Evidence to Support Controversy in Microsurgery

Abstract

Microsurgery practice, including preoperative patient selection, intraoperative technique, and anesthetic considerations, varies from institution to institution and from surgeon to surgeon. Many surgeons' practices are driven by "conventional wisdom," which is handed down from mentors to fellows and residents. In this article, the authors explore the oxymoron that there is evidence to support controversy in microsurgery. Indeed, if there was convincing evidence to support varying microsurgery practices, there would be no controversy. The authors conducted a review with a focus on evidence-based medicine to support microsurgery practice.

The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases

“…Similarly, Coskunfirat et al () demonstrated a strong association of ASA classification with the risk of adverse medical events. BMI also demonstrated statistically significant association with surgical complications, consistent with the consensus in the literature (Fan et al, ). However, as 34% of the US population is classified as obese, obesity should not be considered an absolute contraindication, but rather these patients should be optimized preoperatively (Fan et al, ; Mitchell, Catenacci, Wyatt, & Hill, ).…”

“…BMI also demonstrated statistically significant association with surgical complications, consistent with the consensus in the literature (Fan et al, ). However, as 34% of the US population is classified as obese, obesity should not be considered an absolute contraindication, but rather these patients should be optimized preoperatively (Fan et al, ; Mitchell, Catenacci, Wyatt, & Hill, ). Longer operative times were associated with surgical complications, and longer hospital length of stay was associated with both surgical and medical complications.…”

“…Counterintuitively, our data demonstrated diabetes was associated with lower rates of surgical complications. It is controversial whether diabetes is an independent risk factor in microsurgical outcomes (Fan et al, ). The lower association in our results may be due to close preoperative optimization and close intraoperative monitoring of this patient population.…”

“…Our data described 30-day flap failure rates between 1.6% and 2.8% based on the cohort, with no statistical significance associated with age after controlling for confounding variables. According to a large retrospective study by Kroll et al (1996) (Fan et al, 2015). However, as 34% of the US population is classified as obese, obesity should not be considered an absolute contraindication, but rather these patients should be optimized preoperatively (Fan et al, 2015;Mitchell, Catenacci, Wyatt, & Hill, 2011).…”

Thromboprophylaxis in Head and Neck Microvascular Reconstruction

“…25 A recent review by Fan et al concluded that there are insufficient data to refute this evidence. 42 A recent meta-analysis evaluating the efficacy of thromboprophylactic agents used in microsurgery concluded that HSQ reduced the risk of flap loss by 35% but raised the risk of hematoma, though these differences were significant. 30 In a retrospective review of 470 patients undergoing free tissue transfer, HSQ was found to be a safe agent that did not increase the risk of postoperative bleeding, hematoma, or flap failure.…”