Patient-stated post-operative follow-up and suture preferences after Mohs Micrographic Surgery

Introduction:

Understanding post-operative patient preferences following Mohs Micrographic Surgery (MMS) may uncover opportunities to improve patient experience and quality of healthcare delivered. Potential factors contributing to patient preferences may include prior experience with dermatologic surgeries, health literacy, medical comorbidities, and factors related to the Mohs surgery itself.(1) For post-operative care, patients may follow up in-person, securely send a photo to be reviewed by the Mohs surgeon, or simply be instructed to notify the surgeon if a problem arises. Furthermore, suture type may determine follow-up; while nonabsorbable suture often necessitates an in-person visit for removal, the use of absorbable suture may eliminate the need for such a visit unless to check the wound in-person. Previous studies have found comparable efficacy and complications with absorbable vs. nonabsorbable suture, but patient preference for suture type has not yet been well studied.(2,3) This study aimed to assess patient preferences in terms of follow-up and suture type.

Methods:

We conducted phone surveys of patients older than 18 years old who received MMS from October 2022 to February 2023 at a single academic health center. After providing verbal consent, patients were surveyed on preferences for follow-up (in-person, photo-based, vs. no follow-up) and suture (absorbable vs. non-absorbable). Patients were stratified by preference and factors including patient characteristics, previous dermatologic surgery experience, skin cancer characteristics, and MMS characteristics were compared using chi-squared test for categorical variables and either ANOVA or Kruskal-Wallis test depending on normality of continuous variables. Patients were asked cite as many reasons as they wished for their preferences. Qualitative thematic analysis was then used to classify responses into categories.

Results:

Of 180 patients contacted by telephone, 109 answered and 100 consented to survey (35% female, median age 72.5 years [IQR 65-79], median time since surgery 9.4 weeks [IQR 7.9-11]). Table 1 summarizes patient demographics and case-specific elements such as tumor type, H/M/L location, number of stages, defect and repair size, and reconstruction type.(4) 40 (40%) patients followed up in-person, 38 (38%) securely sent a photo, and 22 (22%) had as-needed follow-up.(Supplemental Table 1) 55 (55%) patients received absorbable (fast-absorbing gut) suture, 31 (31%) received non-absorbable (polypropylene) suture, and 14 (14%) had wounds that were allowed to heal by second intention.

Table 1.

Patient demographics, case-specific elements, and factors associated with follow-up and suture preference. ^#Only 1 case.

