Quantity and Characteristics of Flap or Graft Repairs for Skin Cancer on the Nose or Ears: A Comparison Between Mohs Micrographic Surgery and Plastic Surgery
One benefit of Mohs micrographic surgery (MMS) is maximal tissue sparing compared to standard excisional surgery techniques. It also has the highest statistical cure rate for appropriately selected nonmelanoma skin cancers (NMSCs) in cosmetically sensitive areas, making it a preferred choice for many self-referred patients or their referring physicians. Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists. Our objective was to compare the quantity and characteristics of flap or graft repairs on the nose or ears following skin cancer extirpation performed by either a fellowship-trained Mohs surgeon or plastic surgeons at 1 academic institution. A retrospective chart review of all skin cancer surgeries was performed to collect data on all flap or graft repairs on the nose or ears at Baylor Scott & White Health (Temple, Texas) from October 1, 2016, to October 1, 2017. We collected secondary data on final defect size prior to the repair, skin tumor type, referring specialty for the procedure, and patient demographics. We found that Mohs surgeons performed a larger number of complex repairs on cosmetically sensitive areas compared to plastic surgeons following skin cancer removal, which may be unrecognized in several specialties that refer patients for management of skin cancers, creating a possible practice gap. More data may aid referring providers in optimally advising and managing patients with cutaneous malignancies.
Practice Points
- Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists.
- Compared to plastic surgeons, Mohs surgeons performed a larger number of complex skin cancer repairs on the nose or ears with similar-sized defects.
- Primary care physicians and other specialists may be more likely to involve dermatology in the care of skin cancer through awareness of this type of data.
Statistical Analysis
Sample characteristics were described using descriptive statistics. Frequencies and percentages were used to describe categorical variables. Medians and ranges were used to describe continuous variables due to nonsymmetrically distributed data. χ2 tests (or Fisher exact tests when low cell counts were present) for categorical variables and Wilcoxon signed rank tests for continuous variables were used to test for associations in bivariate comparisons between MMS and plastic surgery.
Results
A total of 7 physicians (1 fellowship-trained Mohs surgeon and 6 plastic surgeons) at our institution met the inclusion criteria. The Mohs surgeon performed a significantly higher number of flaps and grafts (n=276) than the plastic surgeons (n=17 combined; average per plastic surgeon, 2.83) on the nose or ears in a 12-month period (P<.05)(Table). The median final defect size was not significantly different between MMS (1.5 cm) and plastic surgery (1.8 cm)(P=.306). Flap repairs were more common in patients undergoing MMS (80%) vs plastic surgery (53%)(P=.022)(Figure). For flap repair, advancement flaps were used more commonly (MMS, 53%; plastic surgery, 35%) than transposition flaps (MMS, 27%; plastic surgery, 12%) by both specialties.
Patient age was similar between MMS (median, 74 years) and plastic surgery (median, 73 years) patients (P=.382), but a greater percentage of women were treated by plastic surgeons (53%) compared with Mohs surgeons (33%). The predominant skin tumor type for both specialties was basal cell carcinoma (MMS, 85%; plastic surgery, 76%). Dermatology was the largest referring specialty to both MMS (98%) and plastic surgery (53%). Family medicine referrals comprised a much larger percentage of cases for plastic surgery (24%) compared to MMS (1%).
Comment
This study supports and adds to recent studies and data regarding the utilization of MMS for the treatment of NMSCs. Although the percentage of all skin cancer surgery is increasing for dermatology, little has been reported on more complex repairs. This study highlights the volume and complexity of skin surgery performed by Mohs surgeons compared to our colleagues in plastic surgery.
Defect Size
The defect sizes prior to repair were not statistically different between the 2 types of surgeries, though the median size was slightly larger for plastic surgery (1.8 cm) compared to MMS (1.5 cm). These non–statistically significant differences may be explained by potentially larger tumors requiring repair by plastic surgeons in an operating room. Plastic surgeons, however, may be more likely to take a larger margin of clinically unaffected tissue as part of the initial layer. Plastic surgeons also may be less likely to curette the lesion prior to excision to obtain more clear tumor margins, possibly leading to more stages and a subsequently larger defect. Knowing the clinical sizes of these NMSCs prior to biopsy would have been beneficial to our study, but these data often were not available from the referring providers.
