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Original Investigation
June 1, 2017

Cost-effectiveness of Early Division of the Forehead Flap Pedicle

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
JAMA Facial Plast Surg. Published online June 1, 2017. doi:10.1001/jamafacial.2017.0310
Key Points

Question  Can 2-week division of the forehead flap for nasal reconstruction with verification using intraoperative laser fluorescence angiography minimize overall costs when compared with the 3-week timeframe for pedicle division?

Findings  A cost-effectiveness analysis of a sample of 22 patients who underwent 2-week division of the forehead flap after nasal reconstruction was performed. There were no instances of flap loss, and cost-minimization analysis showed that the use of angiography with indocyanine green results in cost savings of $177 per patient on average.

Meaning  Two-week takedown of select forehead flap patients with verification using intraoperative laser fluorescence angiography is safe and cost-effective, with cost savings of $177 per patient.

Abstract

Importance  The paramedian forehead flap is considered the gold standard procedure to optimally reconstruct major defects of the nose, but this procedure generally requires 2 stages, where the flap pedicle is divided 3 weeks following the initial surgery to ensure adequate revascularization of the flap from the surrounding recipient tissue bed, which can cost a patient time out of work or away from normal social habits. It has previously been shown that the pedicle may be safely divided after 2 weeks in select patients where revascularization from the recipient bed was confirmed using intraoperative laser fluorescence angiography to potentially save the patient time and money.

Objective  To demonstrate the cost-effectiveness of takedown of the paramedian forehead flap pedicle after 2 weeks using angiography with indocyanine green (ICG).

Design, Setting, and Participants  Retrospective cohort study of all patients who underwent 2-week division of the forehead flap after nasal reconstruction. Patient, tumor, defect, and outcomes data were collected. Cost-minimization analysis was performed by comparing the overall costs of 2-week takedown with angiography to a hypothetical patient undergoing 3-week takedown without angiography.

Intervention  Two-week division of the forehead flap after nasal reconstruction.

Main Outcomes and Measures  Cost-minimization analysis performed by calculating the total variable costs for a patient in our cohort vs costs to a theoretical patient for whom angiography was not performed and the pedicle was divided at the 3-week mark.

Results  A total of 22 patients were included (mean [SD] age, 70.3 [10.0] years; 8 women [36.4%] and 14 men [63.6%]). The selection criteria for 2-week division of the pedicle are a wound bed with at least 50% vascularized tissue present, partial-thickness defects, and absence of nicotine use. All were divided at the 2-week mark with no instances of flap necrosis. One patient had a squamous eccrine carcinoma histology before reconstruction, all other patients had basal cell carcinoma, squamous cell carcinoma, and melanoma. Cost-minimization analysis showed that the use of angiography with ICG results in cost savings of $177 per patient on average.

Conclusions and Relevance  Two-week takedown of select paramedian forehead flap patients can be performed safely with verification using angiography with ICG. Although this technology inherently adds cost, it is cost-effective, saving a total of $177 per patient.

Level of Evidence  NA.

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