BACKGROUND: Reconstruction of complex defects in the head and neck is best accomplished by free tissue transfer. For many defects the choice of tissue depends on many variables and outcomes are similar among these different reconstructive options. With clinical outcomes being similar, cost is a variable of consideration. To this end, we reviewed the outcomes of microvascular free tissue transfers for reconstruction of complex defects in the head and neck and the impact on healthcare cost.
STUDY DESIGN: Retrospective study.
METHODS: Patients undergoing microvascular free tissue transfer operations between 2010-2015 at two tertiary care institutions (n=1,315). Variables reviewed: defect location, indication, T classification, surgical details, duration of the operation and hospitalization, and complications (major, minor, medical). A convenient sample was selected for overall (operative and inpatient admission) cost analysis (n=200).
RESULTS: The shortest operative times were: RFFF (6.5 hours) and OCRFFF (7.0 hours) while fibula flap were the longest (8.2 hours) (p<0.001). Duration of hospitalization varied by donor tissue: scapula (7.3 days), RFFF (8.4 days), OCRFFF (9.3 days), latissimus free flap (12.4 days) and fibula (10.5 days) (p<0.001). Operations lasting <8 hours, had shorter duration hospitalization (8.9 days) than operations lasting >8 hours (10.1 days) (p=0.006). Age >60 correlated with operations lasting >8 hours (p=0.03). Complication rates were lowest for RFFF (39%), ALT (45%), rectus (46%) and OCRFFF (45%). Rates were highest for scapula (75%) and fibula (58%) (p=0.01). For soft tissue defects, rectus had greatest mean overall cost ($197,340) compared to RFFF ($139628) and ALT ($133,764)(p<0.01). For bony reconstructions mean overall costs were similar between OCRFFF ($135,111) and fibula ($136,025)(p=0.14). Mean overall costs were similar independent of time: <8 hrs ($129,574) compared to >8 hrs ($145,900)(p=0.10). Type of complication correlated with differences in mean overall cost: minor ($121,361), medical ($145,471) and major ($161,549)(p=0.03). Revision of the anastomosis was associated with greater mean overall cost for both salvage of the flap ($177,356) and total loss of the flap ($160,735) compared to if no revision was required ($135,915)(p=0.05).
CONCLUSION: With increasing emphasis on cost effective healthcare, there is a need for critical reviews of current practices and the impact clinical outcomes have on cost. With a variety of options available to reconstruct similar head and neck defects, costs may be a factor to consider in the reconstructive choice.