In most university hospitals, free tissue transfer (FTT) has become a standard method of major reconstruction for a broad spectrum of defects. Because of its complexity, FTT has not been routinely performed in a community hospital setting. This study reports on the outcomes of two equal groups of FTT performed by the same surgeons, comparing the university hospital setting versus the community hospital setting.

725 FTTs were performed at 2 University hospitals (UH) and 6 Community hospitals (CH) in our region. Outcome parameters used in this study included wound infection, wound dehiscence, delayed healing, hematoma, fat necrosis, postoperative vascular compromises as well as partial and total flap loss. The 725 FTTs were performed on 645 patients: 444 females (69%) and 201 males (31%). The mean age at the time of operation was 51.1 years. 379 FTTs were performed at UH (52%) and 346 (48%) were performed at CH. Preoperative comorbidities as measured by ASA scores did not differ between the groups. Categories of FTT reconstruction included 388 breast reconstructions (32% UH, 68% CH), 169 lower extremity reconstructions (75% UH, 25% CH), 140 head and neck reconstructions (80% UH, 20% CH), 13 upper extremity reconstructions (100% UH), 1 gender reassignment (UH), and 1 perineal reconstruction (CH). Type of free flaps used included: 383 TRAM flaps (30% UH, 70% CH), 130 radial forearm flaps (79% UH, 21% CH), 123 rectus abdominus flaps (80% UH, 20% CH), 35 latissimus dorsi flaps (80% UH, 20% CH), 33 fibulas (76% UH, 24% CH), 10 gluteal myocutaneous flaps (50% UH, 50% CH), 9 SGAP flaps (33% UH, 67% CH), 6 omental flaps (83% UH, 17% CH), 4 DIEP flaps (75% UH, 25% CH), 3 lateral arm flaps (UH), 3 VRAM flaps (67% UH, 33% CH), 1 serratus flap (UH), 3 scapular flaps (UH), 3 jejunum flaps (67% UH, 33% CH), 1 gracilis flap (UH), 1 lateral thigh flap (UH), 1 ulnar forearm (CH), and 2 other osteocutaneous free flaps (UH).

60 major postoperative complications occurred in the UH setting (16%) while 42 complications occurred in the CH setting (12%). These included wound infection (n=24 UH vs. n=11 CH, p=0.02), delayed healing (n=12 UH vs. n=5 CH, p>0.05), wound dehiscence (n=6 UH vs. n=3 CH, p>0.05), fat necrosis (n=3 UH vs. n=8 CH, p>0.05), hematoma (n=6 UH vs. n=4 CH, p>0.05), and others. Partial flap loss was present in 6 UH flaps (2 radial forearm, 2 rectus, 2 omentum, 1 TRAM, 1 latissimus) vs. 3 CH flaps (2 TRAM, 1 latissimus), p>0.05. Total flap loss occurred in 6 (1.6%) UH flaps (2 radial forearm, 2 rectus, 1 TRAM, 1 fibula) and 5 (1.4%) CH flaps (2 SGAP flaps, 1 radial forearm, 1 rectus, 1 gluteal), p>0.05.

In conclusion, the frequency of postoperative complications was not different between the university and community hospitals with the exception of wound infection. This sole difference is probably reflected in the difference of the case mix (breast vs. lower extremity reconstruction) between the two settings. Free tissue transfer is an effective and practical method of reconstruction for a myriad of defects that can be safely performed by experienced microsurgeons in both a university hospital as well as at the community hospital.
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