate of complications (Table 5). Multivariate logistic regression models were used to compare the association between days until reconstruction, interpolated flap with cartilage grafting, composite location, bone and/or cartilage exposure, and defect dimensions with the complication rate, because these factors were found to be statistically significant on univariate analysis. The overall model had a likelihood ratio of 31.76 ( P < .001). Among the variables in the model, composite location of defects, inter polated flap with cartilage grafting, and delayed reconstruc tion greater than 2 days were found to have a statistically sig nificant 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). 12/135 (8.9) Abbreviations: DM, diabetes mellitus; HIV, human immunodeficiency virus. a No. of complications/No. is based on number of Mohs reconstruction cases rather than number of patients. b Either Fisher exact test or χ 2 test was used based on the cell value.

Discussion Complication rates associated with MMS defect reconstruc tion in the head and neck have been reported to range from 1%to19%. 3-8 Our study sought to characterize the complica tions associated with delayed (non–same-day) reconstruc tion of head and neck MMS defects, and to determine which, if any, patient and defect characteristics are associated with a higher rate of postoperative complications. Wound infection and a group of complications described as other (including na sal vestibular stenosis, saddle deformity, septal perforation, chronic epiphora, lower eyelid retraction) were most com mon, both occurring in 2.4% of patients. None of the wound infections required return to the operating room for manage ment or hospitalization for intravenous antibiotics. The inci dence of postoperative hematoma or hemorrhage occurred in less than 1%. Our total complication rate was 8.2%, with the following characteristics having a statistically significant as sociation with complications on univariate analysis: larger wounds (>2.0 cm; >1.5 cm on the nose), exposed bone/ cartilage, composite facial defects occupying greater than 1 fa cial subunit, the use of interpolated flaps with cartilage graft ing, and a reconstruction occurring greater than 2 days after MMS. In the multivariate model, the use of interpolated flaps

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(Reprinted) JAMA Facial Plastic Surgery September/October 2016 Volume 18, Number 5 343

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