Inequality in the use of microvascular versus pedicled flaps in oral cancer reconstruction across India: Can we bridge the gap?

Abhishek Vaidya

doi:10.4103/jhnps.jhnps_80_22

GUEST EDITORIAL

Year : 2022 | Volume : 10 | Issue : 2 | Page : 121-126

Inequality in the use of microvascular versus pedicled flaps in oral cancer reconstruction across India: Can we bridge the gap?

Abhishek Vaidya
Senior Consultant Head Neck Oncosurgeon, National Cancer Institute, Nagpur, Maharashtra, India

Date of Submission	24-Nov-2022
Date of Decision	10-Dec-2022
Date of Acceptance	10-Dec-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Abhishek Vaidya
No. 302, Petals, 193, Shivaji Nagar, Dharampeth Extension, Nagpur - 440 010, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_80_22

How to cite this article:
Vaidya A. Inequality in the use of microvascular versus pedicled flaps in oral cancer reconstruction across India: Can we bridge the gap?. J Head Neck Physicians Surg 2022;10:121-6

How to cite this URL:
Vaidya A. Inequality in the use of microvascular versus pedicled flaps in oral cancer reconstruction across India: Can we bridge the gap?. J Head Neck Physicians Surg [serial online] 2022 [cited 2023 Jun 4];10:121-6. Available from: https://www.jhnps.org/text.asp?2022/10/2/121/363933

Background

“Qu'ils mangent de la brioche” (Let them eat cake): A French princess is rumored to have said at the cusp of the French Revolution when informed that her starving peasant subjects had no bread to eat.

In India, oral cancers are the most common cancer in males and the fourth most common in females.^[1] About 2/3 of these present at locoregionally advanced stages;^[2] likely contributed to delays at presentation, referral, and treatment.^[3] Further, <20% of the population are covered by any health insurance, and about 64% of Indians incur out-of-pocket expenditure (OOPE) on health.^[4] This results in as high as 34%–62% of Indians facing a catastrophic health expenditure (CHE) when faced with cancer treatment.^[5],[6] Moreover, there is a polarization of health-care resources in India, such that though primary health care is available to the most population, tertiary care (especially comprehensive cancer care) is available mainly in urban settings. A combination of these factors forms grounds for using the above metaphor, where the proverbial “cake” of state-of-art treatment cannot be provided to the many who are deprived of the basic “bread” of cancer care. Nevertheless, the onus is on caregivers and policymakers to close this care gap and ensure standard equitable treatment to all.

Inequality in Use of Microvascular Flaps: What Ails Broader Usage?

A large proportion of oral cancers undergoing surgery require reconstruction for cosmetic and restorative purposes. With the advancement of microsurgical techniques, microvascular flaps (MVFs) are increasingly considered state-of-art in oral cancer reconstructions, given their versatility and superior cosmetic and functional outcomes.^[7] Some evidence even suggests that MVFs improve “resectability” and lead to lesser positive margins and better oncologic outcomes.^[8],[9],[10] In a systematic review, MVFs were associated with lesser infection and necrosis, and better quality of life (speech, swallowing, and shoulder function) as compared to pedicled flaps (PF); but also had longer operative time, greater cost, and higher postoperative revisions compared to PFs.^[11]This was however, a very heterogenous comparison of retrospective studies comparing different pedicled flaps to microvascular flaps. No real conclusion can be drawn from the study on the improved functionality or quality of life of patients undergoing MVFs as compared to PFs.

The major barriers to universal usage of MVFs are resource and cost constraints, lack of infrastructure, lack of expertise, and steep learning curve as compared to PFs. There is limited and heterogeneous Indian literature regarding the comparison of MVFs versus PFs in oral cancers.^{[12],[13],[14],[15],[16]} A real-world estimate of the relative usage of the two kinds of flaps in India is desirable to understand the trends, inequalities in usage, and likely barriers in the widespread use of MVFs. With this objective, requests were sent to 16 cancer centers across India to share their patterns of MVF and PF/local flap (LF) usage and approximate annual volumes. An attempt was made to understand the payment patterns (self-paid/insurance vs. public health insurance schemes [PHIS]) toward compensation of different kinds of reconstructions. These data are detailed in [Table 1] and depicted in [Figure 1].

Table 1: Distribution of microvascular flaps and pedicled flap/local flap for oral cancer reconstruction across different centers. (Numbers are approximate annual figures.)

