The optimal sequence of microvascular repair during prolonged clamping in free flap transfer.

During free flap transfer, the surgeon may decide to begin with repair of the artery or the vein(s) and to unclamp the first vessel as soon as repair is completed or maintain the clamping of both vessels until completion of all repairs. Complications can lead to prolonged clamping times, potentially increasing the risk of tissue ischemia, vascular damage, and thrombosis. The goals of the present study were to determine whether the sequence of vessel repair and the duration of clamping affect the success of free flap transfer in cases requiring prolonged clamping. Sixty abdominal fasciocutaneous free flaps based on the superficial inferior epigastric vessels were created in Sprague-Dawley rats. To model clinical situations in which prolonged clamping is necessary, the study used a 1-hour delay before the repair of the second vessel. Flaps were randomized into four groups. In group I (n = 15), the artery was repaired first, and the arterial clamp was removed immediately to allow arterial inflow. In group II (n = 15), the arterial repair was first, and the arterial clamp was maintained until completion of venous repair. In group III (n = 15), venous repair was first, with venous clamping maintained until completion of the arterial repair. In group IV (n = 15), initial venous repair was followed by immediate unclamping, before arterial repair. On release of all clamps, the patency of arteries and veins was confirmed immediately and after 1 hour using a "milking" test. On the fifth postoperative day, each flap was assessed for necrosis and for patency of the anastomoses. Of 15 flaps in each group, five (33 percent) failed in group I, four (27 percent) failed in groups II and III, and six (40 percent) failed in group IV. Differences between groups were not statistically significant (p = 0.8). These results demonstrate that in cases requiring prolonged occlusive clamping (2 to 3 hours), factors such as venous congestion, possible clamp injury, and presence of static blood in contact with the new anastomosis have relatively equivalent contributions to the risk of failure. Accordingly, no advantage seems to be gained by beginning with the artery or the vein or by using early or delayed unclamping of the first vessel repaired.

Effects of managed care on teaching, research, and clinical practice in academic plastic surgery.

The aim of this study was to determine: 1) if there have been changes in teaching, research, and clinical practice in academic plastic surgery in recent years; and 2) if there have been, are they associated with changes in the managed care environment? Gaining a clearer perspective on how managed care affects academic plastic surgery will enable academicians to define better the problems and opportunities they face mutually and to respond effectively to these issues. This study used a cross-sectional study design. Reference time periods were the premanaged care era (1990-1991) versus the current time (1997-1998). Data were collected by questionnaires sent to 94 academic program directors in plastic surgery. The main independent variable of managed care was measured as the difference in the percent of income from health maintenance organizations generated by each program in 1990 to 1991 versus 1997 to 1998. The dependent variables of teaching, research, and clinical practice were measured by the percentage of time spent in each category, the number of work hours per week, the number of staff personnel, the location of teaching, the number of grants and publications, and the percentage of reconstructive and cosmetic cases in 1990 to 1991 versus 1997 to 1998. Univariate analysis, paired Student's t-test, Fisher's exact test, Pearson's correlation, Spearman's correlation, and linear regression were used to establish significance (alpha = 0.05) of the effects of managed care on dependent variables. Sixty-six questionnaires were completed and returned (70% response rate). There were significant changes in the managed care environment, clinical practice (operating room and clinics), and research in academic plastic surgery from 1990 to 1997. The percentage of income generated from managed care increased from 9.8% (of total revenue) in 1990 to 23.6% in 1997 (an increase of 13.8%; p < 0.0001). Academic plastic surgeons were found to spend significantly more time in clinical practice (3% more of total time spent; 5.3 hours more per week in 1997; p < 0.016). This change correlated significantly with the increase in managed care (p < 0.015). In addition, the percentage of cosmetic cases increased from 18.0% in 1990 to 28.3% in 1997 (p < 0.001), and that of reconstructive surgery was reduced proportionately (p < 0.001). Also, a significant decrease in the time spent for research was observed (mean reduction, 2.8 hours less per week; p < 0.001). Although the trend was to a lower number, there were no significant changes in the amount of time spent in teaching (p > 0.08) and in administrative duty (p > 0.06), or in the number of personnel employed in the teaching programs (p > 0.05). In summary, these findings suggest that: 1) a greater percentage of revenue was generated from managed care in 1997 than in 1990, indicating a growing fiscal influence by managed care on academic plastic surgery; 2) furthermore, this change is associated with academic plastic surgeons devoting more time to clinical practice and less time to research endeavors; and 3) although managed care policies do affect teaching adversely, this effect has not yet reached significance for the period examined during this study.