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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 reconstructions were delayed was not recorded. Among those with complete follow-up data, 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 could be due to increased use of more 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 a much more rigorous definition for wound infection, requiring wound culture confirmation, whereas our study defined wound 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 sociated with complications in the multivariate model. 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 location was linked to complications, dimension of the defect was not statistically significant in the multivariate model. From a 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 association with complications when 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, while most previous reports assess MMS 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 reconstructions were skin grafts or local flaps with defect size ranging from 1 to 10 cm with a median size of 2 to 3 cm. The total complication rate was 5.5% (3 of 55 pa tients). Two patients had wound infections (3.6%), a rate which 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 compared with 89% of the patients in our study un dergoing repair within 2 days of their Mohs resection. Escobar and Zide 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%) closed with full-thickness skin grafts developed superficial necrosis. Although all reconstruc tions were delayed about 1 week after excision, and MMS 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 after MMS assessed reconstructions performed by non 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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344 JAMA Facial Plastic Surgery September/October 2016 Volume 18, Number 5 (Reprinted)

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