Abstract
Background:
Free flap procedures are essential in reconstructive surgery, yet their use is influenced by multiple factors, including infrastructure, training, financial constraints, and surgeon experience. This study explored the perceptions of Jordanian surgeons regarding the limitations of free flap procedures.
Methods:
A cross-sectional survey was conducted among Jordanian surgeons, including plastic surgeons, neurosurgeons, ophthalmologists, orthopedic surgeons, and vascular surgeons. Data were collected through a structured questionnaire, assessing infrastructure, resources, training, education, funding, insurance, and surgeon experience. Statistical analysis was performed using R version 4.2.1, and comparisons between plastic and reconstructive surgeons and other surgical specialists were made using chi-square and independent t tests.
Results:
A survey of 120 surgeons revealed that 70% had access to sufficient resources, but 55% had limited access to specialized tools and concerns about institutional budgeting and equipment maintenance. Additionally, 50% had no formal training in free flap procedures, whereas 40% received training during residency. Financial constraints influenced decision-making, with 53% citing affordability and insurance issues. Experience was a key factor, with 45.8% reporting limited exposure to free flaps and 88% recognizing surgeon expertise as critical to success. Plastic surgeons were more likely to have formal training and greater experience with free flap procedures than other specialists (P = 0.04, 0.002, respectively).
Conclusions:
The study highlighted challenges in the adoption of free flap procedures in Jordan, such as limited access to specialized tools, inadequate training, financial constraints, and disparities in surgeon experience, emphasizing the need for structured training programs, improved institutional support, and improved insurance policies.
Takeaways
Question: What are the key limitations affecting the use of free flap procedures among surgeons in Jordan?
Findings: A cross-sectional survey of 120 surgeons revealed that 55% had limited access to specialized tools, 50% lacked formal training, and 53% of cases were influenced by financial constraints. Plastic surgeons had significantly more training and experience compared to other specialists (P = 0.04, 0.002).
Meaning: Addressing training gaps, improving institutional support, and refining insurance policies are essential to enhancing the adoption of free flap procedures in Jordan.
INTRODUCTION
Reconstructive surgery, specifically the use of free flaps, is a critical component of modern surgical practice.1–3 This procedure has revolutionized surgical practice across multiple specialties, such as oncology surgery, otorhinolaryngology, maxillofacial surgery, and plastic and reconstructive surgery, among others. Reconstructive surgery has been a breakthrough for patients with congenital or acquired pathologies, resulting in improved quality of life both physically and emotionally by restoring the lost or impaired body parts to the best possible form and function.1–3
Reconstructive surgery is a technically demanding specialty of surgery with a steep learning curve.4,5 Some other limitations to consider include access to specialists and the cost to patients, because insurance coverage for reconstructive procedures is not usually universal.6,7 In Jordan, surgeons encounter limitations related to inadequate resources, insufficient educational tools, and funding constraints. Insurance issues further complicate the situation, often deterring both patients and practitioners due to concerns about adverse outcomes and complications. An additional limitation encountered includes the variability in surgeon experience with free flap procedures, which impacts their success and adoption.
Although exact national data are limited, our estimates suggest that fewer than 50 free flap reconstructions are performed annually across major centers in Jordan. This contrasts sharply with higher volume settings; for instance, a single high-volume center in the United States may perform more than 200–500 free flap procedures per year.8 Similarly, reports from tertiary centers in countries such as the United Kingdom document annual volumes ranging from 200 to more than 1000 cases.9,10
The primary aim of this project was to identify and understand the limitations and challenges associated with the use of free flaps in reconstructive surgery within Jordan. By understanding these limitations, the project sought to provide actionable insights for healthcare policymakers and surgical educators to enhance the resources, training, and support systems necessary for improving the use of free flaps in Jordan, ultimately leading to better patient care and outcomes.
METHODS
This cross-sectional study was conducted at 4 major hospitals in Jordan: King Hussein Cancer Center, Istiklal Hospital, Al-salt Hospital, Al Bashear Hospital, and Royal Medical Services. The study aimed to assess surgeons’ perceptions of the limitations of free flaps in reconstructive surgery.
