Introduction: Typically, a successful microsurgery program requires sufficiently large volume of cases, surgeons with microsurgical expertise, experienced OR support staff, state of the art equipment, and nurses familiar with postoperative monitoring. Four years ago, our county hospital did not meet these standards, and most patients requiring microsurgical reconstruction were transferred to a larger, Level I trauma center. Expanding the scope of our practice to meet the hospital's need for microsurgery led to the following question: can a small county hospital that infrequently performs microsurgery achieve similar success rates as larger institutions that regularly provide the service?

Purpose: The purpose of this study is to review the initial 4 year experience of microsurgical reconstruction performed at a small county hospital.

Materials and Methods: We conducted a retrospective study of all microvascular cases (free tissue transfer, microvascular repair, and replantation) performed during the past 4 years (3/2003- 3/2007) under the supervision of a single attending plastic surgeon who possesses expertise in microsurgery.

Results: Our hospital is a Level III trauma center with a total of 6 operating rooms and 1 full time equivalent plastic surgeon on staff. Over the past 4 years, we attempted to develop a microsurgery program at our hospital, including microsurgical equipment purchase and training both OR personnel and nursing staff on the wards. During the study period, 31 patients underwent 37 microvascular procedures: 16 free flaps, 1 replant, and 20 microvascular repairs. Follow up ranged from 1 to 18 months.

Free flaps—The majority of free flaps were performed for soft tissue coverage of extremity trauma (9/16; 56%) which included: 4 radial forearm flaps, 3 rectus abdominis muscle flaps, and 2 latissimus dorsi muscle flaps. 2 VRAMs and 1 radial forearm flap were required for head and neck oncologic reconstruction (3/16; 19%). 3 Free TRAM flaps were done for unilateral breast reconstruction (3/19; 19%). A 2nd toe transfer for post-traumatic thumb reconstruction was also performed. Monitoring of all microvascular procedures was by clinical exam. None of the free flaps required reexploration. There was no flap loss. Donor site morbidity was minimal.

Replants—One replant was successfully performed (dominant thumb amputated at IP joint level).

Microvascular repairs—20 microvascular repairs were performed: 11 ulnar and/or radial artery, 5 common digital artery, and 4 digital artery repairs. None of the replanted or revascularized digits / hands required postoperative exploration, and all survived. There were no major complications.

Conclusions: Although microsurgery is performed infrequently at our county hospital, we have a success rate that parallels that of a larger center that routinely performs microsurgery. Our study demonstrates that it is feasible for smaller hospitals to develop a microsurgery program. We continue to provide microsurgical reconstruction for patients at our county hospital as part of our plastic surgery practice.