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Periorbital Mohs Reconstruction: Characterization of Tumor Histology, Anatomic Location, and Factors Influencing Post-operative Complications
Brett Michelotti, MD, Trent Gause, BS, Sebastian Brooke, MD, Ryan Mathis, BS, John Roberts, BS, Christie Travelute, MD, Elizabeth Billingsley, MD, Michael Wilkinson, MD.
Milton S. Hershey Medical Center, Hershey, PA, USA.
BACKGROUND: Skin malignancies of the face are encountered frequently by dermatologists and plastic surgeons. As such, it is extremely important of minimize the excision of healthy tissue and preserve normal anatomic features while ensuring complete excision and cure. Mohs surgery has proven to be superior to wide excision by maximizing tissue preservation and reducing disease recurrence. The periorbital region, defined by anatomic landmarks surrounding the globe, accounts for approximately 5 - 10% of all skin cancers. Reconstructive technique following Mohs surgery is determined by the extent of the defect and its anatomic position. Rearranging the tissues of the periorbita can lead to a number of different complications as these tissues heal. The primary aim of this study was to identify the most commonly employed reconstructive techniques for periorbital Mohs defects and to review the outcomes associated with these methods.
METHODS: This was a retrospective review of consecutive patients who underwent periorbital Mohs reconstruction by a single surgeon at a teaching institution from 2008 - 2012. Included were patients who were a consecutive series of patients, referred to the senior author after Mohs surgeons had completed extirpative surgery. Demographics, smoking history, histologic subtype, anatomic location, size of the defect and method of reconstruction were obtained. Post-operative complications were recorded - as described by the primary surgeon. Multivariate logistic regression was performed to identify perioperative risk factors associated with the development of postoperative complications.
RESULTS: We identified 135 consecutive patients who underwent reconstruction of periorbital Mohs defects. Basal cell carcinoma accounted for 92% of these malignancies while 8 % of periorbital malignancies referred for Mohs surgery were squamous cell carcinoma. Recurrent malignancies comprised 6 % of the cohort. Malignancies were classified by anatomic zone for statistical comparisons: Zone I - 0.7%, Zone II - 24.4 %, Zone III - 43.0 %, Zone IV - 5.9 %, Zone V - 4.4% and multi-subunit - 21.5%. Local undermining and complex closure was performed for the majority of reconstructions (74 %), followed by full-thickness skin graft (20 %), and cheek rotational flap (7 %). The post-auricular area was the most common skin graft donor site (61%). Complications occurred in 19 % of reconstructions and overall tumor recurrence was 2.2%. Of all complications, 19 % (5/26) required secondary surgery. Multivariate logistic regression identified several variables that had a significant association with primary complications (p<0.05): cheek rotation (p=0.0134), FTSG (p=0.0017), and lid graft (p=0.0006). Though defect area (cm2) and anatomic zone were not associated with a higher incidence of post-operative complications, reconstruction of a multi-subunit defect trended toward significance(p=0.0747).
CONCLUSIONS: Mohs surgery should be considered for periorbital malignancies in order to minimize the resultant defect while optimizing the cure rate. Complications related to periorbital Mohs reconstruction occur with moderate frequency. These include post-operative epiphora, ectropion, lagophthalmos and hypertrophic scarring - all which may lead to revision surgery. This study helps to better characterize periorbital malignancies and discusses the effect that anatomy and reconstructive techniques have on post-operative complications.
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