Participants
Eligible participants included plastic and reconstructive surgeons, neurosurgeons, head and neck surgeons, orthopedic surgeons, maxillofacial surgeons, and vascular surgeons currently practicing in Jordan. Surgeons who were no longer active in these specialties were excluded.
Data Collection
Data were collected using a structured survey distributed both electronically and in person. The survey covered key areas, including resources and infrastructure—availability of specialized tools, surgical instruments, and institutional support; training and education—access to educational resources, workshops, and hands-on experience; funding and insurance—challenges related to financial coverage and reimbursement policies; patient trust and outcomes—perceptions of patient acceptance, outcome expectations, and concerns regarding complications.
Survey Validation
The survey underwent a rigorous validation process to ensure content accuracy, clarity, and reliability. A panel of expert surgeons, including plastic and reconstructive surgeons, neurosurgeons, and vascular surgeons, reviewed the survey for face and content validity. To assess internal consistency, a pilot study was conducted among a small sample of eligible surgeons (n = 10), and the survey was refined based on their feedback. The Cronbach alpha was calculated for key sections to evaluate reliability, with a threshold of 0.7 or higher considered acceptable.
Data Analysis
Statistical analysis was performed using R version 4.2.1. Categorical variables were summarized as frequencies, percentages, ratios, and rates. Continuous variables were presented as means, medians, SDs, and interquartile ranges, as appropriate. Comparisons between plastic and reconstructive surgeons and other surgical specialties were conducted using the chi-square test for categorical variables and the independent t test or Mann-Whitney U test, depending on data distribution, for continuous variables. A P value of less than 0.05 was considered statistically significant.
RESULTS
Out of 120 distributed surveys, 83 were returned (response rate: 69.2%). The mean age of the respondents was 40.9 ± 9.2 years. The distribution of respondents by specialty is shown in Figure 1. Plastic and reconstructive surgery was the most common specialty, accounting for 53% of all respondents. Most of the respondents have been practicing between 6 and 10 years, as shown in Figure 2.
Fig. 1.
Distribution of respondents by specialty.
Fig. 2.
Distributions of respondents by duration of practice.
Assessment of infrastructure and resources for free flap procedures showed that approximately 70% of all respondents had access to sufficient surgical resources to perform free flap procedures. However, when we assessed the availability of necessary tools and equipment for free flap procedures, the study revealed that about 55% of respondents had the required tools. Most of the respondents (60%) believed that there were some department or institutional budgeting issues that could affect the availability of resources for free flap procedures. Just about half of the respondents (56%) reported issues related to the maintenance of equipment that impacted the ability to perform free flap procedures (Table 1).
Table 1.
Assessment of Infrastructure, Resources, Training, and Education
| Assessment Questions | Responses: Total Responders = 83, n (%) |
|---|---|
| I. Resources and infrastructure | |
| Do you have access to sufficient surgical resources (eg, instruments, materials) to perform free flap procedures? | |
| Maybe | 7 (8.4) |
| No | 18 (21.7) |
| Yes | 58 (69.9) |
| Are the necessary tools and equipment (eg, microvascular instruments, operating room facilities) readily available for free flap procedures? | |
| Maybe | 17 (20.5) |
| No | 20 (24.1) |
| Yes | 46 (55.4) |
| In your opinion, are there any institutional or departmental budget constraints that affect the availability of resources for free flap procedures? | |
| Maybe | 11 (13.3) |
| No | 22 (26.5) |
| Yes | 50 (60.2) |
| Are there any issues related to the maintenance of equipment that affect your ability to perform free flap procedures? | |
| Number of missing values | 2 |
| Maybe | 20 (24.7) |
| No | 16 (19.8) |
| Yes | 45 (55.6) |
| II. Training and education | |
| Have you received formal training in free flap procedures? | |
| No | 42 (50.6) |
| Yes, courses and workshops | 8 (9.6) |
| Yes, during residency/fellowships | 33 (39.8) |
| How would you rate the availability of specialized training or workshops on free flap surgery in your institution or country? | |
| Fair | 13 (15.7) |
| Good | 16 (19.3) |
| Nonspecific | 4 (4.8) |
| Poor | 50 (60.2) |
| Do you believe there is a need for more structured or specialized training in free flap techniques in Jordan? | |
| No | 1 (1.2) |
| Yes | 82 (98.8) |
| Do you feel confident in your skills to perform free flap procedures? | |
| Confident | 9 (10.8) |
| Neutral | 24 (28.9) |
| Not confident | 36 (43.4) |
| Not confident at all | 5 (6.0) |
| Very confident | 9 (10.8) |
The assessment of training and education of the respondents revealed that about 50% of the respondents had not received any formal training in free flap procedures. Only about 40% of the respondents reported receiving some training during their residency. This was also reflected in the respondents’ perceptions of training availability on free flap procedures. More than 60% of the respondents believed that no training institution is available nationlly. Almost all respondents (98.8%) believed that there is a need for additional structured training facilities on free flap procedures across the country (Table 1).
