Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer

Abstract

Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.

A Comparison of Perioperative Blood Transfusions and Other Complications Following Transverse Rectus Abdominis Myocutaneous Flaps versus Deep Inferior Epigastric Perforator Flaps

“…Equally important was the finding of a recent review which highlighted the tendency for increased medical and surgical complications in free flap reconstructions that underwent blood transfusion post operatively [14]. Thus the decision to transfuse blood should not only take into consideration the scarcity of blood products and the cost to the health care system but also the potential harm to the patient.…”

Face transplantation: Anesthetic challenges

“…Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis such as thromboelastography. Use of colloids such as dextrans[22] are not preferred, and there is no data currently available on use of albumin for this surgery.…”

“…Norepinephrine has been analysed as the most potential suitable agent for free flap transfer when compared to epinephrine, dobutamine and doxepine. This is because with norepinephrine, control of blood flow depends mostly on low frequency vasomotion or average blood pressure[22,25]. Though vasoconstriction increased, the blood pressure increased too, resulting in overall increased lap blood flow[26].…”

Intraoperative hypotension and flap loss in free tissue transfer surgery of the head and neck

“…Hemodynamic stability (which is managed predominantly by the anesthesiologist) is a general indication for intraoperative fluid or vasopressor administration. This poses a particular challenge in free tissue transfer surgery of the head and neck: volume of intraoperative crystalloid administration is a predictor of poor flap outcomes, and yet there remains a considerable aversion to vasopressor administration, based on the theoretical concerns that it may worsen flap perfusion and survival . In an attempt to avoid vasopressor or fluid administration, it is possible that many patients undergoing free tissue transfer may be exposed by their care team to unnecessary periods of hypotension, especially during times of minimal stimulation, such as microvascular anastomosis, leading to flap hypoperfusion.…”