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Page 6 of 8 Hussaini et al. Plast Aesthet Res 2022;9:30 https://dx.doi.org/10.20517/2347-9264.2021.132

ECONOMIC IMPLICATIONS FOR A RECONSTRUCTIVE PRACTICE
Worldwide, FTT has become the mainstay of the oral cavity and oropharyngeal reconstruction over the past
two decades, offering precise tailoring of defects with specific tissue types, while delivering superior wound
healing and overall outcomes. However, the amount of resources needed to successfully and efficiently
perform FTT are immense, necessitating surgeons with microvascular training, specialized equipment and
instrument trays, and an intensive care unit (ICU) with nurses familiar with flap monitoring protocols. In a
health care system with limited resources, these costs may lead to fewer patients receiving timely surgical
care and potential diversion to external treatment centers. Numerous studies have demonstrated the adverse
effects of prolonged wait times for treatment of head & neck cancers, including tumor progression, TNM
upstaging, and local recurrence [33,34] . The undertreatment of these patients may ultimately contribute to the
rising cost of head and neck cancer care, which is projected to exceed five billion US dollars annually during
[35]
this decade .
One measure which has been advocated for to reduce the cost of FTT is the utilization of post-operative
step-down units instead of ICUs. Admission to the ICU has been previously associated with nearly a
$23,000-$35,000 increase in costs per admission and has also been shown to increase total hospitalization
length [36-38] . A number of studies over the past two decades have demonstrated that monitoring of flaps can
safely be performed outside of the ICU without adverse outcomes on flap survivability [39-42] . Despite these
results, a recent survey conducted by Kovatch et al. of ACGME-accredited otolaryngology programs
[38]
found that more than 75% of institutions routinely admit patients to the ICU following FTT. Although this
discrepancy may be partially attributed to historical trends and surgeon preference, there remains the
question of the availability of specialty-specific step-down units, with dedicated one-to-one nursing staff
who are able to proficiently monitor flaps. In an institution where FTT may be infrequent, it may not be
economically feasible to develop and maintain these types of units when a general ICU may make more
financial sense.

By its very nature, LRPF provides ways to overcome many of the economic burdens of FTT. Since no
microvascular anastomosis is required, the need for specialized training and equipment is obviated and
procedures can often be performed in a shorter period of time. In addition, since pedicled flaps do not
require close monitoring in the immediate post-operative period, the need for ICU-level care may be
obviated (on a case-by-case basis), which can account for thousands of dollars in savings.

CONCLUSION
Reconstruction of head and neck cancer defects is a taxing endeavor, both in terms of intrinsic challenges
posed on a case-by-case basis, but also because of rising health care costs and limitations in resources. The
current paradigm challenges the reconstructive surgeon to find a cost-effective solution that can be
delivered in a timely manner with satisfactory outcomes. Although LRPF has taken a back seat compared to
FTT over the past decade, there is renewed interest in utilizing these techniques as they may provide
superior results at a reduced cost in certain scenarios.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the review and authorship of the manuscript:
Hussaini AS, Patel UA