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Table.  
Clinical Characteristics of 22 Patients
Clinical Characteristics of 22 Patients
1.
Correa  BJ, Weathers  WM, Wolfswinkel  EM, Thornton  JF.  The forehead flap: the gold standard of nasal soft tissue reconstruction.  Semin Plast Surg. 2013;27(2):96-103.PubMedGoogle ScholarCrossref
2.
Menick  FJ.  A 10-year experience in nasal reconstruction with the three-stage forehead flap.  Plast Reconstr Surg. 2002;109(6):1839-1855; discussion 1856-1861.Google ScholarCrossref
3.
Surowitz  JB, Most  SP.  Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle.  JAMA Facial Plast Surg. 2015;17(3):209-214.PubMedGoogle ScholarCrossref
4.
Ishihara  H, Otomo  N, Suzuki  A, Takamura  K, Tsubo  T, Matsuki  A.  Detection of capillary protein leakage by glucose and indocyanine green dilutions during the early post-burn period.  Burns. 1998;24(6):525-531.PubMedGoogle ScholarCrossref
5.
Ganiats  TG, Neumann  PJ, Russell  LB, Sanders  GD, Siegel  JE.  Cost Effectiveness in Health and Medicine. Second ed. Oxford; New York: Oxford University Press; 2017.
6.
Kanuri  A, Liu  AS, Guo  L.  Whom should we SPY? a cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.  Plast Reconstr Surg. 2014;133(4):448e-454e.PubMedGoogle ScholarCrossref
7.
Woodard  CR, Most  SP.  Intraoperative angiography using laser-assisted indocyanine green imaging to map perfusion of forehead flaps.  Arch Facial Plast Surg. 2012;14(4):263-269.PubMedGoogle ScholarCrossref
8.
Rogers  HW, Weinstock  MA, Feldman  SR, Coldiron  BM.  Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012.  JAMA Dermatol. 2015;151(10):1081-1086.PubMedGoogle ScholarCrossref
9.
Cakir  BO, Adamson  P, Cingi  C.  Epidemiology and economic burden of nonmelanoma skin cancer.  Facial Plast Surg Clin North Am. 2012;20(4):419-422.PubMedGoogle ScholarCrossref
Original Investigation
Sept/Oct 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. 2017;19(5):418-420. 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.

Introduction

The paramedian forehead flap is considered the gold standard procedure to optimally reconstruct major defects of the nose, often with excellent outcomes.1 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.2 The staging of the procedure can cost a patient time out of work or away from normal social habits because the patient needs to live with a pedicle connecting the nose to the forehead. We have previously 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 (SPY Elite, NOVADAQ).3 We aim to determine whether this approach can minimize overall costs when compared with the 3-week timeframe for pedicle division.

Methods

Following institutional review board approval from Stanford University, a retrospective cohort study was conducted. Inclusion criteria were all patients who underwent a paramedian forehead flap procedure by the senior (S.P.M.) author between January 2007 and December 2016, and in whom laser fluorescence angiography was performed prior to pedicle division 2 weeks after the first stage (early division). There were no exclusions. Laser fluorescence angiography was performed by using indocyanine green (ICG), a short-acting diagnostic dye that is confined to the intravascular system, binds to plasma proteins, and has absorption and fluorescence, which occur at similar wavelengths as hemoglobin and oxyhemoglobin, allowing visualization of structures deep to the dermis.4 The SPY Elite system is used to visualize the perfusion of the ICG in real time, over a 30- to 60-second time frame.4

For all patients, we evaluated age, sex, and comorbidities. Indications for the procedure were recorded, and tumor histology was recorded for patients with postcancer resection defects. Defect data including size, depth of defect, and use of cartilage grafting were recorded. Complications were recorded for all patients.

The type of cost-effectiveness analysis performed was cost-minimization analysis.5 The analysis was performed by calculating the total variable costs for a patient in our cohort (early division) and comparing these costs with a theoretical patient for which angiography was not performed and the pedicle was divided at the 3-week mark (late division). Cost analysis was undertaken from both the health care sector and societal perspectives.5 The variable health care sector expenses are mainly the cost of the use the SPY Elite system with ICG for a single patient. The societal perspective included changes in patient productivity that are measured in terms of weekly wage.

Results

A total of 22 patients were included. Procedures were performed between November 2010 and July 2016. Patient and defect data are presented in the Table. All patients underwent Mohs surgery prior to reconstruction. One patient had a squamous eccrine carcinoma histology before reconstruction; all other patients had basal cell carcinoma, squamous cell carcinoma, and melanoma. There were only 2 postoperative complications: brow asymmetry and brow ptosis. No instances of partial or total flap loss were encountered. All of the patients who had angiography were found to be adequately vascularized. No sloughing or other untoward cosmetic effects were encountered in any patient.

The cost of a single-use of the SPY Elite system with ICG is $650 as previously published.6 The median weekly income in the United States was $827 in the third quarter of 2016 as obtained from the Bureau of Labor Statistics (http://www.BLS.gov). The total variable costs per patient would then total $2304. When compared with a hypothetical patient that underwent pedicle division 3 weeks following the first stage, and who did not undergo angiography, the total costs are $2481, and are comprised only of productivity losses. Therefore, the use of angiography with ICG results in cost savings of $177 per patient on average. The savings are mainly comprised of productivity gains.

