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For select patients undergoing Mohs procedures for skin tumors, delaying reconstruction enhanced viability of full-thickness skin grafts and composite grafts and decreased postoperative complication rates, a retrospective, single-institution study found.

Among 310 patients undergoing reconstruction of 320 Mohs defects, overall postoperative complications occurred at a rate of 33.4%, reported J. Jared Christophel, MD, MPH, of University of Virginia Health System in Charlottesville, and colleagues in .

But among those having reconstruction within 6 days of the Mohs procedure, the complication rate was 36.4% versus 22.9% for those with reconstruction delayed by a week or more (P=0.03).

Multivariate logistic regression confirmed that delayed reconstruction showed an apparent protective relationship (OR 0.52, 95% CI 0.27-0.97; P = 0.046).

Male sex, on the other hand, was associated with increased risk for complications (OR 2.51, 95% CI 1.52-4.20; P < 0.001).

The findings also pointed to specific complications rates of: 1.9% for hematoma, 1.3% for infection, 0.9% for dehiscence, 4.4% for epidermolysis, 27.2% for partial graft necrosis, and 3.1% for complete graft necrosis, the investigators found.

Patient records for a six-year period at the authors' institution were analyzed. Median patient age was 68 years and 53.9% were female. Defects had an average area of 2.83 cm², 37 patients needed composite grafts, and 57 were current smokers, which all indicate increased risk of developing postoperative complications. An average 4.73 days elapsed between the ablative and reconstructive operations.

Background and Comment

Previous reports have explored the advantages of waiting to do placements of full-thickness skin grafts, with emphasis on only full-thickness graft reconstruction, the study authors noted. However, "graft loss is an even greater risk in defects reconstructed with composite (skin and cartilage) grafts," Christophel and colleagues wrote.

Implementing changes in surgical technique, systemic and topical pharmacotherapy use, hyperbaric oxygen, and hypothermia all enhance composite graft survival, but the effects of putting off reconstruction are not clear, the researchers continued.

, however, sounded a note of caution in generalizing these results. The current data do not provide a definitive answer to "whether the timing of [Mohs] repair affects the final reconstructive outcome and the complication rate, wrote Jeffrey Moyer, MD, and Shi Yang, MD, both of University of Michigan Medical School in Ann Arbor.

The study results "would seem to be counterintuitive because the prevailing belief is that an increased interval between [Mohs micrographic surgery] and repair has little meaningful effect on the ultimate reconstructive outcome or might actually be detrimental rather than beneficial," Moyer and Yang explained.

However, the present study population consisted mostly of cases that were nasal reconstructions, in which it is normal to have exposed cartilage, the editorialists noted. As also confirmed by other studies, "skin grafting on exposed cartilage, particularly if perichondrium is damaged or missing, often will result in compromised graft healing," Moyer and Yang continued.

"[I]t would seem prudent to use techniques that minimize the chance of necrosis and other complications, particularly in regions where contraction would significantly affect the final reconstructive result," they wrote.

Christophel and colleagues said prospective research is needed to verify their data and those of previous research groups. "Further study is needed into the direct association between wound bed granulation tissue with graft success," the investigators concluded.