Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database.

BACKGROUND: There is a scarcity of externally valid data that investigate the utility of operative time, a common clinical parameter, as a predictor of free flap failures. Our aim was to assess whether prolonged operative time correlates with early flap failure following free tissue transfer in the acute care setting using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program databases were reviewed for encounters that entailed a free tissue transfer via a CPT algorithm. Patients identified as having a flap loss were compared with people who did not with regards to operative time and patient comorbidities. Patients were subdivided into the following cohort groups with regards to operative time: <6 hours, 6-12 hours, and >12 hours. Secondary outcome was association between increasing operative time and postoperative complications. RESULTS: Of the 2,008 patients identified, 62 (3.1%) had early flap failure. After multivariable analysis, it was found that progressive operative time was associated with an increased risk of flap failure; 6-12 hours odds ratio was 4.64 and >12 hours odds ratio was 5.65 (P = 0.0140). Higher American Society of Anesthesiologists class (P = 0.0042) was also shown to be significantly associated with flap failure. On secondary analysis, increasing operative time was correlated with the following complications: pneumonia, blood transfusions, prolonged ventilation, wound dehiscence, and wound complications. CONCLUSION: Our results, one of the largest series in the literature, revealed that prolonged operative time was associated with a stepwise increase in the likelihood of early flap failure as well certain postoperative complications. © 2014 Wiley Periodicals, Inc. Microsurgery 37:12-20, 2017.

Microporous Polysaccharide Hemospheres Potentiate Ischemia-Induced Skin Flap Necrosis in a Murine Model.

BACKGROUND: Microporous polysaccharide hemospheres are an increasingly used adjunctive measure for obtaining operative field hemostasis. However, the impact of these agents on survival of vascularly challenged tissues is unknown. The aim of this study was to investigate the effect, if any, of microporous hemospheres on tissue survival in a murine model. METHODS: Eighteen Sprague-Dawley rats underwent creation of two flanking dorsal, modified McFarlane-style flaps using a length-to-width ratio of 4:1. Microporous polysaccharide hemospheres were applied to the underside of only one flap in each animal. In a subset of five rats, tissue malondialdehyde activity was measured at 24 hours. The remaining 13 animals were killed after 7 days, and the area of flap necrosis was measured photographically. Histopathologic analysis was also performed on the margins of the necrotic area. RESULTS: Size comparison showed a significantly larger area of necrosis in the microporous polysaccharide hemosphere-treated flaps relative to controls (1.69 ± 1.21 cm versus 0.28 ± 0.28 cm; p = 0.00135). Higher malondialdehyde levels were also found in the microporous polysaccharide hemosphere-treated flaps at 24 hours (0.462 ± 0.098 versus 0.315 ± 0.065; p = 0.047). The areas of skin necrosis were noted to be partial thickness on histologic examination. CONCLUSIONS: Microporous polysaccharide hemospheres are associated with an increased incidence of distal tip necrosis in dorsal rat skin flaps. Despite their efficacy in surgical hemostasis, their use should be judicious, especially with marginally perfused tissues such as mastectomy skin flaps.

Investigating the Impact of Flap Overdesign on Viability.

Background Partial or complete flap necrosis is a detrimental outcome complicating reconstructive surgery. The purpose of this study was to evaluate the impact of flap overdesign on viability in the rat model. Methods Forty Sprague-Dawley rats were equally divided into four groups receiving flaps of varying length-to-width ratios: 2:1, 3:1, 4:1, and 5:1. All animals had caudally based, modified McFarlane-style flap created. Areas of survival were assessed 14 days postoperatively and compared among groups using one-way analysis of variance. Results The mean areas of flap survival were 8.0 ± 0.0 cm 2 , 7.8 ± 1.1 cm 2 , 8.3 ± 1.1 cm 2 , and 8.1 ± 1.5 cm 2 for the 2:1, 3:1, 4:1, and 5:1 length-to-width ratio groups, respectively. There were no statistically significant differences in mean areas of flap survival among groups ( p > 0.05). Conclusion Flap overdesign does not increase the risk of flap necrosis in a random-pattern flap.

A Cohort Analysis of Postbariatric Panniculectomy--Current Trends in Surgeon Reimbursement.

BACKGROUND: The overall number of patients undergoing body contouring procedures after massive weight loss (MWL) has progressively increased over the past decade. The purpose of this study was to evaluate the charges and reimbursements for panniculectomy after MWL at a large academic institution in Massachusetts. METHODS: A retrospective review was performed and included all identifiable panniculectomy procedures performed at our institution between January 2008 and January 2014. The annual number of patients undergoing panniculectomy, the type of insurance coverage and reimbursement method of each patient, and the amounts billed and reimbursed were evaluated. RESULTS: During our study period, 114 patients underwent a medically necessary panniculectomy as a result of MWL. The average surgeon fee billed was $3496 ± $704 and the average amount reimbursed was $1271 ± $589. Ten cases (8.8%) had no reimbursements, 31 cases (21.8%) reimbursed less than $1000, 66 cases (57.9%) reimbursed between $1000 and $2000, and no cases reimbursed the full amount billed. When evaluated by type of insurance coverage, collection ratios were 37.4% ± 17.4% overall, 41.7% ± 16.4% for private insurance, and 24.0% ± 13.0% for Medicare/Medicaid insurance (P < 0.001). CONCLUSIONS: Reimbursements for panniculectomy are remarkably low, and in many instances, absent, despite obtaining previous preauthorization of medical necessity. Although panniculectomy is associated with improvements in quality of life and high levels of patient satisfaction, poor physician reimbursement for this labor intensive procedure may preclude access to appropriate care required by the MWL patient population.

