Key points

Introduction

Microvascular free flap surgery has become the gold standard for head and neck reconstruction. Most fellowship training programs focus on microvascular reconstruction as an essential component, and it serves as the cornerstone of the practice of a modern head and neck reconstructive surgeon. Although the basic principles remain the same, the complexity and duration of this type of surgery mean significant variability in the day-to-day routine. Because of the wide variety of practice setups-from a solo free flap surgeon in an independent hospital practice to a multiple surgeon group in a tertiary academic setting-it is not realistic to attempt to standardize all the technical and logistical aspects of microvascular free flap surgery. However, this text will reflect on common aspects of practice management and highlight opportunities for improving surgical efficiency, improving outcomes, and contributing to surgeon well-being and longevity.

Complex patient population

It is no secret that head and neck cancer patients present a unique set of challenges for a surgeon. These patients often present with advanced disease, with the proximity to important structures in such a small area leading to rapid up-staging of tumors compared with other regions of the body. Head and neck squamous cell carcinomas (HNSCCs) can grow rapidly, with recent studies defining mean growth rates of 1.8% per day and up to 70% increase in primary tumor size after 4 weeks. These patients can also be poor health seekers, often delaying medical assessment, exacerbated by a paucity of viable screening techniques. Despite current treatment strategies, HNSCC recurrence is still common, with 50% to 60% of patients developing locoregional recurrence within 2 years and 20% to 30% developing distant metastasis. ^, It follows that depression, functional deficit, and reduced quality of life are serious issues within this patient population. In fact, HNSCC patients have the second highest rate of cancer-related suicide, approximately 5 times higher than the normal population.

Despite this, over the last 30 years the survival for patients with HNSCC has marginally improved, likely attributable to the inclusion of HPV-related cases. ^, As a result, patients are living longer with the functional and aesthetic deficits of surgical and nonsurgical therapy. Microvascular reconstruction has become an integral part of supporting these patients in their recovery from oncologic intervention, improving functional outcomes and quality of life. Given the widespread success of microvascular free tissue reconstruction, emphasis has shifted to optimizing functional and aesthetic outcomes. Research has demonstrated that aesthetic outcomes are key determinants in survivors’ psychosocial functioning. Specifically, a disparity between a patient’s subjective appearance before and after treatment has been associated with depression. Additionally, 17% of head and neck cancer patients may be forced to change employment or leave the workforce after treatment as a result of appearance. Consequently, the importance of considering ultimate aesthetic result is imperative and should be routinely discussed with patients to appropriately shape expectations and goals.

It cannot be underestimated the toll that management of these patients can take on a surgeon. Aspects of management that are not necessarily emphasized during training, including depression and addiction medicine, may lead to discomfort for a surgeon. Opportunities for improvement in this area include pursuing additional coursework or educational activities through home institutions or national organizations to supplement knowledge in specific areas. Additionally, it is vital to utilize additional support services that are often available through cancer centers including nutrition, speech language pathology, psychiatry, and palliative care practitioners. By gaining knowledge in these additional areas of patient care and reaching out for help when outside expertise is needed, can work to improve quality of life and somewhat ease the personal burden that comes with managing these complex cases.

Efficiency

Efficient practice management is essential for optimizing patient outcomes, streamlining workflows, and fostering professional growth. There are several stages before, during, and after microvascular surgery when efficiency can be discussed and often improved. As noted previously, HNSCC patients often present in a delayed fashion for several reasons. Earlier cancer detection and improved access to care are outside the scope of this article but are active areas of research in HNSCC. Strategic patient selection is paramount in microvascular surgery, with comorbidities, tissue availability, and defect complexity factoring into the decision regarding type and extent of surgery offered. Thorough preoperative evaluation with the collaborating anesthesia team can be extremely helpful in optimizing patients before surgery.

With regard to the surgeon as a potentially modifiable factor within the treatment paradigm, huge benefit can be gained from collaboration with senior faculty with more experience and familiarity with microvascular reconstructive cases. Individual surgical performance has been linked to increasing surgical case volume, and years of practice and easy access to experienced colleagues can aid in decision making and patient selection. Collaborative interactive teaching sessions (tumor board or reconstructive rounds) that facilitate case discussion and faculty involvement have been shown to improve physician performance and health care outcomes for patients. ^, A 2-surgeon approach to complex patients can also be highly beneficial. An ablative colleague experienced in microvascular free tissue transfer can be a helpful second opinion in a case of unexpected challenges or complications. Over the past decade, the average number of microvascular surgeons per otolaryngology academic department has increased from 1.6 to 3.2. With the increased number of surgeons, a 2-team approach has become the norm. This has led to decreased operative time and increased surgeon relative value unit (RVU) production without compromising postoperative outcomes. ^, This team approach has also led to shared responsibilities throughout all phases of care. The presence of collegial support and mentorship from skilled partners is critical, as the lack thereof is reported to lead to moderate-to-high burnout. When picking a practice to join, it is important to ensure that collegial support is promoted along with interprovider discussion of challenging cases. Institutions with formal early career mentorship programs also serve as an excellent avenue to promote professional development and career longevity. It is key that health care leadership recognizes the benefit of investing in head and neck division succession and expansion to ensure coverage of caseload and foster an environment of experience, insight, and knowledge.

