Impact of Two Attendings on the Outcomes of Microvascular Limb Reconstruction

Abstract

Background Free tissue transfers are routinely performed for extremity reconstruction. In an era of increasing economic pressure in many healthcare systems, efficiency needs to be optimized for any kind of operative procedure. This study is examining the possible benefit of a two-attending approach to microsurgical reconstruction of the limbs using antero-lateral thigh- (ALT) or gracilis-muscle flaps at a major academic microsurgical center.

Methods 309 patients underwent 392 free ALT- (206) or gracilis-muscle (186) flaps for limb defect reconstruction at our institution (2009–2015). All available data was retrospectively screened for patients' demographics, perioperative details, surgical complications, and overall flap survival. The cases were divided into two groups according to the number of operating microsurgeons: one versus two attendings.

Results No significant differences existed between the two groups (341 “one attending” versus 51 “two attendings”) regarding preoperative comorbidities. Overall, there was no significant difference between both groups regarding operative times, revision surgery rates, total as well as partial flap loss, and hospital length of stay (p > 0.05) during the 3-month follow-up period. Further, evaluating ALT and gracilis flaps separately also showed no significant differences between both groups (one versus two attendings).

Conclusion The addition of a second operating attending does not significantly shorten surgery times, hospital length of stay, need for revision surgery, or complications rates. A two-operation surgeon approach may therefore only provide a marginal benefit in microsurgical limb reconstruction.

Keywords

number of microsurgeons - limb reconstruction - free flap reconstruction

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

• References

• 1 Lin CH, Lin YT, Yeh JT, Chen CT. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007; 119 (07) 2118-2126
• 2 Lorenzo AR, Lin CH, Lin CH. , et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
• 3 Riot S, Herlin C, Mojallal A. , et al. A Systematic Review and Meta-Analysis of Double Venous Anastomosis in Free Flaps. Plast Reconstr Surg 2015; 136 (06) 1299-1311
• 4 Bauermeister AJ, Zuriarrain A, Newman M, Earle SA, Medina III MA. Impact of Continuous Two-Team Approach in Autologous Breast Reconstruction. J Reconstr Microsurg 2017; 33 (04) 298-304
• 5 Weichman KE, Lam G, Wilson SC. , et al. The Impact of Two Operating Surgeons on Microsurgical Breast Reconstruction. Plast Reconstr Surg 2017; 139 (02) 277-284
• 6 Chen WF, Kung YP, Kang YC, Lawrence WT, Tsao CK. An old controversy revisited-one versus two venous anastomoses in microvascular head and neck reconstruction using anterolateral thigh flap. Microsurgery 2014; 34 (05) 377-383
• 7 Hanasono MM, Kocak E, Ogunleye O, Hartley CJ, Miller MJ. One versus two venous anastomoses in microvascular free flap surgery. Plast Reconstr Surg 2010; 126 (05) 1548-1557
• 8 Khouri RK, Cooley BC, Kunselman AR. , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
• 9 Miller TJ, Jeong HS, Davis K. , et al. Evaluation of the American Society of Anesthesiologists Physical Status classification system in risk assessment for plastic and reconstructive surgery patients. Aesthet Surg J 2014; 34 (03) 448-456
• 10 Üstün GG, Aksu AE, Uzun H, Bitik O. The systematic review and meta-analysis of free flap safety in the elderly patients. Microsurgery 2017; 37 (05) 442-450
• 11 Kim BD, Ver Halen JP, Grant DW, Kim JY. Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases. J Reconstr Microsurg 2014; 30 (04) 217-226
• 12 Lee KT, Mun GH. Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis. Ann Plast Surg 2016; 76 (05) 576-584
• 13 Scheer A, Martel G, Moloo H. , et al. Laparoscopic colon surgery: does operative time matter?. Dis Colon Rectum 2009; 52 (10) 1746-1752
• 14 Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007; 120 (04) 952-959
• 15 Tan TW, Kalish JA, Hamburg NM. , et al. Shorter duration of femoral-popliteal bypass is associated with decreased surgical site infection and shorter hospital length of stay. J Am Coll Surg 2012; 215 (04) 512-518
• 16 Macario A. What does one minute of operating room time cost?. J Clin Anesth 2010; 22 (04) 233-236