Avoiding complications in microsurgery and strategies for flap take-back

Abstract

The invention of the operating microscope, the introduction of the vessel triangulation technique, and the development of fine microinstruments and microsutures were seminal factors in the widespread adoption of reconstructive microsurgery. In the decades that followed, advances in our understanding and technology have ushered in a new frontier of microsurgery, revolutionizing soft tissue reconstruction. Where skin grafts or pedicled flaps of limited tissue types were once the mainstay of reconstruction, free tissue transfer of multiple tissue types has enabled dramatic improvements in aesthetic and functional results. \n \nIn the last 45 years since the first free flap, microsurgery has been a process in constant evolution. Success in microsurgery is not an end point, but the culmination of a series of steps that are taken toward achieving a particular objective. Over time and with experience, critical evaluation of each step yields better judgement and alternate, often better ways of doing things. The exercise of physical preparation (staying in “technical shape”), mental reflection, and continual refinement is the key to staying current and obtaining positive results. Indeed, the maxim “Preparation is the only shortcut that you need,” shared many years ago by the esteemed Dr. Robert Acland, remains true today. \n \nRigorous training and sustained practice form the technical foundations of any competent microsurgeon. The learning curve for microsurgery, while steep, can be overcome at a basic level by sufficient practice on ex vivo simulation models and small animals. It has been demonstrated that an average of 25 rat femoral vein anastomoses was necessary to overcome the microsurgical learning curve, with patency rates increasing from 48% to 83.4% [1]. \n \nPatient selection is equally important; while there are no absolute contraindications to microsurgical reconstruction, expectations must be managed if compliance to postoperative restrictions and in particular, tobacco use, is likely to be an issue. Smokers should be counselled on the need for smoking cessation several weeks before and after surgery. Systemic comorbidities such as diabetes and cardiopulmonary conditions must be optimized prior to elective reconstruction to minimize patient morbidity. Great care is warranted when operating within an irradiated field, as these tissues tend to be more friable, with a tendency for vessel delamination during dissection. \n \nThe cornerstone of any successful procedure is obtaining informed consent from the patient and establishing robust lines of communication with his or her family. The reconstructive approach must be tailored to the goals and expectations of the patient. \n \nIf a proficient surgeon is operating on an optimized patient after obtaining informed consent, then the subsequent considerations are technical. Surgical considerations include the selection of recipient vessels, flap type, intraoperative positioning (or need for position changes), and postoperative care. If a two-team reconstructive approach is to be utilized, this should be discussed with the resecting team. The surgeon performing recipient vessel preparation must be well versed with the regional anatomy, with a plan for a backup vessel should the situation go awry. Postoperative care requirements, such as intensive care unit bookings, must be secured prior to the operation. \n \nWith the multitude of variables and uncertainties that accompany a complex reconstructive problem, a mental preoperative checklist is a useful tool to ensure that the entire team is on the same page. The reconstructive plan, comprising the first and second choice of flap, recipient vessel selection, sequence of harvest, patient positioning, and microscope location around the table must be discussed with all parties involved. The relevant staff should be briefed on the “how and where” of postoperative monitoring. A bed within the postoperative care area or a room with telemetry facilities for close monitoring of the patient and flap perfusion should be available. Nursing staff must be aware of the reconstruction performed, the location of the pedicle, and region-specific nursing requirements (e.g., jack-knife position nursing, non-weight-bearing status). Medical staff monitoring the flap must be aware of the baseline vascular perfusion of the flap, as well as the method and frequency of flap monitoring.