The respondents’ perception toward funding and insurance coverage for free flap procedures revealed the following: more than half (53%) believed that financial constraints (eg, insurance and patient affordability) affect the decision to perform free flap procedures. Approximately one-fourth of respondents also believed that there are issues with insurance coverage of free flap procedures. About one-third of the respondents reported delays or insufficient reimbursement for free flap procedures (Table 2).
Table 2.
Assessment of Funding, Insurance, and the Experience of the Responders
| Assessment Questions | Responses: Total Responders = 83, n (%) |
|---|---|
| I. Funding and insurance issues | |
| Do patients face significant challenges with insurance coverage when undergoing free flap procedures? | |
| No, insurance generally covers it | 21 (25.3) |
| Not sure | 23 (27.7) |
| Yes, insurance rarely covers it | 18 (21.7) |
| Yes, there are frequent issues with insurance coverage | 21 (25.3) |
| Do financial constraints (eg, insurance, patient affordability) affect your decision to perform free flap procedures? | |
| Number of missing values | 1 |
| Maybe | 14 (17.1) |
| No | 24 (29.3) |
| Yes | 44 (53.7) |
| Do you encounter issues with delayed reimbursements or insufficient payments for free flap surgeries from insurance companies? | |
| Maybe | 28 (33.7) |
| No | 26 (31.3) |
| Yes | 29 (34.9) |
| II. Experience of the surgeon | |
| How much experience do you have performing free flap procedures? | |
| Extensive experience (more than 20 procedures) | 10 (12.0) |
| Limited experience (1–5 procedures) | 38 (45.8) |
| Moderate experience (5–20 procedures) | 12 (14.5) |
| No experience | 23 (27.7) |
| Do you feel that the variability in surgeon experience impacts the success rate of free flap procedures? | |
| Maybe | 8 (9.6) |
| No | 2 (2.4) |
| Yes | 73 (88.0) |
| Do you believe that the overall skill level of surgeons in Jordan is adequate for performing free flap procedures? | |
| No, there is a need for further training | 48 (57.8) |
| Not sure | 25 (30.1) |
| Yes, most surgeons are well trained | 10 (12.0) |
Experience of the surgeons is also an important consideration for free flap procedures. Our study showed that most of the respondents (45.8%) had limited experience with free flap procedures, and the majority (88%) believed that the experience of the surgeon has a direct impact on the success of free flap procedures (Table 2).
Comparison of plastic and reconstructive surgeons with other surgical specialists revealed that there is a significant difference between the groups in terms of experience and training. Plastic surgeons were more likely to have greater experience (P = 0.0022) and were more likely to have received formal training in free flap procedures (P = 0.041) (Table 3).
Table 3.
