Key Points
Question
Does delaying Mohs reconstructive surgery increase the risk of postoperative complications?
Findings
In this cohort study, a multivariable binary logistic regression model demonstrated that smoking status, defect size, full-thickness defects, interpolated flaps with cartilage grafting, and composite grafts were associated with an increased risk of postoperative complications. There was no association between timing of reconstruction and the risk of postoperative complications.
Meaning
These findings will allow surgeons the flexibility to plan the timing of reconstructive surgery so that it facilitates surgical planning, patient counseling, and scheduling issues.
This cohort study explores whether delaying Mohs reconstructive surgery increases the risk of postoperative complications.
Abstract
Importance
Same-day Mohs reconstructive surgery is not always possible; moreover, a delay can offer benefits such as improved surgical planning and increased blood supply to the cauterized wound bed. However, recent work found that delaying reconstruction by more than 2 days increases the postoperative complication rate.
Objective
To review the outcomes of Mohs micrographic surgery (MMS) reconstruction with respect to patient- and surgery-specific variables, especially timing of repair.
Design, Setting, and Participants
Retrospective, single-institution cohort study of patients who underwent Mohs reconstructive surgery by 1 of the 2 senior authors from January 2012 to March 2017 for cutaneous squamous cell carcinoma or basal cell carcinoma. No patients had to be excluded for inadequate follow-up or incomplete medical records.
Main Outcomes and Measures
Postoperative complications including hematoma, infection, dehiscence, and partial or full graft or flap loss.
Results
A total of 633 defects in 591 patients (median [range] age, 65 [21-96] years; 333 [56.3%] female) were identified over the 5-year period. Reconstructions occurred from less than 24 hours to 32 days after MMS, with 229 (36.2%) delayed longer than 48 hours. Patient-specific variables reviewed included comorbidities, age, smoking status, and use of anticoagulant or antiplatelet medications. Surgery-specific variables analyzed included location and size of defect, time interval between MMS and reconstruction, and reconstructive modalities. Single-variable analysis was performed to determine whether each variable was associated with postoperative complications. On multivariable binary logistic regression, smoking status (odds ratio [OR], 2.46; 95% CI, 1.29-4.71; P = .007), defect size (OR exp(B), 1.04; 95% CI, 1.01-1.06; P = .006), full-thickness defects (OR, 1.56; 95% CI, 1.08-2.25; P = .02), interpolated flaps with cartilage grafting (OR, 8.09; 95% CI, 2.65-24.73; P < .001), and composite grafts (OR, 6.35; 95% CI, 2.25-17.92; P < .001) were associated with an increased risk of postoperative complications.
Conclusions and Relevance
We found no association between timing of Mohs reconstructive surgery and complications, indicating that a delayed repair did not increase the risk of infection or flap failure. Variables associated with an increased risk of postoperative complications include smoking status, size of the defect, full-thickness defects, interpolated flaps with cartilage grafting, and the use of composite grafts.
Level of Evidence
3.
Introduction
Skin cancer is the most common type of cancer worldwide and continues to increase in incidence. Currently, 3.3 million Americans receive a diagnosis of skin cancer annually, and many of these people have more than 1 lesion.1 The face is the most common place for skin cancers to develop, with 80% of basal cell carcinomas, the most common type of skin cancer, affecting facial skin.2 Because Mohs micrographic surgery (MMS) and simple surgical excision have the lowest local recurrence rates in treating head and neck skin cancer, these lesions typically produce defects that require surgical reconstruction.3
When the Mohs dermatologic surgeon performs the reconstruction, he or she typically does so on the same day. However, often a different surgeon performs the reconstruction. When this is the case, factors such as patient and surgeon schedules and operating room availability often make same-day reconstruction impractical or even impossible. Many surgeons are concerned that delaying reconstruction increases the risk of postoperative complications such as infection because the wound is left open and the patient has to properly care for the wound in the period between ablative surgery and reconstructive surgery to minimize contamination. However, delaying reconstruction also has potential benefits such as improved surgical planning, patient counseling and contemplation, and increased blood supply to the cauterized wound bed. This is in addition to the increased flexibility for both surgeon and patient that delaying reconstruction offers.
While multiple articles have looked at the complication rate after Mohs reconstructive surgery, to our knowledge, until recently no group had looked at whether delaying reconstruction increases the risk of postoperative complications relative to a control group of immediate reconstruction. Mordick et al4 reported complications in a cohort of patients undergoing delayed reconstruction, but they did not have a control group for comparison and their sample size was limited. In 2016, however, Patel et al5 retrospectively looked at their Mohs reconstructive cases over a 23-year period and determined that reconstruction delayed more than 2 days after ablative surgery resulted in an increased risk of postoperative complications. This held true on both univariate and multivariate analysis.