Impact of Specialty Training on the Association between Flap Size and Incidence of Complications following Microvascular Head and Neck Reconstruction for Cancer.

BACKGROUND: The scope of otolaryngology and plastic surgery overlap within head and neck reconstruction is increasing; yet comparative outcome studies between these two subspecialties are limited. METHODS: A retrospective review was performed on all patients who underwent microvascular reconstruction of a postablative head and neck defect at a quaternary academic medical center between January 2000 and October 2011. Postoperative outcomes were reviewed by subspecialty and Mann-Whitney analysis was used to investigate any flap size differences between cohorts with and without complications. RESULTS: A consecutive series of 129 (66.8%) otolaryngology cases and 64 (33.2%) plastic surgery cases comprised the entire study sample. Plastic surgery flaps were significantly larger than otolaryngology flaps (9.7 vs. 8.5 cm, p = 0.004). Flap complication rates (31.8 vs. 37.5%, p = 0.429) and flap failure rates (5.4 vs. 4.7%, p = 0.429) were comparable between subspecialties. However, a significant difference in flap size was evident between the cohorts with and without flap complications following microvascular reconstruction by otolaryngology (9.18 vs. 8.15 cm, p = 0.042). This difference was not detected following reconstruction by plastic surgery (9.34 vs. 9.04 cm, p = 0.225). For the overall sample, there was a correlation between increasing flap size and higher tumor stages (significant at T4, p = 0.003) as well as advanced T-stage and medical complications (p = 0.004). CONCLUSION: Plastic surgeons should maintain an active role in the reconstruction of complex, microvascular head and neck cases such as those that require larger flaps and/or of advanced T-stages.

Evaluation of abdominal cutaneous sensibility following abdominoplasty.

BACKGROUND: Cutaneous hypesthesia is an undesirable postoperative outcome following abdominoplasty. The purpose of this study was to evaluate postabdominoplasty cutaneous sensibility using clinical, quantitative, and reproducible methods. METHODS: Thirty patients who underwent abdominoplasty were divided into three groups: 0 to 12 months (short-term follow-up), 12 to 24 months (intermediate-term follow-up), and greater than 24 months (long-term follow-up) following abdominoplasty. Abdominal skin was divided into 12 areas, and superficial tactile sensibility was assessed subjectively using a patient questionnaire and objectively using Semmes-Weinstein monofilaments. Statistical analysis was performed using the t test, with significance defined as p ≤ 0.05. RESULTS: Seventeen patients (56.7 percent) subjectively reported the presence of any abdominal cutaneous sensibility change postoperatively. Of those, 82.4 percent reported indifference toward this outcome. The greatest degree of objective sensibility loss was noted in area 8 (infraumbilical), followed by areas 5 (supraumbilical) and 11 (midline infraincisional). In these areas, there were statistically significant decreases in the average cutaneous pressure thresholds between the short-term and intermediate-term follow-up groups, the intermediate-term and long-term follow-up groups, and the short-term and long-term follow-up groups. CONCLUSIONS: Postabdominoplasty cutaneous sensibility losses improve over time. These findings may enable plastic surgeons to better inform their patients regarding the risk of sensibility loss and the longitudinal outcome of such changes postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk factors associated with prolonged postoperative stay following free tissue transfer: an analysis of 2425 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Length of stay following surgical procedures has a considerable impact on healthcare resource use. This study characterizes risk factors predictive of a prolonged length of stay following free tissue transfer using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: The 2005 to 2011 National Surgical Quality Improvement Program databases were reviewed for all identifiable free tissue transfer cases. Free tissue transfers for breast and nonbreast reconstruction were analyzed separately. Prolonged length of stay was defined as greater than the 75th percentile in each cohort group. A logistic regression model was developed for prolonged postoperative length of stay following breast and nonbreast reconstruction. RESULTS: The authors identified 2425 patients, and 885 (36 percent) had a prolonged length of stay, determined to be greater than 5 days and greater than 13 days in the breast (577 patients) and nonbreast (308 patients) reconstruction groups, respectively. Higher American Society of Anesthesiologists class and prolonged operative time were associated with a prolonged length of stay for both groups. Declining preoperative albumin level (p < 0.0001), increasing age (p = 0.0068), history of diabetes (OR, 2.16; p = 0.0215), perioperative transfusion requirement (OR, 3.64; p = 0.0311), dependent functional status (p = 0.0101), and preoperative irradiation (OR, 4.01; p = 0.0062) were also predictors for a prolonged length of stay in the nonbreast reconstruction group. CONCLUSIONS: This study identified key predictors of prolonged length of stay following free tissue transfer. The diverging findings between cohorts with regard to the impact of comorbidities on length of stay highlight possible avenues to improve healthcare resource use.