Comparison of early outcomes between Plastic Surgeons and Otolaryngologists Performing Head and Neck Free Flap Reconstruction: Based on the American College of Surgeons National Surgical Quality Improvement Program
Parag Butala, MD, Michael C. Cheung, MD, Amber Wilk, PhD, Rachel A. Anolik, MD, Scott T. Hollenbeck, MD.
Duke University Medical Center, Durham, NC, USA.
Free tissue transfer for head and neck reconstruction is utilized by both plastic surgeons and otolaryngologists, yet few comparisons exist between these surgical subspecialties. Clinical outcomes in the acute setting following head and neck reconstruction have largely been based on retrospective chart reviews. The National Surgical Quality Improvement Program (NSQIP) provides a large patient cohort for determining early post-operative outcomes for this technique.
A prospective, multi-institutional study of patients undergoing head and neck surgery was performed from the National Surgical Quality Improvement Program from 2006 to 20011. Reconstructions were determined to have been performed by either plastic surgery or ENT based on CPT coding. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined. Univariate and multivariate logistic regression was performed to identify independent risk factors for complications and outcomes of interest (surgical site infection [SSI], flap failure, reoperation and mortality) as well as surgeon subspecialty comparison.
A total of 281 patients were identified who underwent soft tissue free flap reconstruction. The plastic surgery patients had a higher incidence of preoperative MI, CVA, steroid usage, radiation, and bleeding disorders. The type of surgery that led to reconstruction most commonly were glossectomies, maxillectomies, and pharyngectomies; however, there was no difference in the type of resection between the surgical subspecialties. There were 83 muscle flaps and 198 fasciocutaneous flaps. Osteocutaneous flaps were excluded due to insufficient numbers for analysis. Forty percent of patients were above the age of 65. Interestingly, although operative times were similar between groups, head and neck surgeons performed significantly more fasciocutaneous flaps compared to myocutaneous flaps (70.5% vs. 29.5%), whereas plastic surgeons equally performed fasciocutaneous and myocutaneous flaps (51.5% vs. 48.5%). The 30-day mortality was 2%. Wound infections were the most common complication at 24.9%; the reoperative rate was 7.8%, and flap failure rate was 3.2%. Multivariate analyses (table 1) demonstrated that prolonged operative time significantly predicted an increased risk of wound infection. Furthermore, complications of flap failure, reoperation, and thromboembolic phenomena correlated to patients with low albumin and to type of free flap utilized, with fasciocutaneous flaps being associated with increased complications. Interestingly, age of patient and surgeon subspecialty did not demonstrate any differences in reconstructive outcomes.
This study demonstrates that overall early outcomes for both plastic and head and neck surgeons are excellent and do not differ. This is despite the fact that the patients referred to plastic surgery had more co-morbidities. There also appears to be differences in flap selection between the subspecialties and this is likely related to scope of training and comfort with flap variation.
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