In our practice, we receive referrals to perform Mohs reconstructive surgery from many local Mohs dermatologic surgeons. Whereas most reconstructions are planned within 24 hours of MMS, many are unscheduled consults due to multistage Mohs resection. Furthermore, sometimes we purposefully delay reconstruction to allow granulation tissue to develop at the base of the wound and/or to see whether a wound will heal well by secondary intention. We have not observed an increased risk of complications by delaying reconstruction but until now have not tracked these data. Thus, we hypothesized that delaying reconstruction does not increase the risk of postoperative complications compared with immediate reconstruction after Mohs ablative surgery.
Methods
Study Design
We performed a retrospective, single-institution cohort study from January 2012 through March 2017. All patients who undergo Mohs reconstructive surgery at our institution sign a consent approved by the University of Virginia Institutional Review Board for Health Sciences Research for data and photograph entry into our previously published database. Institutional review board approval extends to all research using this database, so specific approval for this study was not required.6 Patients were included if they had undergone reconstructive surgery of Mohs cutaneous defects by the 2 senior authors (S.S.P. and J.C.) during the study period. Patients had to be seen at least once after surgery, a week after or longer. Patients undergoing reconstruction secondary to wide excision of melanoma were excluded because standard of care dictates confirmation of negative margins prior to final reconstruction, which typically takes a few days at our institution. No patients had to be excluded for incomplete medical records or inadequate follow-up.
Data Collection
A data file was constructed using SPSS software (IBM) to collect patient demographic, comorbidity, perioperative, and postoperative data. Patient characteristics collected included sex, age, smoking status, history of diabetes, use of anticoagulant or antiplatelet therapies, and prior radiation therapy to the head and neck. Perioperative characteristics included MMS surgeon, date of MMS, date of reconstructive surgery, defect location, defect size, and whether the defect was full thickness. Defects that involved more than 1 facial unit were labeled composite defects, and full-thickness defects were characterized for defects of the lips, nose, eyelid, and auricles. Ten different Mohs ablative surgeons referred patients included in this study, so wound management from time of ablation until reconstruction was not standardized. Reconstructive modalities tracked included use of a local flap, interpolated flap, full-thickness skin graft, local and interpolated flap, cartilage grafting, composite graft, and combined reconstruction.
Main Outcome Measures
The primary outcome measure was postoperative complication; aesthetic outcomes were not assessed in this study. Specific complications included hematoma, infection, dehiscence, and partial or full flap and/or graft necrosis. Hematoma was defined by clinical examination and included as a complication regardless of whether intervention was required. Infection was defined clinically and treated with antibiotics with or without surgical intervention. Graft and/or flap viability was defined clinically by 90% to 100% graft/flap take, 60% to 90% take, and less than 60% take. Even if the area of necrosis healed with wound care, it was counted as partial necrosis. Anything less than 90% take was considered a complication for the purpose of our analyses. Dehiscence was defined as any separation at the suture line.
Statistical Analysis
Descriptive statistics were calculated using SPSS software. Cross-tabulation was performed with Pearson χ2 and Fisher exact testing to determine statistically significant categorical predictors of postoperative complications. All of the P values were 2-sided, with a level of significance of P < .05. Linear discriminant analysis was used with analysis of variance to determine whether continuous variables were statistically significant predictors of postoperative complications. A multivariable logistic regression model was then created including all variables with P < .20 on univariate analysis. SPSS software was used for all statistical analysis.
Results
A total of 633 defects in 591 patients met inclusion criteria. Demographic characteristics and patient comorbidities are listed in Table 1. Current smokers made up 20.5% (n = 121) of our patient population, and 71 (12.0%) patients had diabetes mellitus. A total of 139 patients (23.5%) were taking antiplatelet therapy.
