{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T17:36:53Z","timestamp":1786988213235,"version":"build-2736575974"},"reference-count":14,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T00:00:00Z","timestamp":1779235200000},"content-version":"vor","delay-in-days":19,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Microsurgery"],"published-print":{"date-parts":[[2026,5]]},"abstract":"ABSTRACT<\/jats:title>\n \n Background<\/jats:title>\n Reconstructive strategies are commonly evaluated according to complication rates and technical success at the individual patient level. However, interventions that reduce complications may simultaneously increase cumulative procedural exposure, operative utilization, and healthcare resource consumption across patient populations. This distinction reflects a broader epidemiologic trade\u2010off between universal prophylactic intervention and selective escalation following clinically significant failure.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We performed a value\u2010based reinterpretation of the donor\u2010site reconstruction study by Angela Alnemri et\u00a0al., comparing staged reconstruction of radial forearm free flap donor sites using Integra followed by delayed split\u2010thickness skin grafting (STSG) with primary STSG closure. Using published cohort data, we conducted a composite procedural burden analysis evaluating cumulative donor\u2010site closure procedures under observed treatment patterns and under a procedural\u2010economy counterfactual in which all patients underwent primary STSG with selective operative salvage only when clinically necessary.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The original study demonstrated lower rates of skin graft breakdown and tendon exposure with staged reconstruction. However, staged reconstruction required a second operative episode for nearly all patients by design, resulting in substantially greater cumulative procedural exposure. Across 179 patients, the observed treatment strategy resulted in 313 donor\u2010site closure procedures. In contrast, the modeled procedural\u2010economy strategy resulted in 179 + r procedures, where\n r<\/jats:italic>\n represented patients requiring operative salvage following donor\u2010site complications. Under the base\u2010case assumption (\n r<\/jats:italic>\n \u2009=\u20090), this corresponded to 134 fewer operative procedures. Even under conservative sensitivity assumptions permitting selective reoperation, substantial procedural reduction persisted before parity with universal staging was reached.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Lower complication rates do not necessarily translate into lower healthcare utilization or greater value at the population level. In donor\u2010site reconstruction, staged strategies reduce individual\u2010level morbidity but do so through universal escalation of procedural intensity. Reconstructive decision\u2010making should therefore incorporate procedural economy, operative exposure, and health\u2010system resource utilization alongside conventional complication\u2010based endpoints. Integrating epidemiologic and health\u2010economic principles into reconstructive algorithms may better align technical outcomes with value\u2010based surgical care.<\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/micr.70235","type":"journal-article","created":{"date-parts":[[2026,5,21]],"date-time":"2026-05-21T04:23:58Z","timestamp":1779337438000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["When Fewer Complications Cost More: A Value\u2010Based Reanalysis of Donor\u2010Site Reconstruction"],"prefix":"10.1002","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2208-8539","authenticated-orcid":false,"given":"Georgios","family":"Karamitros","sequence":"first","affiliation":[{"name":"Department of Plastic Surgery Vanderbilt University Medical Center Nashville Tennessee USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory A.","family":"Lamaris","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, R. Adams Cowley Shock Trauma Center University of Maryland Medical Center Baltimore Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William C.","family":"Lineaweaver","sequence":"additional","affiliation":[{"name":"Department of Plastic Surgery Vanderbilt University Medical Center Nashville Tennessee USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,5,20]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1002\/micr.70174"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0000000000007497"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1002\/pad.1846"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.305.6856.757"},{"key":"e_1_2_12_6_1","first-page":"415","volume-title":"The Oxford Handbook of Professional Economic Ethics","author":"Glennerster R.","year":"2016"},{"key":"e_1_2_12_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/micr.70105"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2012.218"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2010.09.008"},{"key":"e_1_2_12_10_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2018.1150"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/0270-0255(86)90088-6"},{"key":"e_1_2_12_12_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.g6501"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1093\/asj\/sjz258"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1146\/annurev.publhealth.012809.103720"},{"key":"e_1_2_12_15_1","doi-asserted-by":"publisher","DOI":"10.1177\/0272989X20954387"}],"container-title":["Microsurgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/micr.70235","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/micr.70235","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/micr.70235","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T17:21:23Z","timestamp":1786987283000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/micr.70235"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5]]},"references-count":14,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,5]]}},"alternative-id":["10.1002\/micr.70235"],"URL":"https:\/\/doi.org\/10.1002\/micr.70235","archive":["Portico"],"relation":{},"ISSN":["0738-1085","1098-2752"],"issn-type":[{"value":"0738-1085","type":"print"},{"value":"1098-2752","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5]]},"assertion":[{"value":"2026-01-22","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-04-28","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-05-20","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70235"}}