Careful attention to outcome measures is also crucial in complex microvascular reconstruction. Implementing data systems early on to analyze clinical outcomes and patient satisfaction not only helps in identifying potential issues with prompt care delivery but also ensures that standard of care is consistently met. It also affords the opportunity to report any logistical or technical improvements that may benefit other facilities.

The practice of complex head and neck oncologic surgery epitomizes the importance of teamwork. On average, the duration of these cases is longer than major cases or any other surgical subspecialty. Prolonged operative time is associated with increased risk of complications. In 1 study, every additional hour of operative time increased the risk of postoperative complications by 11%. Consequently, longer surgeries are associated with extended hospital stays and operating room takebacks. Additionally, a larger number of team members and multiple intraoperative handovers can increase the risk of errors, miscommunications, and information loss. Efforts to reduce operative time and enhance team efficiency are imperative. Extensive research has demonstrated that patient safety, as well as the quality and efficiency of surgical procedures, is contingent on high quality communication and collaborative knowledge transfer. When communication is limited or reduced, goals of care can be lost, and failures can occur. ^, Communication failures have been implicated in adverse outcomes including delays in care, surgical errors, extended and inappropriate hospitalizations, serious injury, and death. ^,

Several efforts have been made to improve communication and handoffs during these surgical cases. Structured microvascular reconstructive perioperative checklists or plans can be incredibly helpful in improving efficiency and streamlining team planning. Literature indicates that prior to the implementation of these plans complication rates were higher. Studies looking at such checklists have noted that one-fifth of operative time occurs before knife to skin, and on average 270 entries and exits from the room occur during each case. Communication failures have been reported in 30% of all operating room interactions, compromising patient safety by increasing cognitive load, interruptions, and team tension. The use of systematic communication tools can help attenuate these communication errors and improve overall operative time.

In addition to issues with communication, team dynamics and composition play a huge role in the success of a microvascular surgery. It is not uncommon for surgical teams to be established in an impromptu fashion, and rotating staff has been shown to challenge the adaptability and dynamics within the team. A recent systematic review found that the implementation of dedicated operative teams was associated with improvements in mortality, turnover time, teamwork, communication, and costs. It should be noted that the creation and maintenance of a dedicated operating room team is not realistic within the confines of many practice models. However, the available literature on the topic can be utilized to advocate for this when possible. Another technique for improving intraoperative experience is a model of relational coordination that focuses on a mutually reinforcing process of communication and integration of individuals across differing levels of expertise to positively enable task integration. This is a model of teamwork and communication that creates an environment of shared knowledge, mutual respect, and unified goals through problem solving rather than blaming communication. Cultivating a culture of respect within the operating room can be key in promoting a culture of safety and in turn lead to improved efficiency. ^,

Overall, the surgeon plays a critical role in leading by example and managing the team dynamics. By fostering collaboration and promoting a positive collegial work environment surgeons can enhance team performance and ultimately improve patient outcomes.

Wellness and work life balance

The lifestyle of microvascular free flap surgeons is widely recognized as demanding, primarily because of the long cases, complex patients, and elevated complication rates among head and neck cancer patients. Despite maintaining an average work schedule of 65 hours per work, these surgeons express a profound sense of professional fulfillment, with 95% strongly affirming that their work provides them a high sense of personal meaning. Additionally, most married microvascular surgeons reported feeling well supported by their spouses. Despite the fulfillment of their career and support at home, 73% still reported moderate burnout in 2010. A commonly suspected source of burnout is the long work week inherent to this subspecialty. Surprisingly, studies show no significant correlation between increased caseload and burnout among this group of surgeons. This trend mirrors findings among general surgeons, suggesting that the root causes of burnout for surgeons likely extends beyond workload alone. Notably, both groups of surgeons identified an imbalance between work and family life as a significant contributor to burnout. For head and neck microvascular surgeons, the challenges of maintaining this balance were exacerbated by a lack of protected academic time and lack of a supportive clinical partner. Less than 10% protected research or academic time demonstrated a threefold higher rate of emotional exhaustion compared to peers with more protected time. As a surgeon, having less than 3 days of operating room block time was found to be protective of depersonalization. However, as many practice models incorporate some form of work-based incentive in their pay structure, the conflict between clinical productivity and scholarship can be difficult to navigate. Although many surgeons are primarily clinical, the reality is that their time is further fragmented into efforts toward education, administration, and research. Increased protected time for scholarly activities allows surgeons to balance multiple interests while strategically progressing in their career, further leading to overall career satisfaction. For research efforts specifically, a survey of 144 academic surgeons by the National Institutes of Health (NIH) identified protected time as one of the major factors in successfully obtaining funding and the lack thereof as one of the largest barriers facing academic surgeons. The ability to negotiate for protected time in general can be challenging, but is critical to increase longevity and success of one’s surgical career. Various surgical societies have now developed guides to help surgeons advocate for themselves during contract negotiations in a way that benefits their lifestyle and career goals.

Clinics care points

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  Encourage a mentorship culture where junior surgeons can learn from experienced faculty, enhancing skills and improving surgical outcomes.

  
  
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  Implement a two-team approach when feasible to streamline procedures, enhance focus, and improve overall surgical outcomes.

  
  
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  Adopt surgical perioperative checklists to standardize procedures, minimize errors, and enhance patient safety.

  
  
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  Establish dedicated operating room teams for microvascular procedures when feasible to improve efficiency and foster a collaborative environment.

  
  
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  Advocate for designated time within the surgical practice to allow for focused clinical and professional development, promoting longevity in the surgical career.

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