Outcomes and cost implications of microvascular reconstructions of the head and neck

Abstract

Background Critical review of current head and neck reconstructive practices as related to free flap donor sites and their impact on clinical outcomes and cost. Methods Retrospective multicenter review of free tissue transfer reconstruction of head and neck defects (n = 1315). Variables reviewed: defect, indication, T classification, operative duration, and complications. A convenience sample was selected for analysis of overall (operative and inpatient admission) charges per hospitalization (n = 400). Results Mean charges of hospitalization by donor tissue: radial forearm free flap (RFFF) $127 636 (n = 183), osteocutaneous RFFF (OCRFFF) $125 456 (n = 70), anterior lateral thigh $133 781 (n = 54), fibula $140 747 (n = 42), latissimus $208 890 (n = 24), rectus $169 637 (n = 18), scapula $128 712 (n = 4), and ulna $110 716 (n = 5; P = .16). Mean operative times for malignant lesions stratified by T classification: 6.9 hours (±25 minutes) for T1, 7.0 hours (±16 minutes) for T2, 7.3 hours (±17 minutes) for T3, and 7.8 hours (±11 minutes) for T4 (P < .0001). Complications correlated with differences in mean charges: minor surgical ($123 720), medical ($216 387), and major surgical ($169 821; P < .001). Operations for advanced malignant lesions had higher mean charges: T1 lesions ($106 506) compared to T2/T3 lesions ($133 080; P = .03) and T4 lesions ($142 183; P = .02). On multivariate analysis, the length of stay, operative duration, and type a postoperative complication were factors affecting overall charges for the hospitalization (P < .018). Conclusion Conclusion: The RFFF and OCRFFF had the lowest complication rates, length of hospitalization, duration of operation, and mean charges of hospitalization. Advanced stage malignant disease correlated with increased hospitalization length, operative time, and complication rates resulting in higher hospitalization charges.

Factors impacting successful salvage of the failing free flap

“…Although rare, vascular compromise of a free flap still occurs, resulting in great effort and significant resources utilization to salvage the free flap. 15 Even with these heroic efforts, 20% to 75% of free flaps undergoing vascular compromise will eventually fail. 5,16,19,[20][21][22][23][24] This study investigated free flaps experiencing vascular compromise to evaluate factors impacting the ability to successfully salvage a free flap used for head and neck reconstruction.…”

“…16,33 Management of a compromised free flap is associated with significant resource utilization and increased overall cost. 15 Previously it was found flap compromise with successful salvage resulted in a 1.3 times increase in the mean hospitalization cost. 15 If flap compromise was due to arterial insufficiency, mean cost of the hospitalization was 1.3 times greater than if due to venous congestion.…”

“…There is significant interest in factors impacting successful free flap salvage, as free flap failures occurring in the head and neck region are associated with increased patient morbidity, a complicated postoperative course, and increased length of hospitalization and expense. 14,15 While there has been a great deal of focus in the literature on free flaps which have failed, there is limited data on those free flaps which have been successfully salvaged after experiencing a vascular compromise. This is due to their low incidence, multitude of clinical confounders, and the technical complexities associated with their salvage.…”

“…Previously it was found flap compromise with successful salvage resulted in a 1.3 times increase in the mean hospitalization cost 15 . If flap compromise was due to arterial insufficiency, mean cost of the hospitalization was 1.3 times greater than if due to venous congestion 15 . With increased awareness of health care cost and efforts taken to limit health care spending, future investigations into the cost‐effectiveness of free flap salvage efforts, including quality adjusted life years analysis, will be imperative 34 …”

“…Free flap survival rates in recent years are consistently cited as greater than 95%, 4‐10 with still a small percentage of free flaps experiencing vascular compromise. Salvage of a compromised free flap is often attempted as complete failure of a free flap results in significant morbidity for the patient, increased length of hospitalization, and increased health care cost 7,11‐15 . The ability to salvage a compromised free flap has been cited as high as 60% to 80% 9,16‐19 .…”