Introduction: Despite significant advances in the field of head and neck (H&N) microvascular free tissue transfer (MFTT) over the past decade, there is a lack of standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. Microvascular training for otolaryngologists has become common, with 39 advanced H&N oncology fellowships currently offered through the American Head and Neck Society (AHNS). This study aims to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management.
Methods: A survey of ACGME-accredited residency programs and additional AHNS fellowship sites (United States and Canada) was distributed using Qualtrics software. A single representative surgeon from each unique program was surveyed, with answers reflecting institutional practices.
Results: Forty-eight (42.5%) programs responded, with 46 (95.8%) routinely performing MFTT and 14 (29.2%) having a dedicated microvascular fellowship program. Responses represent 133 microvascular fellowship trained surgeons (median 3 per institution, range 0-9), with 107 (78.8%) actively performing MFTT in current practice. Of institutions performing MFTT, 44 (93.6.%) reported the use of a two-surgeon team (ablative and reconstructive), most commonly both otolaryngologists (75.4%), and less commonly in collaboration with another department (eg, plastic surgery, 9.5%) or single surgeon performing both roles (15.1%). Median case volume was 60 flaps/year (range 10-200). Flap types performed at a majority of programs include radial forearm (100% of programs), fibula (100%), anterolateral thigh (95.7%), latissimus (71.7%), and scapula/parascapula (67.4%). Residents and fellows assist in flap harvest at 78.2% and 34.8% of programs, respectively, with nearly identical trends seen for assistance with microvascular anastomosis. Twenty-two programs (47.8%) reported access to H&N trained anesthesiologists for MFTT cases. Eight programs (17.4%) report routine postoperative sedation of durations ranging 12-48 hours. Assuming uneventful postoperative course, patients are admitted to ICU (77.9%), step-down unit (13.2%), or general care floor (9.0%). Postoperative flap checks are performed by a wide range of team members at variable frequencies (Table 1). Routine flap monitoring includes color (93.3% of programs), doppler signal (86.7%), capillary refill (84.4%), pin prick/bleeding rate (51.1%), temperature (48.8%), implanted doppler (44.4%), and infrared monitor (2 programs, 4.4%). Flap monitoring is discontinued on POD #7 or earlier at 77.8% of programs, with 22.2% stopping monitoring POD #4 or earlier. Postoperative anticoagulation routinely includes aspirin (82.2% of programs), subcutaneous heparin (44.4%), and lovenox (37.8%). Additional variability in practices was noted concerning postoperative restriction of activity/medications, antibiotic duration, transfusion threshold, and frequency of labs. Median self-reported rates of complication requiring return to operating room (5%, range 1-30%) and overall success rate (95%, range 90-99%) were consistent across programs despite variation in perioperative care regimens.
Conclusion: While some perioperative practices for MFTT are performed nearly uniformly, many elements continue to show variation at an institutional level. Self-reported flap complication and success rates showed no significant differences on the basis of perioperative care and monitoring regimen. There is a notable shift toward a two-surgeon approach with defined ablative and reconstructive roles, often both fellowship trained otolaryngologists.
