xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Original Investigation Research

Complication Rates in Delayed Mohs Reconstruction Surgery

cations; of the 51 who underwent full-thickness skin graft for reconstruction, the complication rate was 7.8% (4 of 51 pa tients). The complications noted include hematoma (1 pa tient), partial/full loss (2 patients), and infection (1 patient), but we did not assess for graft hypertrophy, graft depression, and wound contracture; all of which are linked with use of a skin graft, and were listed as complications in the aforemen tioned studies. Our study has several limitations, mainly related to its ret rospective nature. Many patients had to be excluded owing to lack of descriptions of wound characteristics and lack of ad equate follow-up. For those included, we were limited be cause some complications may not have been recorded in the medical record. In addition, defining certain complications, such as a wound infection, is subjective and may differ with multiple reconstructive surgeons documenting follow-up. For this reason, we excluded any unfavorable wound healing, such as scar erythema or thickening. Another limitation is that the cohort underwent reconstruction by multiple surgeons, and there may be variation in reconstructive techniques used. At our institution, the goal is for all patients to undergo immedi ate reconstruction of MMS head and neck defect, but same day reconstruction is not always possible. The lack of a con trol or comparison group, specifically those undergoing Mohs reconstruction on the same day, is an additional limitation. We used a historical data as comparisons to identify the risk of com plications from same-day Mohs reconstruction. Finally, al though certain factors were found to be significant in univari ate analysis, with the small sample size for some of these groups, some of these associations could be due to chance and thus must be interpreted with caution. This is also true for the multivariate model because only 19 patients underwent re construction delayed more than 2 days. Conclusions To our knowledge, our study is the largest series of patients undergoing delayed reconstruction for MMS defects in the head and neck, with an overall complication rate of 8.2%. In univariate analysis, higher rates of complication were associ ated with larger defects, those with bone and/or cartilage exposure, composite location, interpolated flap with carti lage grafting, and those undergoing reconstruction more than 2 days after MMS. In multivariate analysis, composite location, use of an interpolated flap with cartilage grafting, and reconstruction delayed more than 2 days were signifi cantly associated with complications when controlling for the significant univariate variables. Many of these defects require a more complex reconstruction, increasing the possi bility of complications.

specifically those with cartilage exposure, were associated with an increased risk of complication in the multivariate model; for these, there is a separate donor site, and this type of pro cedure is often reserved for larger-sized defects. These recon structions are also likely to have a higher rate of preoperative bone or cartilage exposure, which was associated with a sig nificantly higher rate of complication on univariate but not multivariate analysis. Newlove and Cook 7 had similar find ings with respect to the complication rate for interpolated flaps. Although they 7 did not provide a summed complication rate for all interpolated flaps, they concluded that there was a higher rate of complications with flap repair, particularly with epi dermolysis, bleeding, and a higher rate of infection. For our series, over half of the complications among those undergo ing interpolated flaps were specific to the nasal and perior bital region, such as saddle nose deformity, nasal vestibular stenosis, septal perforation, and epiphora. 4,10-12 These com plications are likely related more to the type and extent of de fect than delay of reconstruction. Medical comorbidities, such as tobacco abuse and diabe tes, are often linked with poor wound healing. 8,13,14 How ever, in our study, these factors were not associated with sig nificantly higher rates of complications. Complications related to bleeding, such as hematoma or hemorrhage, were the most commonly reported in multiple other studies, 3,5,7 but inour series, it was noted among 6 of 415 patients (1.4%). For recon struction, anticoagulants are typically held to minimize the risk of bleeding, but in certain patients, this is not an option. We did not abstract specific data on how many patients contin ued their anticoagulation therapy and whether this was linked to increased bleeding risk. Interestingly, 2 different case control studies comparing those who underwent facial plas tic surgery in whom anticoagulation was continued with those in whom it was held, there was no statistically significant dif ference in the rate of complications. 15,16 Days until reconstruction was linked to a higher inci dence of complications in our study in both the univariate analysis and the multivariate model, when classified as more than 2 days or 2 days or less. But only 19 of 415 patients un derwent reconstruction after more than 2 days, of whom 6 of 19 had a complication. Five of the 6 who experienced compli cations had large wounds, and 2 of the 6 required cartilage grafting. Although not statistically significant owing to the small numbers of patients undergoing repair after more than 2 days, it is possible that the increased risk of complications was more related to the wound and complexity of repair in these patients than the delay itself. In fact, others have shown that longer delay may even improve outcomes. 2,17-19 Ithasbeen theorized that this delay allows for secondary wound healing to ensue, thereby increasing the blood supply. 17-19 In our study, use of a skin graft was not linked with a higher rate of compli

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Published Online: May 26, 2016. doi:10.1001/jamafacial.2016.0363.

ARTICLE INFORMATION Correction: This article was corrected online on September 15, 2016, to add odds ratios to the Results section of the Abstract and main article. Accepted for Publication: March 19, 2016.

Study concept and design: Liu, Murakami, Berg, Bhrany. Acquisition, analysis, or interpretation of data: Patel, Liu, Akkina, Bhrany. Drafting of the manuscript: Patel, Liu, Akkina, Bhrany.

Author Contributions: Drs Patel and Bhrany had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

(Reprinted) JAMA Facial Plastic Surgery September/October 2016 Volume 18, Number 5 345

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