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Original Investigation
Mar/Apr 2018

Clinical Factors Associated With Reoperation and Prolonged Length of Stay in Free Tissue Transfer to Oncologic Head and Neck Defects

Author Affiliations
  • 1The University of Pennsylvania, Department of Otorhinolaryngology, Philadelphia
  • 2Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia
  • 3University of California, Davis Medical Center, Department of Otolaryngology, Sacramento
  • 4The University of Pennsylvania, Division of Plastic and Reconstructive Surgery, Philadelphia
JAMA Facial Plast Surg. 2018;20(2):154-159. doi:10.1001/jamafacial.2017.1771
Key Points

Questions  What are the clinical factors associated with reoperation and prolonged hospitalization in patients undergoing free tissue transfer for reconstruction of detects related to head and neck malignant neoplasms?

Findings  In this review of the American College of Surgeons National Surgical Quality Improvement Program, reoperation, smoking, a clean-contaminated wound class, patient age, a bone-containing flap, and prolonged operative time were associated with prolonged hospital stay. Similar factors were associated with reoperation, and an independent reconstructive team was protective against reoperation.

Meaning  Surgical teams should focus on wound complication prevention and collaborate with dedicated reconstructive teams to improve rates of reoperation and prevent prolonged hospital stays in this patient population.


Importance  Prolonged hospitalization and reoperation after free tissue transfer may be associated with certain clinical factors.

Objective  To determine patient and surgical factors associated with length of stay (LOS) and reoperation following surgical procedures for malignant neoplasm of the head and neck involving microvascular free tissue transfer reconstruction.

Design, Setting, and Participants  This was a retrospective review of American College of Surgeons National Surgical Quality Improvement Program data from 2012 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9), codes for malignant neoplasms of the head and neck. Multivariable logistic regression modeling was used to examine correlation of patient and surgical variables with reoperation and LOS. The national retrospective database included outcomes from community and academic participant hospitals (517 member institutions in 2014). A total of 1115 cases of head and neck malignant neoplasm ablation with microvascular free tissue transfer flap were reviewed retrospectively.

Main Outcomes and Measures  Incidence of reoperation within 30 days of index operation and hospitalization equal to or longer than 13.0 days, which is equal to being in the top quartile for duration of stay.

Results  Of the 1115 patients, 370 (33.2) were female, and the mean (SD) age was 66.8 (3.9) years. Predictors of prolonged length of stay included return to the operating room (odds ratio [OR], 4.8; 95% CI, 3.3-6.9), smoking (OR, 2.1; 95% CI, 1.5-3.1), clean-contaminated wound (OR, 2.2; 95% CI, 1.3-4.0), bony flap (OR, 1.8; 95% CI, 1.2-2.8), age (OR, 1.5; 95% CI, 1.2-1.7), and operative time (OR, 1.2; 95% CI, 1.1-1.3). Reoperation occurred 298 times for 225 patients (20.2%). Mean (SD) time to reoperation was 8.0 (7.7) days, with 180 (80%) occurring before discharge from the primary operation. The most common indications for reoperation were neck exploration (37 [12.4%]) or incision and drainage of neck (35 [11.7%]).

Conclusions and Relevance  American College of Surgeons National Surgical Quality Improvement Program data allow for large database analysis of free flap transfer to the head and neck. The data herein provide information to help guide surgeons on which patients will require longer stay in hospital and the most common reasons for return to the operating room. Wound class of index operation, subsequent wound-related complications, and long duration of the index operation were the primary drivers of increased risk for reoperation and, therefore, prolonged hospitalization. These same factors were also associated with prolonged hospitalization without reoperation.

Level of Evidence  NA.