Introduction
The use of microvascular free flaps is standard practice in reconstructive plastic surgery.  While the technical aspects of microsurgery have been refined there is great variability in perioperative care.  The goal of this study was to better characterize differences in perioperative care amongst microsurgical centers in the United States in attempt to define the current standard of care and produce a report to be used as a guideline for a more cost efficient protocol. 

Methods
A 45-question survey, developed based on standard aspects of perioperative care for microvascular free flaps, was sent to all plastic surgery and plastic surgery based microsurgery program directors in the United States.  Questions focused on the number and type of flaps performed, use of postoperative anticoagulation, perioperative fluid status, flap monitoring devices, length of stay, and postoperative complications.  Program directors were also questioned on postoperative setting, monitoring personnel, and training provided to personnel.

Results
The response rate was 31%, which consisted of 3,407 microvascular free flaps per year at 26 centers.  The most common initial monitoring location was the recovery room with patients being moved to a specialized monitoring unit (ICU vs. flap unit) by 12 hours postoperatively.  The average length of stay in the specialized monitoring unit was 74.4 ± 53.6 hours.  Most patients were primarily monitored by a nurse with flap checks performed every hour.  Flap viability was assessed by clinical evaluation and the hand-held Doppler.  In 45% of responding centers patients were cared for in a higher-level unit (ICU) secondary to a lack of adequately trained nurses at alternative sites.  While each center has individualized postoperative protocols, only 39% provided a printed protocol to their nursing staff.  There were no significant differences between programs with regards to perioperative fluid status or postoperative complications.  Less than half of all centers routinely use postoperative anticoagulation.

Conclusion
Reductions in the level of required care and length of stay are two factors that provide for a more cost efficient healthcare system.  In this study, 1,533 flaps were monitored in the ICU for an average of 3.1 days (74.4 hours).  Each day of ICU care is associated with an average increase cost of $1,200 per day.  This translates to an annual increased cost of $219 thousand per center or an increase of $5.7 million to the responding centers.  If applied to all microsurgery centers in the United States this increased cost could approach $18.4 million.  Patients were often cared for in the ICU secondary to a lack of properly trained nurses in alternative settings.  Interestingly, only 39% of centers provided printed protocols to the nursing staff as part of their training.  Better education and training of nurses, including the distribution of preprinted protocols, could allow patients to be monitored in a non-ICU setting, ultimately leading to reduced costs of postoperative care.  Other aspects of postoperative management should also be clarified with prospective studies.  A reduction in unnecessary care or over-care would provide for a more cost efficient postoperative treatment protocol.