Table 1. Patient Demographic Characteristics and Comorbidities and Defect and Reconstruction Characteristics.
| Characteristic | Value |
|---|---|
| Age, median (range, SD), y | 65 (21-96, 12.5) |
| Sex, No. (%) | |
| Male | 258 (43.7) |
| Female | 333 (56.3) |
| Current smoking, No. (%) | 121 (20.5) |
| Diabetes mellitus, No. (%) | 71 (12.0) |
| Prior radiation therapy, head and neck, No. (%) | 6 (1.0) |
| Anticoagulation therapy, No. (%) | 26 (4.4) |
| Antiplatelet therapy, No. (%) | 139 (23.5) |
| Defect location, No. (%) | |
| Scalp | 45 (7.1) |
| Forehead | 50 (7.9) |
| Eyelid | 15 (2.4) |
| Nose | 382 (60.3) |
| Cheek | 73 (11.5) |
| Lips | 48 (7.6) |
| Ears | 20 (3.2) |
| Composite defects,a No. (%) | 56 (8.8) |
| Full-thickness defects (eyelid, nose, lips, ears), No. (%) | 54 (10.4) |
| Defect size, median (range), cm2 | 2.5 (0.1-90.1) |
| Interval between ablation and reconstruction | |
| Median (range), d | 1 (0-32) |
| ≤2 d, No. (%) | 404 (63.8) |
| >2 d, No. (%) | 229 (36.2) |
| Type of reconstruction, No. (%) | |
| Local flap | 281 (44.4) |
| Local flap with cartilage graft | 42 (6.6) |
| Interpolated flap | 16 (2.5) |
| Interpolated flap with cartilage graft | 21 (3.3) |
| Full-thickness skin graft | 91 (14.4) |
| Composite graft | 43 (6.8) |
| Combined reconstruction | 139 (22.0) |
Defects involving multiple facial units.
The interval between ablative and reconstructive surgery was 2 days or less for 404 (63.8%) defects, and the other 229 (36.2%) had more than 2 days separating their ablative and reconstructive procedures (range, 0-32 days) (Table 1). Table 1 demonstrates the distribution of defect locations in our sample. The nose was the most common location, and 56 (8.8%) defects involved more than 1 facial unit. Fifty-four (10.4%) defects involving the nose, eyelid, ears, or lips were full thickness. With regard to type of reconstruction, local flap reconstruction was the most common modality used, and 139 (22.0%) defects required more than 1 modality of reconstruction (Table 1).
The overall complication rate in our population was 9.3% (55 patients), and the most common complications were partial flap necrosis and wound dehiscence (Table 2). On univariate analysis, sex and smoking status were the only 2 patient characteristics significantly associated with postoperative complications (Table 3). The mean (SD) size of defect that developed a postoperative complication was 11.3 (15.4) cm2, whereas that of defects that did not have complications was 5.2 (7.8) cm2 (P < .001) (Table 3). With regard to interval between ablative and reconstructive surgery, the mean (SD) interval in the complication group was 3.2 (3.9) days and in the group without complications it was 3.3 (4.6) days (P = .87) (Table 3). With regard to defect characteristics and surgical variables, size of the defect, full-thickness defects, and type of reconstruction were significantly associated with complications (Table 3).
Table 2. Types of Postoperative Complications.
| Complication | No. (%) of Procedures (N = 633) |
|---|---|
| Hematoma | 11 (1.7) |
| Infection | 9 (1.4) |
| Dehiscence | 17 (2.7) |
| Graft and/or flap loss | |
| 60%-90% viable | 31 (6.9) |
| <60% viable | 6 (0.9) |
Table 3. Univariate Potential Predictors of Postoperative Complications.
| Characteristic | Postoperative Complication Yes/No | P Value |
|---|---|---|
| Age, mean (SD), y | 66.4 (11.7)/64.7 (12.6) | .32a |
| Interval, mean (SD), d | 3.2 (3.9)/3.3 (4.6) | .87a |
| Defect size, mean (SD), cm2 | 11.3 (15.4)/5.2 (7.8) | <.001a |
|
No. Complications/ No. Defects (%) |
||
| Patient Characteristics | ||
| Sex | ||
| Female | 24/352 (6.8) | .02b |
| Male | 35/281 (12.5) | |
| Current smoking | ||
| Yes | 21/136 (15.4) | .01b |
| No | 38/497 (7.6) | |
| Diabetes mellitus | ||
| Yes | 12/79 (15.2) | .06b |
| No | 47/554 (8.5) | |
| Prior head and neck radiation therapy | ||
| Yes | 1/6 (16.7) | .45b |
| No | 58/627 (9.3) | |
| Anticoagulant use | ||
| Yes | 3/29 (10.3) | .75b |
| No | 56/604 (9.3) | |
| Antiplatelet use | ||
| Yes | 13/145 (9.0) | >.99b |
| No | 46/488 (9.4) | |
| Defect Characteristics | ||
| Reconstruction | ||
| Local flap | 35/457 (7.7) | .003c |
| Interpolated flap | 11/77 (14.3) | |
| Full-thickness skin graft | 24/191 (12.6) | |
| Cartilage graft | 13/88 (14.7) | |
| Composite graft | 10/58 (17.2) | |
| Full-thickness defect | 10/54 (18.5) | .006c |
| Defect location | ||
| Nose | 30/382 (7.9) | .26c |
| Forehead | 4/50 (8.0) | |
| Scalp | 4/45 (8.9) | |
| Eyelid | 2/15 (13.3) | |
| Cheek | 13/73 (17.8) | |
| Lips | 4/48 (8.3) | |
| Ears | 2/20 (10.0) | |
Determined using linear discriminant analysis.