	Overall (n=100)	Follow-up Preferences					Suture Preferences
		In Person (n=27)	Photo (n=32)	In Person or Photo (n=9)	PRN (n=32)	p- value	Absorbable (n=68)	Non- absorbable (n=3)	No- preference (n=15)	p- value
Age (years; median [Q1, Q3])	72.5 [65.0, 79.0]	74.0 [67.0, 79.0]	73.0 [67.5, 80.0]	75.0 [63.0, 78.0]	68.5 [64.0, 78.2]	0.584	72.5 [66.8, 79.0]	72.0 [69.5, 76.5]	75.0 [62.5, 77.0]	0.866
Female?	35 (35.0)	14 (51.9)	9 (28.1)	3 (33.3)	9 (28.1)	0.194	26 (38.2)	2 ( 66.7)	5 (33.3)	0.555
Drive time (mins; median [Q1, Q3])	30.0 [20.0, 45.0]	25.0 [15.0, 36.2]	40.0 [22.5, 56.2]	22.0 [17.5, 37.5]	37.5 [20.0, 60.0]	0.047	36.2[20.0, 56.2]	25.0[18.8, 30.0]	22.0[17.5, 38.8]	0.050
Skin cancer type? (%)						0.65				0.763
BCC	47 (47.0)	17 (63.0)	14 (43.8)	4 (44.4)	12 (37.5)		36 (52.9)	2 ( 66.7)	6 (40.0)
SCCis	16 (16.0)	2 ( 7.4)	4 (12.5)	2 (22.2)	8 (25.0)		12 (17.6)	0 ( 0.0)	1 ( 6.7)
iSCC	25 (25.0)	7 (25.9)	8 (25.0)	2 (22.2)	8 (25.0)		12 (17.6)	1 ( 33.3)	4 (26.7)
MIS	7 ( 7.0)	1 ( 3.7)	3 ( 9.4)	1 (11.1)	2 ( 6.2)		4 ( 5.9)	0 ( 0.0)	3 (20.0)
MM	4 ( 4.0)	0 ( 0.0)	3 ( 9.4)	0 ( 0.0)	1 ( 3.1)		3 ( 4.4)	0 ( 0.0)	1 ( 6.7)
Other	1 ( 1.0)	0 ( 0.0)	0 ( 0.0)	0 ( 0.0)	1 ( 3.1)		1 ( 1.5)	0 ( 0.0)	0 ( 0.0)
Skin cancer location? (%)						0.465				0.21
H	53 (53.0)	16 (59.3)	18 (56.2)	3 (33.3)	16 (50.0)		39 (57.4)	2 ( 66.7)	5 (33.3)
M	35 (35.0)	8 (29.6)	12 (37.5)	3 (33.3)	12 (37.5)		22 (32.4)	0 ( 0.0)	6 (40.0)
L	12 (12.0)	3 (11.1)	2 ( 6.2)	3 (33.3)	4 (12.5)		7 (10.3)	1 ( 33.3)	4 (26.7)
Number of stages > 1?	42 (42.0)	14 (51.9)	11 (34.4)	4 (44.4)	13 (40.6)	0.596	28 (41.2)	1 ( 33.3)	6 (40.0)	0.962
Defect Size?						0.432				0.792
<1 cm	17 (17.0)	5 (18.5)	6 (18.8)	2 (22.2)	4 (12.5)		10 (14.7)	1 ( 33.3)	2 (13.3)
<2 cm	56 (56.0)	17 (63.0)	14 (43.8)	4 (44.4)	21 (65.6)		40 (58.8)	2 ( 66.7)	7 (46.7)
<3 cm	20 (20.0)	2 ( 7.4)	10 (31.2)	3 (33.3)	5 (15.6)		14 (20.6)	0 ( 0.0)	4 (26.7)
>=3 cm	7 ( 7.0)	3 (11.1)	2 ( 6.2)	0 ( 0.0)	2 ( 6.2)		4 ( 5.9)	0 ( 0.0)	2 (13.3)
Reconstruction type?						0.009				0.03
Linear	71 (71.0)	13 (48.1)	25 (78.1)	7 (77.8)	26 (81.2)		60 (88.2)	1 ( 33.3)	10 (66.7)
Second intention	15 (15.0)	4 (14.8)	5 (15.6)	1 (11.1)	5 (15.6)		1 ( 1.5)	0 ( 0.0)	0 ( 0.0)
Graft and/or flap	14 (14.0)	10 (37.0)	2 ( 6.2)	1 (11.1)	1 ( 3.1)		7 (10.3)	2 ( 66.7)	5 (33.3)
Repair size linear (cm) (mean (SD))	5.1 (1.8)	5.1 (1.6)	4.9 (1.5)	6.4 (2.8)	5.0 (1.7)	0.26	5.0 (1.8)	5.0#	5.8 (1.5)	--
Repair size area (cm2) (mean (SD))	7.7 (10.3)	9.3 (11.5)	9.9 (12.6)	5.8 (3.6)	1.8 (1.1)	0.457	14.6 (11.6)	5.7 (3.1)	11.8 (16.2)	0.689
History of previous MMS?	51 (51.0)	13 (48.1)	17 (53.1)	6 (66.7)	15 (46.9)	0.742	34 (50.0)	3 (100.0)	7 (46.7)	0.221
History of previous excision?	38 (38.0)	10 (37.0)	11 (34.4)	3 (33.3)	14 (43.8)	0.868	25 (36.8)	0 ( 0.0)	10 (66.7)	0.035
History of previous surgical complications?	6 ( 6.0)	2 ( 7.4)	3 ( 9.4)	1 (11.1)	0 ( 0.0)	0.362	4 ( 5.9)	0 ( 0.0)	2 (13.3)	0.526
Has MyChart set-up?	83 (83.0)	17 (63.0)	30 (93.8)	8 (88.9)	28 (87.5)	0.012	59 (86.8)	3 (100.0)	10 (66.7)	0.12

