Patient Concerns About Nasal Reconstruction After Mohs Surgery and Implications for Shared Decision Making

Approximately 5.5 million new diagnoses of nonmelanoma skin cancer (NMSC) are estimated annually in the United States.¹ The rising incidence of NMSC and its associated costs are an increasing public health burden.² More patients require excision of NMSC followed by reconstructive surgery. As life expectancy continues to increase, the aging population may present with more comorbidities and additional social and financial considerations when weighing treatment choices.

Reconstructive options after NMSC treatment range from wound healing by secondary intention to free tissue transfer. Decisions about choices are complex for patients, patients’ families, and physicians. Patients undergoing nasal reconstruction after Mohs surgery in particular share concerns, such as financial burden, appearance, and the invasiveness of reconstructive surgery. This mixed-methods study examines these patient concerns to develop an intervention to improve the shared decision-making process for patients with NMSC.

Adults (≥18 years) who were planning to undergo nasal reconstruction after Mohs surgery for an NMSC of the nose from September 1, 2016, through December 31, 2017, and could read and write English were included in the study. Patients with a previous diagnosis of skin cancer or whose planned Mohs excision would likely extend beyond the nose were excluded from the study. Oral informed consent was obtained from all patients, and data were deidentified. This research study was approved by the institutional review board of Washington University in St Louis, Missouri.

At the initial prereconstruction office visit with the facial plastic surgeon (J.J.C.), the patients completed a form with the following open-ended request: “Please list any concerns you have about your nasal reconstruction surgery.” As part of clinical care, the principal investigator (J.J.C.) then reviewed the responses with the patients in a structured interview. The interview explored the role of nasal reconstruction in NMSC treatment followed by a review of the patients’ responses and a discussion of options for reconstruction. A summative content analysis of the written and interview responses was performed by 2 reviewers (A.R., J.J.C.) with NVivo software, version 11 (QSR International), using a line-by-line coding approach to establish the major themes and subthemes.

All patients presenting for nasal reconstruction were prescreened for study eligibility. Twenty-six patients were approached; 25 patients completed the form and interviews (8 men and 17 women; mean [SD] age, 63.3 [10.7] years). One patient was ineligible because of a previous undocumented skin cancer diagnosis. Five major areas of concern were identified: appearance, surgery, cancer outcomes, financial cost, and recovery process (Table). Appearance-related concerns were most common (17 of 25 patients [68%]). In addition, 12 of the 25 patients (48%) inquired about recovery, including recovery time, activity limitations, and likelihood of restoring normal breathing after surgery, and 10 of the 25 patients (40%) described concerns about nasal reconstruction after Mohs surgery.

Quality of life after plastic surgery has gained increasing attention from patients, payers, and physicians.^3-5 Appropriate counseling and education are critical components of the preoperative discussion, especially for reconstructive operations in which there are often multiple available treatment options. Shared decision making is a process in which practitioners and patients make decisions together using the best available evidence.⁶ Patients are encouraged to weigh the pros and cons of each treatment or intervention.

The goal of this study was to investigate the factors that can affect patients’ decisions about nasal reconstruction after Mohs surgery to build a patient-centered intervention to address these concerns. A limitation of the study is that it is a single-institution experience with a single facial plastic surgeon. To draw broader conclusions, a multicenter study would be appropriate. However, information gained from this project may help advance the development of shared decision-making tools and resources in plastic and reconstructive surgery.

Adequate counseling of patients with skin cancer on the various reconstructive options for their facial defects can be challenging. Each patient’s circumstances are unique, and the best reconstructive choice for each patient must be individualized and consistent with the patient’s values and preferences.⁶

Accepted for Publication: July 15, 2018.

Corresponding Author: John J. Chi, MD, MPHS, Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Washington University in St Louis, 660 S Euclid Ave, Campus Box 8115, St Louis, MO 63110 (johnchi@wustl.edu).

Published Online: September 27, 2018. doi:10.1001/jamaoto.2018.2368

Author Contributions: Dr Chi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chi, Hahn, Piccirillo, Politi, Kallogjeri, Kukuljan.

Acquisition, analysis, or interpretation of data: Chi, Rosenberg, Kallogjeri.

Drafting of the manuscript: Rosenberg, Politi.

Critical revision of the manuscript for important intellectual content: Chi, Rosenberg, Hahn, Piccirillo, Kallogjeri, Kukuljan.

Statistical analysis: Piccirillo, Kallogjeri.

Administrative, technical, or material support: Chi, Hahn, Piccirillo, Kallogjeri, Kukuljan.

Supervision: Politi.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This study was supported by the Leslie Bernstein Investigator Development Grant from the American Academy of Facial Plastic & Reconstructive Surgery (Dr Chi).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Piccirillo is Editor and Dr Kallogjeri is Statistics Editor of JAMA Otolaryngology–Head & Neck Surgery, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: Aimee James, PhD, Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri, provided guidance with the qualitative analysis. She was not compensated for her work.