Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Assessing Recurrence Rates Following Wide Local Excision of Head and Neck Malignant Melanoma: Immediate versus Delayed Reconstruction
Tiago R. Matos, M.D. M.Sc.1, Pieter G. Koolen, M.D.2, Ahmed M. S. Ibrahim, M.D.2, Jie Sun, BA3, Bernard T. Lee, M.D., M.B.A.2, Robert A. Frankenthaler, M.D.2, Samuel J. Lin, M.D.2.
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, 3Harvard School of Dental Medicine, Boston, MA, USA.

PURPOSE:
The standard of treatment for primary head and neck cutaneous malignant melanoma (HNCMM) includes wide local excision (WLE) with a safety margin. Studies have demonstrated inconsistent results with regards to recurrence rates following immediate reconstruction compared to delayed procedures. The objective of this study was (1) to assess and compare recurrence rates after WLE of HNCMM followed by immediate or delayed reconstruction, and (2) to determine recurrence-free survival estimates.
METHODS:
A retrospective analysis of 451 consecutive patients undergoing WLE of primary HNCMM followed by reconstruction from a period of 20 years was performed. Patients with a negative sentinel node procedure and histologically negative tumor margins were included. In total, 207 patients met the inclusion criteria. Patients were divided into 2 groups based on timing of reconstruction (immediate versus delayed). Univariate analyses and Kaplan Meier survival analyses were performed to assess distribution and survival estimates, respectively. Additionally, a multivariate COX proportional hazard model was configured to adjust for potential confounders and to obtain hazard ratios.
RESULTS:
Among 207 patients, 69.1% (n=143) underwent immediate reconstruction, and 30.9% (n=64) received delayed defect reconstruction. Mean patient age was 58.9±15.2 vs 62.5±17.5 (p=0.126) years, melanoma size in millimeters was 13.1±14.4 vs 12.7±10.0 (p=0.856) and Breslow thickness in millimeters was 3.2±5.6 vs 2.5±2.6 (p=0.355), respectively. Furthermore, univariate analysis showed a higher overall melanoma recurrence rate in patients undergoing immediate reconstruction compared to delayed (49.0% vs 23.4%, p=0.001). However, after adjusting for potential confounders no significant association between reconstruction timing (immediate vs delayed) and recurrence-free survival was observed (p=0.070). Subgroup analysis did not reveal any significant differences in local (p=0.399), regional (p=0.197), nodal (p=0.685) or distant (p=0.477) recurrences (Table 1). Additionally, subset analysis of patients experiencing melanoma recurrence did not demonstrate a significant difference in the type of reconstruction among groups (p=0.430) (Table 2). The presence of ulceration served a significant predictor for melanoma recurrence (p=0.010, HR 2.11).


CONCLUSION:
Multivariate regression analysis demonstrates no significant association between reconstruction timing and recurrence-free survival. The presence of ulceration increases the risk of recurrence over twofold. Concerns related to higher recurrence rates following immediate reconstruction have prompted surgeons to delay their reconstructions until after confirmation of negative margins, however, immediate reconstruction did not show a significantly different recurrence-free survival rate when compared to delayed repair. Furthermore, the type of reconstruction does not appear to affect recurrence.


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