xRead - Facial Reconstruction Following Mohs Micrographic Surgery

Given the importance of balancing adequate pain control with minimizing opioid prescriptions, prescribing recom mendations are warranted. The Delphi method obtains expert opinion through rounds of questionnaires with interval feedback regarding the group ’ s responses. Each round aims to narrow the range of responses in order to arrive at a consensus. This approach allows for a smaller group to provide expert consensus. 13 This Delphi study aimed to provide prescribing recommendations by identi fying scenarios in which an opioid prescription should, or should not, be routinely prescribed after MMS and reconstruction. Methods After obtaining approval from the University of Texas Southwestern Institutional Review Board, a panel of American College of Mohs Surgery members was formed. Seventy-one potential panelists were invited to participate in the study in an attempt to create a panel that represents a broad geographic range and various practice settings, and it included surgeons who were in different stages of their posttraining practice. The initial questionnaire allowed participants to describe scenarios in which they prescribe opioids at different frequencies. Invitees were informed that they would be excluded from further participation in the study if they provide opioid prescriptions to all patients afterMMS. Scenarios that were listed by participants in the initial questionnaire, along with previously described potential predictors of postoperative pain, 5 – 8,10 – 12 underwent 2 Delphi rating rounds. In the rating rounds, panelists were asked to rank the frequency at which they provide an opioid prescription in specific scenarios. The response scale ranged from 1 to 9 with 1 to 3 representing “ never to rarely, ” 4to6 “ about half the time, ” and 7 to 9 as “ often to always. ” Consensus was set a priori at $ 80% agreement of panelists. Scenarios in which $ 80% of panelists “ often or always ” prescribe an opioid were considered indications for an opioid prescription. Conversely, for scenarios in which $ 80% of panelists “ never or rarely ” provide an opioid prescription, a recommendation was made to not routinely provide opioid prescriptions. A narrative of the results and a draft of the recommendations were distributed to the panelists for review and approval. Results Twenty-four Mohs surgeons responded to the initial invitation. One declined to participate due to conflict, but no respondent met the exclusion criteria of always pro viding opioid prescriptions. Characteristics of the 23 participants are shown in Table 1. Sixty-five percent of participants noted that there is no scenario in which they always provide an opioid prescription, with over-the counter analgesics, including acetaminophen and non steroidal anti-inflammatory agents being first line (See TableS2, Supplemental Digital Content 1 , http://links.lww. com/DSS/A430). When providing opioids, 70% of panelists “ often to always ” prescribe # 10 pills, 83% “ never to

rarely ” prescribe $ 16 pills, and none provide refills (See TableS3, Supplemental Digital Content 1 , http://links.lww. com/DSS/A430). In the rating rounds, there were no scenarios for which consensus was met to routinely prescribe an opioid. Consensus was reached that an opioid should not routinely be prescribed after MMS based solely upon the number of stages required up to 4 stages, at which point consensus was no longer met. Similarly, there was consensus to not routinely prescribe an opioid based on the depth of the defect when it extends to muscle or cartilage. There were several areas of consensus regarding opioid prescribing based on repair type and location (See Table S2, Supplemental Digital Content 1 , http://links.lww.com/DSS/ A430). Consensus to not routinely prescribe an opioid was reached for most linear repairs, defects allowed to heal by second intention, grafts # 20 cm 2 , and delayed closures in all locations other than the nail unit. Consensus was not met for flaps, grafts . 20 cm 2 , cartilage grafts, and all nail unit repairs. However, 45.5% of panelists prescribed opioids “ often to always ” for flaps . 60 cm 2 on the scalp and 52.4% of panelists for paramedian forehead flaps on the nose. For patient characteristics (See Table S3, Supplemental Digital Content 1 , http://links.lww.com/DSS/A430), there was consensus to not routinely prescribe an opioid based on age, gender, or distance lived from the clinic or a pharmacy. Patient description of pain tolerance and experience of pain are taken into account by 78.3% and 82.6% of panelists, respectively, when providing an opioid prescription. Con sensus was met to not routinely prescribe an opioid to patients with self-described high pain tolerance, well tolerated pain after previous MMS, or a history of addiction to opioids, alcohol, or illicit drugs. Discussion Although every patient scenario warrants individual consideration, the following are recommended based on the results of this Delphi consensus study: 1. Opioids should not routinely be prescribed to every patient who undergoes MMS. 2. When providing an opioid prescription, providers should consider limiting the number of tablets to # 15 pills with no refills. 3. Factors that do not independently warrant routine opioid prescriptions include a. # 4 Mohs stages required to achieve clear margins. b. Deeper Mohs defects, not extending to bone. c. Defects allowed to heal by second intention or repaired with linear repairs (scalp if # 2.5 cm), flaps # 10 cm 2 , grafts # 20 cm 2 , or delayed repair in any location other than the nail unit. d. Patients with self-described high pain tolerance and those without severe pain with previous MMS. e. Distance patient lives from clinic or a pharmacy. f. Patient age or gender. There is great heterogeneity in the tumor, repair, and patient characteristics that Mohs surgeons encounter. Mohs micrographic surgery can be a relatively straightforward procedure with simple healing but can also produce large

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168 DERMATOLOGIC SURGERY • February 2021 • Volume47 • Number 2

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