Comparison Between Plastic Surgeon Versus Others
| Plastic (N = 44), n (%) | Other (N = 39), n (%) | P | |
|---|---|---|---|
| Are the necessary tools and equipment readily available for free flap procedures? | 0.175* | ||
| Maybe | 12.0 (27.3) | 5.0 (12.8) | |
| No | 8.0 (18.2) | 12.0 (30.8) | |
| Yes | 24.0 (54.5) | 22.0 (56.4) | |
| Have you received formal training in free flap procedures? | 0.041* | ||
| No | 17.0 (38.6) | 25.0 (64.1) | |
| Yes, courses and workshops | 4.0 (9.1) | 4.0 (10.3) | |
| Yes, during residency/fellowships | 23.0 (52.3) | 10.0 (25.6) | |
| Do you believe there is a need for more structured or specialized training in free flap techniques in Jordan? | 0.285* | ||
| No | 0.0 (0.0) | 1.0 (2.6) | |
| Yes | 44.0 (100.0) | 38.0 (97.4) | |
| Do patients face significant challenges with insurance coverage when undergoing free flap procedures? | 0.026* | ||
| No, insurance generally covers it | 17.0 (38.6) | 4.0 (10.3) | |
| Not sure | 9.0 (20.5) | 14.0 (35.9) | |
| Yes, insurance rarely covers it | 9.0 (20.5) | 9.0 (23.1) | |
| Yes, there are frequent issues with insurance coverage | 9.0 (20.5) | 12.0 (30.8) | |
| Do financial constraints affect your decision to perform free flap procedures? | 0.001* | ||
| Number of missing values | 0.0 | 1.0 | |
| Maybe | 4.0 (9.1) | 10.0 (26.3) | |
| No | 20.0 (45.5) | 4.0 (10.5) | |
| Yes | 20.0 (45.5) | 24.0 (63.2) | |
| Do you encounter issues with delayed reimbursements or insufficient payments for free flap procedures from insurance companies? | 0.003* | ||
| Maybe | 11.0 (25.0) | 17.0 (43.6) | |
| No | 21.0 (47.7) | 5.0 (12.8) | |
| Yes | 12.0 (27.3) | 17.0 (43.6) | |
| How much experience do you have performing free flap procedures? | 0.022* | ||
| Extensive experience (more than 20 procedures) | 7.0 (15.9) | 3.0 (7.7) | |
| Limited experience (1–5 procedures) | 23.0 (52.3) | 15.0 (38.5) | |
| Moderate experience (5–20 procedures) | 8.0 (18.2) | 4.0 (10.3) | |
| No experience | 6.0 (13.6) | 17.0 (43.6) |
*Statistical significance determined by Chi-square test.
DISCUSSION
Reconstructive surgery and free flap procedures have revolutionized the management of complex wounds, making it possible to achieve favorable surgical outcomes.11,12 Tumors that were once considered inoperable can now be resected, with the resulting defects reconstructed with free flaps.1,2,13 There are several limitations of free flap reconstruction, including prolonged procedure time, increased risk of complications such as tissue necrosis due to compromised blood supply, donor site scarring, and dependence on the amount of available tissue from the donor area. Other limitations included technical complexity, donor site morbidity, flap failure, and multiple incisions and scars.14–16
To perform free flap procedures, there is a need for a well-motivated and adequately trained surgical team, adequate perioperative monitoring of the flaps, a well-equipped operating theater, and availability of a well-equipped intensive care unit.17–19 The reality is that, except in a few developed nations, these facilities are not readily available, and even if available, these facilities are often shared by all surgical specialists and may not be accessible to reconstructive surgeons when needed. Despite these limitations, low- and middle-income countries (LMICs) have a significantly larger population of patients requiring free flap services than developed countries.6,17–20
In our study, one of the limitations we found was the lack of adequate infrastructure and resources dedicated to free flap procedures. We found that most practicing surgeons in Jordan do not have access to sufficient surgical resources to perform free flap procedures. They also lack the necessary tools and equipment for free flap procedures. One of the key deficiencies noticed was the lack of adequate facilities for microvascular procedures. Budget constraints and lack of maintenance have also affected the ability of surgeons in Jordan to perform free flap procedures. Similar challenges were reported by Nangole et al18 in Kenya, Lupon et al20 in Cambodia, and de Berker et al19 when they conducted a systematic review and meta-analysis.
Lack of adequate training and specialization has been a major limitation to the advancement of reconstructive surgery and free flap procedures. Holler et al21 reported the lack of adequately trained personnel as the main limitation for reconstructive surgery in a survey of 86 specialist surgeons from LMICs. This is similar to the findings of our study, as most respondents believed there is a need for more structured or specialized training in free flap techniques in Jordan. This also reflects the lack of well-experienced surgeons identified in our survey. Most of the respondents in our study reported limited experience with reconstructive surgery and free flap procedures.