The majority (88%) of patients were satisfied with the type of follow-up received. However, 30% of patients would prefer a different follow-up type in the future than the one received; those who followed up in-person were significantly more likely to prefer a change in follow-up type to either photo-based or as needed (p=0.023). While no patients who received absorbable suture would prefer a change in suture type, 19 (61.3%) who received non-absorbable would prefer a change if deemed clinically appropriate by the surgeon (p<0.001). Patients who preferred photo or as-needed were more likely to have received (p=0.04) and prefer (0.001) absorbable suture. (Supplemental Table 2)

Table 1 summarizes factors associated with preferred follow-up type. Patients with longer driving time to clinic were more likely to prefer sending a photo, followed by as-needed follow-up, compared to in-person (p=0.047). In terms of reconstruction type, those who had a graft and/or flap were more likely to prefer in-person follow-up, while those with linear repair or wounds allowed to heal by second intention were more likely to prefer photo or as-needed (p=0.009). Having an active account with the health system’s online patient portal (MyChart, Epic Systems, Verona, WI) was associated with different preferences (p=0.012); those without active accounts were more likely to prefer in-person follow-up. Co-variates significantly associated with suture preference were similar to those associated with follow-up preference; increased driving time (p=0.050), linear repair (p=0.03), and history of previous excision (p=0.035) were significantly different across preference groups. Follow-up and suture preference did not differ based on age, gender, skin cancer type, area H/M/L, number of stages, defect size, or repair size.(4)

Several themes emerged in most common reasons for follow-up and suture preference. In order of frequency cited, the most common reasons respondent preferred in-person follow-up were reassurance, perception of photo quality, and difficulty photographing or visualizing the site given its location.(Supplemental Table 3) Respondents who preferred photo-based follow-up cited convenience, reassurance, technology ease, and avoiding in-person challenges. Respondents who preferred as-needed follow-up cited convenience, wound care literacy, and avoiding in-person challenges. Similarly, the most common reasons cited for preferring absorbable suture were convenience, comfort, and effort associated with having sutures removed. The main reason cited for preferring non-absorbable sutures was perceived efficacy. Anecdotally, respondents reported comorbidities and in-person challenges making an in-person visit challenging including dyspnea on exertion, wheelchair transportation barriers, immunocompromised status, and post-traumatic stress disorder worsened in crowded areas such as a waiting room.

Conclusions:

These trends in patient-stated preferences for follow-up and suture type indicate several factors at play. Patient-specific factors such as distance to clinic, prior experience with dermatologic surgery, comorbidities, and overall health literacy may lead to a preference for photo-based or as-needed follow-up and absorbable suture. With the rise of teledermatology, COVID-related concerns for attending in-person appointments, time spent traveling to the dermatologic surgeon's office, and cost associated with attending in-person appointments (direct travel costs and indirect costs of time off work or school), there may be a role for innovations in care delivery models such as utilization of absorbable suture and photo-based follow-up.

Simultaneously, a large cohort of patients appreciated in-person and photo-based follow up for the reassurance of proper wound healing, indicating preference heterogeneity. Ultimately, these findings suggest a role for offering alternate workflows for post-op wound checks as well as querying patient preferences during the clinical encounter. Limitations include single-center academic patient cohort, recall bias, and response bias. Future directions include investigating how preferences may vary based on cultural, socioeconomic, and mental health factors such as anxiety (prior to and after MMS) as well as how receiving preferred follow-up and suture type may impact patient satisfaction.