The Revolution and Evolution of Free Flaps in Facial Reconstructive Surgery

Potential Issues

As the United States continues to move toward a value-based health care model, the question of cost may become an issue, given the high upfront costs of the procedure. While allowing that the procedure is expensive at face value, Dr. Alam emphasized that free flaps offer a far more efficient way to reconstruct large defects than other flaps. He and his colleagues at the Cleveland Clinic have done many metric analyses of the procedure, he said, that show that better outcomes are achieved with free flaps versus conventional procedures in terms of cost containment and patient outcomes.

“The future of free flaps is solid,” he said. “The indication is growing, and it is a growing specialty and, as with all growing specialties, it will need checks and balances to ensure appropriate use. That is the natural growth of a specialty.”

For Dr. Tsue it is very simple. “The functional outcomes [with free flaps] speak very loudly,” he said, adding that he sees only an expansion of the indication for the procedure. He emphasized, however, that physicians are still trying to come up with more efficiencies to shorten the operative time.

According to Dr. Alam, this outcome has been achieved. “We have reduced hospitalizations from what used to be 10 to 14 days or longer to mostly seven to 10 days,” he said, adding that if conventional flaps are used on patients with large defects, they often require multiple surgeries to achieve the same goal.

As of now, however, Dr. Wax emphasized that cost is not an issue, because the free flap procedure, is not an elective procedure and getting patients approved for it is no more difficult than it is for many other procedures that are done.

Future Trends in Free Flap Surgery

One interesting area of investigation that may affect the future use of free flaps, according to Dr. Tsue, is the increasing use of endoscopic resections with robots and lasers, which may at some point reduce the need for facial reconstruction. “Minimally invasive surgery that does not require transcutaneous entry to get at the large defect areas may somewhat change the practice pattern,” he speculated.