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Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less 'rescue' fluid administration during the perioperative period.

S ince the 1940s, the prevailing wisdom regarding the amount of fluid to administer to surgical patients has undergone several paradigm shifts (1-4). The fluid management of patients undergoing microvascular free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation. The use of vasopressors in these cases is contraindicated so as not to compromise blood flow to the flap. Inadequate volume replacement in these patients can potentially lead to poor flow in the flap with resultant ischemia and flap loss. Aggressive fluid administration in these patients, to maintain adequate blood pressure, can result in flap edema, venous engorgement and, ultimately, flap loss. There have been several retrospective studies that have examined fluid administration in these patients and found that excessive perioperative fluid administration has been associated with flap loss (5,6).

Until now, the tarsal strap has been a poorly understood entity, despite being an anatomically and clinically significant eyelid structure. Knowledge of its significance is essential to restoring the lateral canthus and returning periorbital structures to their youthful state. It should be routinely sought out and properly released.

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