Unresolved Issues

A variety of tissue transferring techniques are available for head and neck reconstruction, including skin grafts, regional skin flaps, acellular dermal graft (Alloderm, Lifecell Corporation, The Woodlands, TX),10 musculocutaneous flaps, and free flaps. All these techniques have been published in the literature. However, a major issue remains unresolved: which reconstructive technique represents the optimal approach for a particular defect or deformity.

The critically important first step in resolving such a controversy is to agree on the goals of reconstruction. The traditional goals are restoration of form and preservation of function. However, contemporary dynamics in health care in the United States require that other goals be included. Reconstructions of defects created with ablation of advanced-stage malignancies really need to be completed at the time of the resection, rather than with a technique that requires multiple stages. The primary reason is that patients with advanced-stage lesions are now part of multimodal therapeutic protocols that require administration of adjuvant therapy within a specific time period, for optimal impact on disease erradication. Therefore, those tissue-transferring techniques that are capable of completing the reconstruction in one stage certainly are preferred.

Many issues affect the overall cost of the reconstructive procedure achieved in the most cost-effective fashion—a clear goal. The assumption is that microvascular surgery can be more costly because it adds operative time and is usually undertaken with two separate surgical teams. However, the added cost associated with these two factors could be offset by the claims of some that length of stay is shorter with free flaps because of the presumed decreased incidence of fistulization or other wound-healing problems associated with regional flaps. Although some investigators have looked into the issue of cost, comparing hospitalization costs associated with free flap reconstruction with the costs associated with regional flaps,11'12 an accurate total cost of care for patients undergoing different reconstructive techniques remains to be calculated.

The cost of rehabilitation is also an issue that can impact this consideration.

In addition to the cost of two surgical teams, when free flaps are used, it is a labor-intensive undertaking that creates a component of inefficiency of time—when one surgical team is not doing the entire procedure, this inefficiency adds indirectly to the cost of the reconstruction.

A variety of unresolved issues also remain with regard to the advantages for a variety of reconstructive approaches. Although this issue is discussed in greater detail in a subsequent section, suffice it to say that it remains to be established unequivocally whether (1) pharyngeal reconstruction using sensate free flaps actually improves swallowing function, (2) free flap mandibular reconstruction is truly something other than cosmetic surgery, or (3) reinnervated muscle free flaps translate into superior approaches to achieving the goals of reconstruction.

The literature, although it does contain some information, is somewhat compromised in resolving these issues because publications have been predominantly single-institution uncontrolled reports. Although some publications seemingly address these issues,9,12 current study designs are still open for criticism. The "gold standard" of a prospective randomized multi-institutional trial has not been undertaken to help resolve some of these issues regarding the superior reconstructive technique for a particular reconstructive task when assessed by virtue of its ability to restore form and function in a cost-effective manner.

As experience with these techniques continues to expand, it appears that the potential for conducting well-controlled randomized trials has diminished as a result of surgeons developing a bias based on their personal experience with a particular reconstructive approach. This bias interferes with objectivity and subsequent willingness to participate in a randomized study that creates potential to use a reconstructive technique not favored by the particular surgeon.

However, it appears that the increasing trend to practice evidence-based medicine will create pressure from third-party payors to develop outcomes studies that address these issues so that payors can make rational decisions about the appropriateness of certain techniques based on fact rather than opinion. These unresolved issues exist for the full spectrum of the reconstructive tasks encountered by the otolaryngologist-head and neck surgeon.

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