Funding and budgeting have been significant barriers to the advancement of reconstructive surgery, especially in LMICs. In some nations, nongovernmental organizations have stepped up to fill the gap, especially in resource-limited settings. Chao and McAllister7 identified a total of 131 reconstructive surgery nongovernmental organizations serving 718 sites in 136 LMICs. Some of these sites are located in the Middle East and North Africa. The findings from our study support this fact, and most of our respondents reported issues with insurance coverage, financial constraints, and reimbursements after surgery.
These findings are largely consistent with those reported in other LMICs, where similar barriers have been identified. For instance, studies in sub-Saharan Africa and parts of Southeast Asia reported limited availability of microsurgical training and poor infrastructure as the primary reasons for the low use of free flaps.22 In contrast, high-income countries have more established microsurgical programs. For example, a UK-based survey reported that more than 75% of plastic surgery trainees had hands-on experience with free flap procedures, and confidence levels were substantially higher.23 Similarly, in the United States, board-certified plastic surgeons commonly perform free flap procedures, with microsurgical fellowships widely available.24
Thus, compared with these international benchmarks, Jordan shows a significant gap both in practice volume and in the structural and educational support needed for widespread adoption of this reconstructive option. National surgical societies and health authorities play a pivotal role in addressing the current gaps in free flap reconstructive surgery. Their leadership is essential for driving a unified national vision and ensuring the long-term sustainability of services. A comprehensive, multipronged approach is required—beginning with targeted investments in training, infrastructure, and the integration of reconstructive surgery into national health policies and surgical planning.25,26 Structured microsurgical training programs should be incorporated into residency and fellowship curricula, supported by hands-on workshops, simulation laboratories, and mentorship opportunities.27 Equally important is investment in microsurgical instruments and operating room infrastructure to build local capacity.28 In addition, developing national databases and quality registries can provide the data needed to monitor outcomes and guide continuous improvement.29 Finally, international collaborations and short-term training exchanges can help bridge the existing skills gap while local expertise is being developed.30
This study provided valuable insights into the limitations and challenges surrounding the use of free flap reconstruction in Jordan, particularly from the perspective of practicing surgeons. A key strength of this work lies in its focus on a largely understudied setting, offering a context-specific analysis that can inform local policy and training initiatives. Additionally, the inclusion of both plastic surgeons and other specialties allowed for a broader understanding of perceptions and barriers across disciplines. However, the study has several limitations, including a relatively small sample size and its reliance on self-reported data, which may be subject to response bias. Moreover, as a cross-sectional study, it does not establish causality or capture changes over time. Future research should focus on multicenter or longitudinal studies to explore the impact of targeted interventions, such as microsurgical training programs or policy changes, on increasing the uptake and success of free flap procedures in low-resource settings.
CONCLUSIONS
Reconstructive surgery and free flap procedures in Jordan are facing several constraints, including lack of adequate infrastructure; lack of adequately trained personnel; limited resources and funding; and, finally, lack of structured training for the few available surgeons. There is a need for policymakers to dedicate resources and infrastructure toward developing this specialty in Jordan and the broader Middle East.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
PATIENT CONSENT
The requirement for written informed consent was waived for this study, as it poses no more than minimal risk to participants. Instead, voluntary participation was ensured by including an approval statement at the beginning of the questionnaire. By proceeding with the survey, participants acknowledge that they have read and understood the study’s purpose, confidentiality measures, and their right to withdraw at any time without consequences. This approach aligns with ethical research guidelines for minimal-risk studies.
ACKNOWLEDGMENTS
The authors would like to extend their heartfelt gratitude to all individuals who have contributed to the successful completion of this research endeavor. Their unwavering support, expertise, and dedication have been crucial in advancing our understanding of the perceptions and limitations of free flap procedures among surgeons in Jordan. The authors also express their deepest appreciation to the institutional review board at Istiklal Hospital for their meticulous review and invaluable feedback, ensuring the ethical conduct of the study and safeguarding the safety of our participants. The authors also extend their sincere thanks to all who participated in this study. Their willingness to share their experiences and insights has been invaluable and has greatly enriched the findings of the research.
ETHICS APPROVAL
This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the ethics committee of Istiklal Hospital.
Footnotes
Published online 24 September 2025.
Disclosure statements are at the end of this article, following the correspondence information.
The data supporting this article are available within the article.
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