The Effects of Primary Defect Characteristics on Reconstruction Type and Adjunctive Intervention in Mohs Micrographic Surgery: A Retrospective Review

March 2020 | Volume 19 | Issue 3 | Original Article | 264 | Copyright © March 2020

Published online February 21, 2020

Oscar Trujillo MD MS,a,b Adetokunbo Obayemi MD,a,b Gulce Askin MPH,c Kristina Navrazhina BA,d Brienne D. Cressey MD MBA,d Rohan Joshi MD,a,b Kira Minkis MD PhD,d Anthony Sclafani MDa

aDepartment of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY bDepartment of Otolaryngology-Head and Neck Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY cDepartment of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY dDepartment of Dermatology, Weill Cornell Medicine, New York, NY

Abstract
Background: Cosmetic concerns following Mohs Micrographic surgery (MMS) are significant and may require adjunctive treatments for unsatisfactory appearance.
Objective: To determine factors associated with adjunctive cosmetic intervention for facial defects following MMS.
Methods and Materials: A retrospective review of 699 patients undergoing repair of facial defects after MMS from 2008-2018 was performed. Tumor types, defect sizes, patient demographics, repair methods, complications, and post-operative cosmetic interventions were examined.
Results: 666 Mohs cases and resultant defects were analyzed. The most common method of repair following MMS was primary closure (52.3%), and the most common post-operative intervention was steroid injection (18.3%). The lip subunit was more than twice as likely as other locations to be treated with steroid injections (P<.001). The lip subunit also had the highest frequency of scar revision (13%; P<0.001). Patients who had primary closure were less likely to require scar revision (P=0.003) or dermabrasion (P=0.042), and there was no significant association between skin graft repair and cosmetic intervention.
Conclusions: Both defect subunit and closure type were independently associated with adjunctive cosmetic intervention following MMS. Defect size was not significantly associated with an adjunctive intervention in our study. Understanding the factors affecting the need for adjunctive cosmetic interventions may improve patient counseling prior to Mohs repair.

J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4701

INTRODUCTION

Skin cancer is currently the most common type of cancer worldwide as it affects more than 3 million Americans annually.1 When feasible, many head and neck non-melanoma skin cancers (NMSC; basal cell carcinoma and squamous cell carcinoma) are treated surgically with Mohs micrographic surgery (MMS). As compared with wide local excision alone, MMS offers a lower local recurrence rate for both primary and recurrent NMSC.2 After tumor extirpation, MMS defects often require surgical reconstruction.3 Reconstructive options in the head and neck are numerous and include primary closure or adjacent tissue rearrangement with local flaps or skin grafts.

Recent literature has shown the excellent safety profile of Mohs surgery, with complication rates of less than one percent in large database reports. In a large 2012 review by Alam et al of 20, 821 MMS procedures, common adverse events reported were infections (61.1% of complications), dehiscence or wound necrosis (20.1%), and bleeding/hematoma.4 Clinical predictors of postoperative complications traditionally include smoking status, diabetes, concomitant anticoagulation, and the use of interpolated flaps with cartilage grafting.5 Additionally, it is well documented that MMS procedures may require revision in order to optimize cosmesis. A 2013 observational study indicated that patients with skin cancer had persistent concerns about their physical appearance 1-2 weeks postoperatively with fluctuations in self-reported quality of life.6 Indeed, cosmesis is a primary concern of patients, given that these excisions and repairs are performed on a highly visible and cosmetically sensitive areas of the body.

Prior studies have identified putative surgical risk factors for complications post-MMS, including defect location and closure type. Sclafani et al noted that reconstruction of the nasal ala subunit was independently associated with complications- including pin cushioning and the need for adjuvant corticosteroid treatment.7 Similarly, a recent retrospective review by Lee et al comprising 418 patients noted that 91% of nasal reconstructions post-Mohs involved either skin grafting or local/regional