Facial Plastic and Reconstructive Surgery

Early discharge after free-tissue transfer does not increase adverse events

Free- tissue transfer comprises many of the most complex procedures performed in Head and Neck surgery. Traditionally, these surgeries have been commensurate with protracted hospital stays, related to the need for free flap monitoring, the elevated potential for postoperative complications, and morbidity associated with surgery. However, as free flap indications and use have expanded, a dichotomy has surfaced; some procedures remain associated with high morbidity, protracted recovery, and longer hospital stays, while others, which involve minimal access approaches and less extensive, low morbidity free flaps, have a more straightforward and reliable postoperative course. In these select patients, more rapid postoperative discharge has appeared feasible.

Research in the Section of Facial Plastic and Microvascular Surgery has demonstrated that carefully selected free flap patients may be discharged within 24 to 72 hours after surgery without increasing the rates of postoperative complications or readmissions.¹ Based on an earlier study of 51 free-tissue transfers,² a retrospective chart review was performed on an expanded cohort of patients who underwent free-tissue transfer for head and neck reconstruction between February 2010 and May 2018 and were discharged by postoperative day 3.

The review included 101 patients who underwent 104 free flaps with an average age of 56 (3 to 84) years old. Free flap indications included orbital and maxillary defects (N = 22), palatal defects (N = 16), nasal and septal defects (N = 16), cranioplasty and scalp defects (N = 16), mandibular defects due to osteoradionecrosis (N = 14), facial contouring and parotid defects (N = 12), and complex postsurgical and radiotherapy wounds or fistula closure (N = 8). Free flaps performed were anterolateral thigh (N = 97), radial forearm (N = 2), serratus (N = 2), latissimus (N = 1), fibula (N = 1), and supraclavicular (N = 1). The recipient vessels used via minimal access approaches were facial (N = 43), superficial temporal (N = 29), angular (N = 20), and others. There were 3 flap failures (2.9%) recognized in follow-up. No flap failures or perioperative complications were associated with early discharge. There were only 2 (2%) patients readmitted (1 for pneumonia and 1 for successful flap salvage) and 1 patient watched in overnight observation (epistaxis) within 30 days postoperatively.

Patient Demographics and Comorbid Conditions in Order of Frequency (N = 104)
Patient DemographicsN (%)
Gender
Male64 (61.5%)
Female40 (38.4%)
Mean age (range)56 (3-84)
Comorbid ConditionsN
Tobacco abuse28
Hypertension24
CAD/CVA/MI11
Endocrine disease10
Arrhythmia8
Hyperlipidemia7
Gastroesophageal reflux disease7
Diabetes mellitus5
Other neoplasm5
Pulmonary disease5
Vascular disease5
Nephrologic disease4
Seizures/traumatic brain injury4
Transplant status4
Psychiatric disease2
Congestive heart failure/cardiomyopathy2
Valvular disease2
Alcohol abuse2
Hematologic disease2
Deep vein thrombosis/pulmonary embolism1

CAD = coronary artery disease, CVA = cerebrovascular accident, MI = myocardial infarction

List of Adverse Events in the Postoperative Periods of all Free-tissue Transfers as well as 30-day Re-admissions and 23-hour Observations Postoperatively (N = 104)
Adverse eventsN(%)
Wound breakdown/dehiscence87.7%
Thigh hematoma11.0%
Thigh seroma21.9%
Surgical site infection43.8%
Free flap failure32.9%
Total events1817.3%
Readmissions & 23-hr observationsN
HCAP + sepsis1
Flap salvage1
Epistaxis (23 Hr Obs)(1)
Total 30-day readmissions (23-Hr Obs)2 (3)1.9% (2.9%)

HCAP = healthcare associated pneumonia, Hr = hour, Obs = observation

This updated review of the institute’s experience with more than double the cohort size substantiates previous conclusions that early discharge after free-tissue transfer is a safe option in select patients. Moreover, earlier discharge is a critical management choice that reduces cost and decreases hospital-related adverse events.

References
  1. Hanick A, Meleca JB, Fritz MA. Early discharge after free-tissue transfer does not increase adverse events. Am J Otolaryngol. Mar-Apr 2020;41(2):102374. doi:10.1016/j.amjoto.2019.102374. Epub 2019 Dec 10.

  2. Devine CM, Haffey TM, Trosman S, Fritz MA. Short-stay hospital admission after free tissue transfer for head and neck reconstruction. Laryngoscope. 2016 Dec;126(12):2679-2683.