PREPARATION OF THE PATIENT

Preoperative Consultation

Most of our patients undergo micrographic (Mohs) surgery for a cutaneous malignancy. Many patients are referred to the dermatology department by the patient’s personal dermatologist. In such instances, a telephone consultation is performed to discuss Mohs surgery without a required visit to the dermatologic surgeon; however, photographs and pathologic slides resulting from biopsies performed by the referring dermatologist are reviewed before the teleconference with the patient. We work with the referring dermatologic surgeon to provide an efficient and convenient coordination of care. Every attempt is made to schedule reconstruction on the same day as micrographic surgery. To enable a smooth transition between the two procedures, all patients are seen preoperatively by the facial plastic surgeon. The consultation provides the opportunity to anticipate the extent of the defect to be repaired, assess the aesthetic demands of the patient, and discuss the reconstructive options. Depending on the location and anticipated size of the defect, patients may be provided with several reconstructive options.

Consideration is given to patient age, occupation, and aesthetic demands. As a general rule, younger patients have the highest aesthetic concerns and are more willing to tolerate a complex, multistage operation to obtain an optimal aesthetic result. Although many older patients also have high aesthetic standards, some are willing to compromise the outcome in return for a single-stage operation with a more rapid recovery. The occupation of the patient may influence the choice of reconstructive procedures. For example, patients in occupations that require considerable public interaction will be unable to perform their duties during the initial stage of reconstruction in which an interpolated forehead flap is used. The interpolated cheek flap, however, may be covered with a surgical bandage and allow the patient an earlier return to his or her occupation. Occupational use of corrective or protective eyewear or protective headwear should be considered when an interpolated paramedian forehead flap is required because the patient may not be able to use these items during the interval between flap transfer and flap inset.

Factors are considered that may influence the extent of the facial defect. These include tumor size and depth, histology, and whether the tumor represents a recurrence. Recurrent tumors or those with aggressive histologic features often require significantly larger excisions of tissue than would be required for primary tumors with a less aggressive histology.

Most patients have a difficult time visualizing the local flaps used in facial reconstruction. This is especially true in the case of interpolated cheek and paramedian forehead flaps. To prepare patients, they are shown a photograph album displaying preoperative and postoperative photographs of patients undergoing surgical procedures similar to their anticipated operation. For staged repairs, such as with interpolated flaps, photographs are shown that display an individual at each stage of the reconstruction. We have found this to be especially useful for younger patients for whom the shock of the initial deformity caused by an interpolated flap, without prior visual preparation, can be emotionally traumatic and may create in the patient a feeling of hostility or resentment toward the surgeon. Photographs also allow patients to view the outcome of representative examples of different reconstructive techniques. The scar and differences in skin color and texture in the area of reconstruction are pointed out, particularly to those patients with the greatest aesthetic concerns. To develop realistic expectations about the outcome, patients with fair to average surgical results are included in the photograph album. A realistic estimate of when the patient may return to work and social activities is discussed, aided by photographs of representative reconstructive sequences.

The average number of surgical procedures and length of time required to complete all stages of the reconstruction are discussed with the patient ( Table 5.1 ). In cases of repair of the nose where an interpolated covering flap is planned, the reconstructive sequence includes initial flap transfer, pedicle division 3 weeks later, a contouring procedure 2 to 3 months after flap inset, and possibly dermabrasion of scars in the office 2 months after contouring the flap. We therefore advise patients that up to 6 months may be necessary to complete the restoration.

Preoperative consultation with the patient is ideally scheduled 4 to 6 weeks before surgery, allowing adequate time for the patient to stop anticoagulant agents. Medications to be avoided beginning up to 3 weeks before surgery include all nonsteroidal anti-inflammatory drugs and vitamin E supplements ( Table 5.2 ). Coumadin should be discontinued 3 to 5 days before surgery. A number of herbal supplements also possess anticoagulant properties and should be avoided.

A medical history is obtained from the patient, and a physical examination is performed as part of the consultation. The general health of the patient is noted, with special attention given to hypertension, symptomatic coronary artery disease, and smoking history. Smokers are strongly encouraged to quit and are instructed on the higher risk for complications for users of tobacco products. An electrocardiogram is obtained from all males older than 60 years and females older than 65 years. All patients older than 65 years scheduled for monitored anesthesia (intravenous sedation) are required to have an electrocardiogram and may require an additional blood test ( Table 5.3 ). During the physical examination, a note is made of prior facial cutaneous surgery or ear surgery involving the cartilage. The patient is examined for scars on the face that may potentially influence the design of flaps. The redundancy of the facial skin is assessed, particularly in the area of the anticipated cutaneous defect. The position of the anterior hairline is noted when a paramedian forehead flap for nasal reconstruction is anticipated. Patients with low hairlines are informed about the possibility of the flap extending to hair-bearing scalp and the need for subsequent depilation procedures on the flap.

We provide patients with prescriptions for medications at the time of the preoperative consultation ( Table 5.4 ). Oral diazepam (5–10 mg) is prescribed for patients younger than 70 years of age with instructions to take it the evening before and 1 hour before the operation. Benzodiazepines help reduce preoperative anxiety and counteract the toxic effects of local anesthetics used during the procedure. In instances when skin or composite grafting is planned or when cartilage and bone grafting is anticipated, patients are given a postoperative course of an oral antistaphylococcal antibiotic for 3 days. A tapering dose pack of prednisone is prescribed for those patients undergoing composite grafting. An analgesic of choice is prescribed in appropriate quantity. In addition to the standard medications, those patients requiring a forehead flap are prescribed a 2-day supply of antiemetic suppositories.

Patients are encouraged to visit the office on the day of their micrographic surgery after completion of tumor resection if they are undergoing reconstruction the next day. This visit enables the surgeon to examine and photograph the defect and to confirm or modify the surgical plan. This visit is often reassuring to the patient and allows the surgeon sufficient time to make adjustments and alterations of the surgical plan and the operative schedule.