FREE TISSUE TRANSFER: COMPARISON OF OUTCOMES …



Title: Free Tissue Transfer: Comparison of Outcomes Between University Hospitals and Community Hospitals

Authors: Jeffrey A. Gusenoff, MD, Stephen J. Vega, MD, Shao Jiang, MD, Amir B.Behnam, MD, Hani Sbitany, BS, and Joseph M. Serletti, MD

In most university hospitals, free tissue transfer (FTT) has become a standard method of major reconstruction for a broad spectrum of defects. Because of its complexity, FTT has not been routinely performed in a community hospital setting.1 This study reports on the outcomes of two equal groups of FTT performed by the same surgeons, comparing the university hospital setting versus the community hospital setting.

Method: 725 FTTs were performed at 2 University hospitals (UH) and 6 Community hospitals (CH) in our region. Outcome parameters used in this study included wound infection, wound dehiscence, delayed healing, hematoma, fat necrosis, postoperative vascular compromises as well as partial and total flap loss. The 725 FTTs were performed on 645 patients: 444 females (69%) and 201 males (31%). The mean age at the time of operation was 51.1 years. 379 FTTs were performed at UH (52%) and 346 (48%) were performed at CH. Preoperative comorbidities as measured by ASA scores did not differ between the groups. Statistical analysis to determine the comparison of outcomes between the groups was performed using the unpaired Student’s T-test.

Characteristics of Reconstruction: Categories of FTT reconstruction included predominantly breast, lower extremity, head and neck, and upper extremity reconstructions (Table 1). Most of the breast reconstructions were performed in the CH setting, whereas most of the lower extremity and head and neck reconstructions were performed at the UH setting. The types of free flaps used included TRAM, radial forearm, rectus abdominus, latissimus dorsi, fibula, gluteal myocutaneous, and SGAP flaps among others (Table 2). Most of the TRAM flaps were performed at the CH setting as compared to the radial forearm and rectus abdominus flaps, which were used more frequently in the UH setting.

Results: 60 major postoperative complications occurred in the UH setting (16%) while 42 complications occurred in the CH setting (12%). Among the complications, only wound infection differed significantly between the UH and CH setting (Table 3). Partial flap loss was present in 6 UH flaps (2 radial forearm, 2 rectus, 2 omentum, 1 TRAM, 1 latissimus) vs. 3 CH flaps (2 TRAM,1 latissimus), p>0.05. Total flap loss occurred in 6 (1.6%) UH flaps (2 radial forearm, 2 rectus, 1 TRAM, 1 fibula) and 5 (1.4%) CH flaps (2 SGAP flaps, 1 radial forearm, 1 rectus, 1 gluteal), p>0.05.

Conclusion: The frequency of postoperative complications was not different between the university and community hospitals with the exception of wound infection. This sole difference is probably reflected in the difference of the case mix (breast vs. lower extremity reconstruction) between the two settings. Free tissue transfer is an effective and practical method of reconstruction for a myriad of defects that can be safely performed by experienced microsurgeons in both a university hospital as well as at the community hospital.

|Table 1. Categories of | | | | |

|Free Tissue Transfer | | | | |

|Reconstruction | | | | |

| | | | | |

|Category | |Number |UH (%) |CH (%) |

| | | | | |

|Breast | |388 |32 |68 |

|Lower extremity | |169 |75 |25 |

|Head and neck | |140 |80 |20 |

|Upper extremity | |13 |100 |0 |

|Gender reassignment | |1 |100 |0 |

|Perineal | |1 |0 |100 |

| | | | | |

|UH = University | | | | |

|Hospital, CH = Community| | | | |

|Hospital | | | | |

| | | | | |

| | | | | |

|Table 2. Types of Free | | | | |

|Tissue Transfer Used | | | | |

| | | | | |

|Category | |Number |UH (%) |CH (%) |

|TRAM | |383 |30 |70 |

|Radial forearm | |130 |79 |21 |

|Rectus abdominus | |123 |80 |20 |

|Latissimus dorsi | |35 |80 |20 |

|Fibulas | |33 |76 |24 |

|Gluteal myocutaneous | |10 |50 |50 |

|SGAP | |9 |33 |67 |

|Omental | |6 |83 |17 |

|DIEP | |4 |75 |25 |

|Lateral Arm | |3 |100 |0 |

|VRAM | |3 |67 |33 |

|Scapular | |3 |100 |0 |

|Jejunum | |3 |67 |33 |

|Serratus | |1 |100 |0 |

|Gracilis | |1 |100 |0 |

|Lateral thigh | |1 |100 |0 |

|Ulnar forearm | |1 |0 |100 |

|Other osteocutaneous | |2 |100 |0 |

| | | | | |

| | | | | |

|Table 3. Comparison of | | | | |

|Postoperative | | | | |

|Complications | | | | |

| | | | | |

|Category | |UH |CH |p - value |

| | | | | |

|Wound infection | |24 |11 |0.02 |

|Delayed healing | |12 |5 |NS |

|Wound dehiscence | |6 |3 |NS |

|Fat necrosis | |3 |8 |NS |

|Hematoma | |6 |4 |NS |

Reference:

1. Serletti, J.M. et al. Comparison of the Operating Microscope and Loupes for Free Microvascular Tissue Transfer. Plastic and Reconstructive Surgery 95: 270-276, 1995.

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