Calloway Hollin E, Moubayed Sami P, Most Sam P
Division 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 Sep 1;19(5):418-420. doi: 10.1001/jamafacial.2017.0310.
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.
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.
Two-week division of the forehead flap after nasal reconstruction.
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.
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.
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.
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正中旁前额皮瓣被认为是最佳重建鼻重大缺损的金标准术式，但该术式通常需要分两期进行，在初次手术后3周切断皮瓣蒂部，以确保皮瓣从周围受区组织床获得充分的血管再生，这可能使患者误工或改变正常社交习惯。此前研究表明，在部分患者中，使用术中激光荧光血管造影确认受区床血管再生后，可在2周后安全地切断蒂部，这有可能为患者节省时间和金钱。
证明使用吲哚菁绿（ICG）血管造影在2周后切断正中旁前额皮瓣蒂部的成本效益。
设计、地点和参与者：对所有鼻重建后2周切断前额皮瓣的患者进行回顾性队列研究。收集患者、肿瘤、缺损和结局数据。通过比较2周血管造影切断术与假设的未进行血管造影、在3周时切断蒂部的患者的总体成本，进行成本最小化分析。
鼻重建后2周切断前额皮瓣。
通过计算队列中患者的总可变成本与未进行血管造影且在3周时切断蒂部的理论患者的成本进行成本最小化分析。
共纳入22例患者（平均[标准差]年龄，70.3[10.0]岁；8名女性[36.4%]和14名男性[63.6%]）。2周切断蒂部的选择标准为伤口床至少有50%的血管化组织、部分厚度缺损且不吸烟。所有患者均在2周时切断蒂部，无皮瓣坏死情况。1例患者在重建前组织学检查为鳞状小汗腺癌，其他所有患者为基底细胞癌、鳞状细胞癌和黑色素瘤。成本最小化分析表明，使用ICG血管造影平均每位患者可节省177美元。
对于部分正中旁前额皮瓣患者，使用ICG血管造影进行验证后，可安全地在2周时切断皮瓣。尽管该技术本身会增加成本，但具有成本效益，每位患者总共可节省177美元。
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