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Figure 1: Distribution of Reconstruction for oral cancers across centers studied

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There was a surprising contrast between the utilization of MVFs for oral cancer reconstructions among different centers, varying from as low as 1.5% to as high as 88.9%. The cumulative average percentage distribution of MVF and PF/LF across the entire group was 35.5% and 64.5%, respectively. Some trends were noted from the data: (1) Centers with a greater proportion of self-paying/insured patients tended to utilize MVFs more commonly, (2) Those with a greater proportion of patients availing PHIS had more utilization of PF/LF reconstructions, (3) Regional centers with a heavy workload and more patients availing government PHIS used MVPs frugally, (4) An exception to this was centrally funded institutions (e.g., Tata Memorial Hospital (TMH)) which could provide both MVFs and PF/LF to a comparable proportion of patients across payment structures, (5) Few institutions could provide MVFs to a considerable proportion of patients under PHIS, and (6) For tier two cities, there was heterogeneity in data about the proportion of MVFs in all reconstructions.

It may be surmised that in addition to longer operative time, more return rate to operating theaters, and logistical and personnel issues, the major roadblocks to wider use of MVFs are long waiting lists and inadequate compensation under government PHIS. Literature has no data on cost–benefit analysis of free flaps in India. Some evidence from the USA suggests that microvascular reconstruction for the head–neck is profitable, and generates substantial revenue for the hospital.^[17] On the other hand, data from Italy suggests that there exists a discrepancy between compensation for MVFs and their actual cost,^[18] and that the NHS tariff for MVFs is inadequate.^[19] Thus, it follows that for MVFs to be cost-efficient to a hospital, the compensation for these needs to be adequate. As seen from our data, a significant number of patients avail of state PHIS for their treatment. The compensation for MVPs in these PHIS may often not be adequate [Table 2]. As a result, many patients are likely required to spend from their pockets to supplement the compensation in PHIS. In an interesting study from NEIGRIHMS, Shillong, Caleb Harris and colleagues showed that despite receiving health insurance scheme, more than half of patients had to pay OOPE, incurred CHE, and were pushed to poverty (Unpublished data; Personal Communication; Presented at SSO conference).

Bridging the Gap in Reconstruction of Oral Cancers

Both MVFs and PFs/LFs occupy their place of importance in the reconstructive algorithm for oral cancers. There is no requisite percentage of a particular type of reconstruction that any head–neck cancer practice must adhere to. However, there exist inequalities in the use of MVFs across India, and a central tendency is desirable. Closing the gap in this inequality may require a multipronged approach and concerted efforts.

Decentralization of cancer care from urban hubs

While the present data reveals promising percolation of cutting-edge treatment in some nonmetro cities, there remains an increased need for more comprehensive cancer centers, especially in areas where there is a care deficit. It is desirable that these cancer centers have specialized personnel, adequate human resources, infrastructure, and logistics to support advanced resection, reconstruction, and rehabilitation programs. The focus of such centers should be regions where the biggest public health gains are to be made.

Comprehensive microvascular training during residencies/fellowships

There are close to 250 seats (MCh and DNB) available every year for super-specialization in plastic and reconstructive surgery in India. However, whether comprehensive microvascular training features in all these courses are unknown. Early exposure and training in microsurgery in these courses would encourage younger surgeons to take up this subspecialty in their careers. Further, microvascular surgery should be a part of the armamentarium of the modern trainee head–neck surgeon. Fellowships and MCh courses in head–neck should specifically include training in microvascular reconstruction. This will also promote a two-team approach to such surgeries, leading to decreased operative time, dedicated ablative and reconstructive roles, and shared responsibilities throughout all phases of care.^[20]

Better compensation for microvascular flaps in public health insurance schemes based on a detailed cost analysis

This study points out that except in centrally funded centers, there is usually a lesser utilization of MVFs in patients availing of state health schemes. As pointed earlier, it is likely that even patients receiving PHIS had to bear OOPE. In Indian PHIS, most of the decisions regarding reimbursement were based on expert opinions, and not on any formal cost analysis.^[21] Furthermore, there is a lack of similarity between the compensation of different schemes [Table 2]. A previous study has calculated the cost of treatment for head–neck cancers in India with different types of radiotherapy.^[21] While this study had a brief mention of surgical costs, to the best of our knowledge, there is no detailed cost analysis study for composite resection and reconstruction (MVF/PF) in India. A thorough cost analysis for resection-reconstruction based on economic costing and bottom-up methodology that takes in consideration infrastructure costs, fixed costs, recurrent costs, salaries, overheads, and consumables is the need of the hour. Estimates of OOPE should also be considered in this analysis. Such a cost analysis would guide authorities in formulating package rates for specific surgeries.

Table 2: Representative compensation for microvascular flaps in different government public health insurance schemes

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Consensus guidelines regarding reconstructions

Although the concept of “one size fits all” does not hold true for head–neck defect reconstructions, the large heterogeneity in usage demands that a loosely framed, well-accepted consensus statement should guide reconstruction in varied scenarios. Such consensus statement should consider in addition to specific defects: The performance status of patients, availability of expertise, expected disease outcomes, and economic viability. Such a consensus guideline should incorporate a reconstruction algorithm according to tiers of available infrastructure and should include both PF/LF and MVF.