Calculated using Fisher exact 2-sided test.
Calculated using Pearson χ2 test.
A multivariable binary logistic regression model was then created with all the variables that had P < .20 on univariate analysis: sex, smoking status, diabetes mellitus, defect size, full-thickness defects, and type of reconstructive modality. The model provided a very good fit for outcome measurement, with an area under the curve of 0.765 (discriminatory C statistic). Smoking status, defect size, full-thickness defects, interpolated flaps with cartilage grafting, and composite grafts were significantly associated with postoperative complications (Table 4). Interpolated flaps with cartilage grafting and composite grafts had the greatest increase in risk of postoperative complications (odds ratio, 8.09 [95% CI, 2.65-24.73] and 6.35 [95% CI, 2.25-17.92], respectively) (Table 4).
Table 4. Multivariate Binary Logistic Regression Analysis.
| Characteristic | ORa (95% CI) | P Valueb |
|---|---|---|
| Sex | 1.57 (0.87-2.86) | .14 |
| Current smoker | 2.46 (1.29-4.71) | .007 |
| Diabetes mellitus | 1.64 (0.78-3.44) | .19 |
| Interval between Mohs micrographic surgery and reconstruction | 0.98 (0.92-1.05) | .63 |
| Size (exp(B)), cm2 | 1.04 (1.01-1.06) | .006 |
| Full-thickness defect | 1.56 (1.08-2.25) | .02 |
| Type of reconstruction | ||
| Local flap | 1.00 (NA) | >.99 |
| Local flap with cartilage graft | 1.22 (0.26-5.66) | .80 |
| Interpolated flap | 0.00 (NA) | >.99 |
| Interpolated flap with cartilage graft | 8.09 (2.65-24.73) | <.001 |
| Full-thickness skin graft | 1.61 (0.67-3.89) | .29 |
| Composite graft | 6.35 (2.25-17.92) | <.001 |
| Combined reconstruction | 1.81 (0.84-3.88) | .13 |
Abbreviations: NA, not applicable; OR, odds ratio.
Calculated using multivariate binary logistic regression model coefficients.
Calculated using multivariate binary logistic regression.
Discussion
Whereas complications after Mohs reconstructive surgery are not common, different series in the literature show that they do occur in 1% to 19% of cases.4,5,7,8,9 Recently, Patel et al5 found that delaying Mohs reconstructive surgery more than 2 days after the resection is associated with a higher rate of complications. At our institution, we perform a substantial number of Mohs reconstructive procedures on patients referred from both the internal MMS, as well as many community Mohs dermatologic surgeons. Whereas we often strive to reconstruct these defects as quickly as possible because of patient wishes, our group has not been concerned about a higher rate of complications in patients in whom we delay reconstruction. In fact, we sometimes purposefully delay reconstruction for certain reasons such as to see whether the wound will heal well via secondary intention, to allow for an increased bed of granulation tissue with its vascular ingrowth, and to provide more time for patient counseling, patient contemplation, and surgical planning. However, we did not have evidence to support our specific practice and to our knowledge, the only prior study to specifically compare postoperative complication rate in reconstructive surgery performed within 2 days of ablative surgery vs delayed reconstruction demonstrated a higher complication rate in the delayed group.