Discussion

We have demonstrated again3 that 2-week division of the forehead flap pedicle may be performed safely without any incidence of partial or total flap loss in a select patient population. As outlined in our previous study,3 the selection criteria for 2-week division of the pedicle are a wound bed with at least 50% vascularized tissue present (exposed cartilage does not count as vascularized tissue), partial-thickness defects, and absence of nicotine use.3 In a previous study at our center,7 we have shown that there is significant neovascularization seen as early as week 1.

Based on our review of the literature, we believe this is the first study to demonstrate that the use of angiography with ICG is cost-effective when used to divide the forehead flap pedicle after 2 weeks, achieving $177 savings per patient. While not taken into account herein, early flap takedown also has considerable benefit in reducing the psychosocial impact of forehead flap surgery on patients. Taken together, this indicates that use of ICG to reduce the time between flap procedures is valuable to both the patient and the health care system.

There is no account for the number of paramedian forehead flap procedures performed annually. However, from 2006 to 2012, there was an increase from 1.9 to 2.2 million (14%) procedures for nonmelanoma skin cancer,8 and it is currently the most common malignancy in the United States.9 This represents a potential opportunity for cost savings.

To our knowledge, our study is the largest study in the English literature to date comparing timing of paramedian forehead flap takedown and assessing outcomes. It also is the largest review where ICG laser fluorescence angiography has been used to assess paramedian forehead flap vascularity prior to flap takedown, and we show that it is safe and cost-effective to perform the second stage in 2 weeks or less in select patients using angiography with ICG.

Limitations

This study was limited by its retrospective nature and limited sample size. Also, an inherent weakness of our cost-minimization analysis is that measuring productivity by wages represents a value judgement and may not apply to the pediatric population, to a retired population, and was not calculated from a profession-based perspective as this data was not available. A future perspective would be to perform larger studies to establish the safety of a 2-week takedown, which would eventually obviate the use of ICG angiography and produce even more cost savings.

Conclusions

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 up front, it is cost-effective, saving a total of $177 per patient.

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Article Information

Corresponding Author: Sam P. Most, MD, 801 Welch Rd, Stanford, CA 94305 (smost@stanford.edu).

Accepted for Publication: February 23, 2017.

Published Online: June 1, 2017. doi:10.1001/jamafacial.2017.0310

Author Contributions: Dr Most had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Moubayed, Most.

Acquisition, analysis, or interpretation of data: Calloway.

Drafting of the manuscript: Calloway, Moubayed.

Critical revision of the manuscript for important intellectual content: Most.

Statistical analysis: Moubayed.

Administrative, technical, or material support: Most.

Study supervision: Most.

Conflict of Interest Disclosures: Dr Most was an invited speaker at a conference by NOVADAQ in January, 2016.

References
1.
Correa  BJ, Weathers  WM, Wolfswinkel  EM, Thornton  JF.  The forehead flap: the gold standard of nasal soft tissue reconstruction.  Semin Plast Surg. 2013;27(2):96-103.PubMedGoogle ScholarCrossref
2.
Menick  FJ.  A 10-year experience in nasal reconstruction with the three-stage forehead flap.  Plast Reconstr Surg. 2002;109(6):1839-1855; discussion 1856-1861.Google ScholarCrossref
3.
Surowitz  JB, Most  SP.  Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle.  JAMA Facial Plast Surg. 2015;17(3):209-214.PubMedGoogle ScholarCrossref
4.
Ishihara  H, Otomo  N, Suzuki  A, Takamura  K, Tsubo  T, Matsuki  A.  Detection of capillary protein leakage by glucose and indocyanine green dilutions during the early post-burn period.  Burns. 1998;24(6):525-531.PubMedGoogle ScholarCrossref
5.
Ganiats  TG, Neumann  PJ, Russell  LB, Sanders  GD, Siegel  JE.  Cost Effectiveness in Health and Medicine. Second ed. Oxford; New York: Oxford University Press; 2017.
6.
Kanuri  A, Liu  AS, Guo  L.  Whom should we SPY? a cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.  Plast Reconstr Surg. 2014;133(4):448e-454e.PubMedGoogle ScholarCrossref
7.
Woodard  CR, Most  SP.  Intraoperative angiography using laser-assisted indocyanine green imaging to map perfusion of forehead flaps.  Arch Facial Plast Surg. 2012;14(4):263-269.PubMedGoogle ScholarCrossref
8.
Rogers  HW, Weinstock  MA, Feldman  SR, Coldiron  BM.  Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012.  JAMA Dermatol. 2015;151(10):1081-1086.PubMedGoogle ScholarCrossref
9.
Cakir  BO, Adamson  P, Cingi  C.  Epidemiology and economic burden of nonmelanoma skin cancer.  Facial Plast Surg Clin North Am. 2012;20(4):419-422.PubMedGoogle ScholarCrossref
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