Background: Complex head and neck cancer defects can be reconstructed using free tissue transfer from an out-of-field autologous donor site. A single surgical team can perform both the ablative and free flap reconstructive components of these surgeries in sequence. In recent years, a two-team approach, wherein one surgeon carries out the resection of the tumour and a second surgeon the reconstruction of the defect, has increased in popularity.
Objectives: To investigate the benefit of two surgeon-led teams in operating room efficiency and post-operative outcomes.
Methods: Retrospective series of consecutive head and neck free flap reconstruction at an academic tertiary referral centre between 2015 and 2021. Cases were categorized as single surgeon versus two-team and were compared for disease characteristics, anesthetic and operative time, and post-operative outcomes. Univariate and multivariate statistics were carried out.
Results: Five-hundred seventy-three consecutive free flaps were performed (n= 259 single surgeon, n=314 two-team) during this period. The two-team group was slightly younger (61.1 + 14.9 vs 64.0 + 14.9, p0.026) but otherwise there were no differences in baseline patient demographic or disease characteristics. Chi-squared analysis demonstrated that more fibula free flap reconstructions were done by the two-team group (32.3% vs. 13.5%, p<0.005) and more radial forearm flaps done in the single surgeon cohort (35.3% vs 50.6%, p<0.005). A two-team approach enabled significantly reduced operative and anesthetic times, with reductions of 28.0% and 22.9%, or 96 minutes and 88 minutes, respectively (p<0.0001). There were no significant differences in post-operative complication rates nor length of stay. Multivariate analysis for operative time in all comers showed that virtual surgical planning (OR 0.401 (CI 95% 0.189-0.851) p=0.018), early stage (OR 0.481 (CI 95% 0.253-0.913) p=0.026) and non-malignant lesions (OR 0.289 (CI 95% 0.120-0.695) p= 0.006) were associated with decreased duration of surgery. Conversely, nasopharyngeal and sinonasal primary malignancies conferred significantly longer operating times when compared to all other tumour sites. Similarly, scapular donor flap reconstructions resulted in longer operative times in comparison to anterolateral thigh (OR 3.116 (CI 95% 1.074-9.037) p=0.037) and radial flaps (OR 6.55 (CI 95% 2.96-14.52) p<0.0001), and the fibula flap conferred longer operative times compared to the radial flap (OR 4.78 (CI 95% 2.46-9.28) p<0.0001). Tracheostomy was an independent predictor for increased operative time (OR 15.6 (CI 95% 9.330-26.118) p<0.001), length of stay (OR 1.210 (CI 95% 1.166-1.256) p<0.001) and Clavien-Dindo complications >3 (OR 1.714 (CI 95% 1.081-2.716) p=0.022).
Conclusions: A two-team approach had a robust impact on lowering operative and anesthetic times, despite a higher proportion of bony free tissue transfer. Reducing overall operative time may allow for improved utilization of precious hospital infrastructural resources, personnel and costs.