Hence, we decided to perform the present study to evaluate the effect of delaying reconstruction and look for other possible variables associated with complication rate after Mohs defect reconstructive surgery. In our study, the interval between Mohs ablative surgery and reconstruction was not associated with an increased risk of postoperative complications. The mean interval for the cohort that developed postoperative complications was virtually identical to that of the group that did not experience complications after reconstructive surgery. This differs from the findings by Patel et al.5 This difference may be explained by the low percentage of patients in their study who underwent delayed reconstruction, as well as the high percentage of complex wounds reconstructed in delayed fashion in that group.5 Mordick et al4 demonstrated a complication rate of 6% in their case series of delayed Mohs reconstruction, although they did not compare this with a control group. With regard to full-thickness skin graft Mohs reconstruction, multiple groups have demonstrated that delaying graft placement more than 1 day after ablative surgery decreases the risk of postoperative complications.10,11,12
Our study demonstrated an overall complication rate of 9.3%, which is consistent with prior findings.4,5,7,8,9 Of the 59 defects that had a postoperative complication, 42 underwent reconstruction involving a skin, cartilage, and/or composite graft (72%) whereas only 17 (29%) consisted solely of flap repair. It is difficult to compare studies because they are typically retrospective and there are no uniform criteria for defining complications such as wound infection, hematoma, and graft necrosis. However, the rates of specific complications in our population closely match those in other studies, supporting the consistency of our results with prior reports in the literature.4,5,7,8,9
Our multivariable regression model demonstrated that smoking status, wound size, full-thickness defects, composite grafts, and interpolation flaps with cartilage grafting were associated with increased risk of complications. Other studies have demonstrated that smoking is associated with increased risk of postoperative complications after Mohs reconstructive surgery.8,13,14,15,16 Patel et al5 also found that defect size, full-thickness defects (although defined differently than in our study), and interpolated flaps with cartilage grafting were associated with an increased risk of postoperative complications. The difficulty of performing reconstruction with composite grafts has been described, and our results support the higher rate of postoperative complications with use of a composite graft.17,18
We did not find that diabetes mellitus and use of anticoagulation or antiplatelet therapy increases risk of postoperative complications after Mohs reconstruction. Whereas theoretically patients who are taking anticoagulants such as warfarin sodium and/or antiplatelet agents such as aspirin should experience an increased risk of complications, prior studies also do not support this association.19,20 While surgeons should evaluate each patient individually to weigh the risks and benefits of temporarily discontinuing antiplatelet and anticoagulation therapies, it is encouraging that we continue to find that these therapies do not necessarily increase risk of complications because it is unsafe for many patients to discontinue them for relatively minor surgery. This is emphasized in the recently published cutaneous surgery guidelines.21 Whereas diabetes has been associated with a higher rate of complications after free tissue transfer, prior work does not demonstrate an increased risk in Mohs reconstructive surgery of the face.5,22,23 However, our study did not examine whether a patient’s diabetes was controlled, so we cannot comment on uncontrolled diabetes as a potential risk factor for postoperative complications after MMS reconstruction.
Whereas some variables for postoperative complications after Mohs reconstruction suggested by our regression model cannot be changed, knowledge of others can help in patient counseling and management. For example, active smoking increases the odds of a patient developing a postoperative complication by a factor of 2.5. This can be discussed with patients during the preoperative counseling period so that they can work toward smoking cessation. Although use of cartilage grafting with interpolated flaps and the use of composite grafts is often the best mode of reconstruction for a defect, if there are alternative reconstructive modalities, these should be considered because the prior 2 methods do have an increased risk of complications. Of note, use of cartilage grafts with local flaps was not associated with an increased risk of complications in our study. Many surgeons do not always prescribe postoperative antibiotics after Mohs reconstruction. When a physician is deciding on postoperative antibiotic therapy, it is helpful to know that defect size, smoking status, and type of reconstruction are associated with postoperative complications including postoperative infection.
Limitations
The limitations of our study primarily relate to its retrospective nature and the reliance on documentation in patient medical records. For example, if a complication was not properly documented, then it would not have been included in this study. The 2 senior authors were both reconstructing surgeons in our patient population, introducing a source of potential variation with regard to reconstruction techniques and documentation. We did not use patient photographs in this study because not all patients have complete photographic documentation. This would have provided another method to confirm complications such as graft loss. Last, we did not assess whether the interval between ablation and reconstruction and other variables relate to aesthetic outcomes. For example, we did not look at alar retraction as a complication, and with large alar defects this is a risk of delaying reconstruction to let the wound granulate.
Conclusions
We have demonstrated using a multivariate binary logistic regression model with very good fit that smoking status, defect size, full-thickness defects, composite grafts, and interpolated flaps with cartilage grafting were associated with an increased risk of complications after Mohs reconstruction. Importantly, we showed that delaying reconstructive surgery more than 2 days after MMS was not associated with an increased risk of complications. This information allows surgeons to plan reconstruction so that it facilitates surgical planning, patient counseling, and scheduling issues.
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