Alternatives to Microvascular Flaps and Situations for Preferential Use of Pedicled Flaps

Despite attempts to narrow the gap in the use of MVFs, there will remain regions and centers which do not have these facilities. Furthermore, some situations would demand the preferential use of PFs over MVFs. Knowledge and experience of a broad variety of pedicled and LF should, therefore, also be an essential part of head–neck surgeon's skillset. Examples of where PFs may arguably be preferred are (1) poor performance status, (2) existing comorbidities, (3) certain vascular (e.g., vasculitis and peripheral vascular disease) or hematological diseases (e.g., sickle cell disease and coagulopathy), (4) short survival expectancy, and (5) severely vessel-depleted necks.

A detailed treatise of PF for different defects is beyond the scope of this discussion. A short account of various pedicled/LF that may be used in lieu of MVFs is given below and in [Figure 2].

Figure 2: Simple Reconstruction algorithm for PFs/LFs in oral cancers. PF: Pedicled flaps, LF: Local flap

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Pectoralis major myocutaneous flap

This flap was previously the workhorse of oral cancer reconstructions and still remains the first choice flap at many centers in India.^[13],[14] We employ a modified method of pectoralis major myocutaneous (PMMC) harvest, where the pedicle is completely islanded cranial to the sternocostal fibers of the muscle. In our series of more than 400 such islanded PMMC flaps, there was no supraclavicular bulge, no infraclavicular hollow, better reach, lesser dehiscence, better patient-reported quality of life outcomes, and a trend toward better shoulder function as compared to conventional PMMC. With its extreme versatility and muscle bulk, it can be sued to reconstruct almost any defect in the oral cavity.

Submental artery flap

This is a versatile flap that is reliable and oncologically safe in Nzero necks. It is sturdy, cosmetically satisfactory; and has a shorter procedure time and much lesser cost as compared to radial artery forearm flap.^[11],[22] Two potential issues are hair growth in a male patient (and hence should be used in males either de-epithelized or when adjuvant radiotherapy is anticipated), and relative contraindication due to oncological clearance concerns in N + necks. It can be used to reconstruct buccal mucosa, tongue, and RMT or palatal defects.

Supraclavicular artery island flap

It is a pliable, versatile, reliable, easy-to-harvest flap with good cosmetic and functional outcomes. Potential concerns are distal flap necrosis, oncological concern with level IV/V nodes, and limitation in length and reach.^[23] It can be used for small–medium buccal mucosa, floor mouth, or tongue defects.

Infrahyoid flap

This is a reliable and convenient flap that can be used as an alternative to MVFs in small–medium oral defects.^[24] It is easier to harvest and cost-effective as compared to radial artery forearm flap.^[11],[24] Potential issues are a higher incidence of skin paddle congestion and necrosis, and a vertical scar in the neck. It can be used for tongue and buccal mucosa defects. Previous neck irradiation and nodal metastases at level III/IV are contraindications.

Islanded nasolabial flap

The advantages of this flap are reliability, versatility due to the long vascular pedicle, large arc of rotation, and safe distance from lymph nodal basins.^[25] Potential issues are that its best reserved for per-oral resections, and contraindicated in all except early buccal cancers and when lip split is required. It is best used for partial glossectomy defects.

Facial artery myomucosal flap

This is a reliable, simple-to-harvest, pliable flap that has no external scar and is cheaper compared to MVFs. Potential issue is the small amount of soft-tissue available. It can be used for small tongue and floor mouth defects.

Conclusion

MVFs are increasingly becoming the mainstay of oral reconstruction globally, and in some centers in India too. Their cost, risk of re-exploration, longer operative time, and need for microvascular skills have put them beyond the realm of universal usage in many Indian centers. This study brings out the inequality in the usage of MVFs across the country and suggests key measures for closing the gap including more dedicated centers, especially in smaller cities, better microsurgical training, better compensation in state schemes, and formulating consensus guidelines for reconstruction. Irrespective of this, PF and LF will continue to have a major role to play for oral reconstructions in India. Modern head–neck surgeon should arm oneself with skillset of all these flaps and use them “horses for courses.”

Acknowledgments

We would like to thank Drs. Alok Thakar, Gouri Pantvaidya, P. Arun, Dushyant Mandlik, Elizabeth Matthew Iype, Arvind Krishnamurthy, K. K. Thankappan, Sourav Datta, Harsh Dhar, Nirav Trivedi, Raj Nagarkar, Deepak Sarin, Parag Watve, Kaberi Kakati, Samskruthi Murthy, Shamit Chopra, Rajdeep Guha, Kapila Manikantan, Vidisha Tuljapurkar.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

Not Applicable.

Informed consent

Not Applicable.

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