Effects of Vasopressor Administration on the Outcomes of Microsurgical Breast Reconstruction

Abstract

The use of vasopressors during microsurgery is still debated. General anesthesia often induces hypotension, but microsurgeons are reluctant to use intraoperative vasopressors with the potential risks of vasoconstriction. A retrospective review was performed on 187 consecutive patients undergoing 258 deep inferior epigastric perforator flaps, free transverse rectus abdominis myocutaneous flap, and muscle-sparing free transverse rectus abdominis myocutaneous flap operations. A total of 102 patients (140 flaps) received intraoperative ephedrine and/or phenylephrine and 85 patients (118 flaps) did not. The administration of vasopressors did not affect the rates of reoperation, complete flap loss, partial flap loss, or fat necrosis. Patients receiving vasopressors had no differences in operative time, number of perforators, or number of rows of perforators harvested. There was no statistically significant association between dosage, timing, and complications. Although we do not recommend routine vasopressor use during microsurgery, administration does not seem to increase complications in microsurgical breast reconstruction.

Impact of vasopressors on outcomes in head and neck free tissue transfer

“…Again, the most commonly used vasopressors were phenylephrine and ephedrine. Our study, as well as the studies by Monroe et al 5 and Chen et al, 6 are retrospective series that demonstrate no significant effect on major free tissue transfer complications with intraoperative vasopressor administration. However, each of these series, including our own, are likely underpowered to definitively answer the question.…”

“…The complete flap failure rate was 2.9% in the vasopressor group and 6.7% in the no-vasopressor group. Chen et al 6 published a study of 187 patients who underwent 258 free tissue transfers for breast reconstruction. Of the 187 patients, 102 (54.5%) received intraoperative vasopressor drugs.…”

“…There is a paucity of research on this subject, with only two large-population human series that were both recently published. 5,6 The microvascular surgeon's fear of vasopressors likely stems from the belief that these drugs may provoke pedicle vasospasm, which can lead to thrombosis and flap failure. The existing animal literature is controversial on the issue of pedicle vasospasm, with some authors reporting that the pedicle is alpha-agonist resistant 7 while other authors report that the pedicle is highly sensitive to alpha-agonists.…”

“…5 Another recent retrospective study in patients undergoing breast reconstruction found no impact of vasopressor administration on the free tissue transfer complication rate. 6 There are two main objectives of this study. The first is to determine the frequency of intraoperative vasopressor administration among patients undergoing free tissue transfer for head and neck reconstruction, and the second is to determine the impact of intraoperative vasopressor on free tissue transfer outcomes, including the impact of cumulative vasopressor dose and timing of intraoperative vasopressor administration.…”

Flap-based breast reconstructions

“…However, recent literature showed that intraoperative use of vasopressors did not affect the rate of flap loss or reoperation [28]. The thought is that an attenuated pressor response occurs after surgical sympathectomy, which occurs during vessel dissection [29]. Dobutamine was found to improve flap flow and both dobutamine and norepinephrine improved free flap skin blood flow [30].…”