Comment on Assessing the Influence of Attending Surgeon Continuity on Free Flap Outcomes Following Unplanned Returns to the Operating Room
We read with interest the article “Assessing the Influence of Attending Surgeon Continuity on Free Flap Outcomes Following Unplanned Returns to the Operating Room” by Zhao et al. In their case series, free flap salvages were more likely to succeed if the primary surgeon was involved, compared with a covering one (20 vs. 47%, p-value < 0.0001). The authors conclude that lack of exact knowledge about the index procedure may explain this and advocate the importance of optimal handover of patients. We commend the authors for their results, as it helps better to understand the factors relevant for a successful free flap salvage. However, we would like to suggest that there may be more potential explanations for this phenomenon.
Recipient vessels are usually not a surprise for the experienced microsurgeon. Most lower limb free flaps are anastomosed to the posterior tibial vessels; breast flaps to either internal mammary or thoracodorsal systems; and facial artery, superior thyroid, facial vein, or internal jugular vein are frequently used in head and neck reconstruction. The pedicle and corresponding anastomoses tend to be easily found in any take-back procedure. Even though stacked flaps can present a higher degree of complexity, the components of the involved anastomoses should become apparent after careful inspection of the pedicles. Therefore, we do not believe that precise knowledge regarding the disposition of the anastomoses solely explains the outcomes difference.
Effective communication between surgeons when handing over the care of patients is a key nontechnical skill, and we agree with its importance. However, there may be other human factors also at stake in this scenario. Even though a flap salvage is a team effort, the responsible surgeon with their mindset is still at the center of the working system. Having developed a patient–doctor relationship and spent a significant amount of time and effort performing the index procedure, the primary surgeon may be more inclined to make any reasonable attempt to salvage a flap, moved by the avoidance of personal failure and sparing of their own patient disappointment. Furthermore, the repercussions a flap failure will likely involve the primary surgeon in terms of complication management. Even though a covering surgeon has the patient's best interest at heart, they may have a lower threshold for admitting defeat and declaring a flap unsalvageable. In contrast to the primary surgeon, this decision will not affect their own record or future workload. The primary surgeon may also be more inclined to decide to take the patient back to the operating room at the minimal clinical suspicion, while a covering surgeon could potentially delay this to accommodate other pressing commitments in busy centers.
Even though we assume that it is a professional responsibility for microsurgeons to deliver the best possible care in all circumstances, it is paramount to acknowledge importance of human factors in the flap take-back setting. We would like to thank the authors of this article to give us the opportunity to reflect on this, including unconscious biases that may play a role in our microsurgical practice.
23 November 2020 (online)
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- 1 Zhao R, Shammas RL, Broadwater G. et al. Assessing the influence of attending surgeon continuity on free flap outcomes following unplanned returns to the operating room. J Reconstr Microsurg 2020; 36 (08) 583-591
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- 4 Nikkhah D, Green B, Sapountzis S, Gilleard O, Sidhu A, Blackburn A. Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin. Eur J Plast Surg 2016; 39: 221-224