The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature

Abstract

Background/Objectives Microvascular free tissue transfer has become essential to head and neck reconstruction and recent advancements in microvascular surgery have led to excellent surgical outcomes. However, there continues to be controversy and a stigma associated with the use of perioperative intravenous vasopressor agents among both surgeons and anesthesiologists. Due to concern for vasoconstriction of peripheral vasculature flowing to the denervated tissue flap, there remains concerns about potential thrombosis, decreased tissue perfusion and ultimately flap failure. This topic becomes even more important as vasopressors play an essential role in new Extended Recovery After Surgery (ERAS) protocols being put in place to optimize postoperative recovery for patients. The purpose of this study was to comprehensively review the role and safety as well as discuss current trends with intraoperative vasopressor agents in free tissue transfer for head and neck reconstruction. Methods A scoping literature review was conducted of all studies that examined the use of vasopressor agents during head and neck free flap tissue transfer. Primary and secondary outcomes included free flap survival, arterial thrombosis, venous congestion, need for revision surgery, and other postoperative complications. Results One prospective and nine retrospective studies were identified. Phenylephrine and ephedrine were the most common vasopressors reported; the rate of vasopressor use ranged from 53% to 85% and administration methods included both bolus and infusion. The included studies did not show any significant association between the use of vasopressors and free flap failure, pedicle thrombosis, or other flap complications. Conclusion The administration of vasopressors during microvascular free tissue transfer for head and neck reconstruction does not seem to be associated with increased flap failure rates or other postoperative morbidities. Moreover, vasopressors may provide overall improved hemodynamic stability and help to limit overall fluid administration and subsequent postoperative complications. Additional prospective investigation is warranted to further elucidate and establish evidence-based recommendations regarding the type, timing, and dose of vasopressors to further enhance free flap survival and patient outcomes.

Jaw-in-a-Riley-Day: Mandibular Free Flap Reconstruction With Virtual Surgical Planning in a Patient With Familial Dysautonomia

“…A direct alpha-1 adrenergic agonist, in our case continuous phenylephrine infusion, was used perioperatively to correct hypotension [6]. Intravenous fluids were judiciously administered in small boluses to avoid fluid overload [7]. Dexmedetomidine infusion as reported in the literature proved useful for sequestering the autonomic crisis episode encountered in our patient [8].…”

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study

“…The safety of vasoactive agents in reconstructive microsurgery observed in this study falls in line with the findings of several recent publications. 9 , 33 , 34 …”

Einfluss der Gabe von Katecholaminen bei Mund-Kiefer-Gesichtschirurgischen Lappenplastiken nach Tumorresektion

“…Die 5-Jahres-Überlebensrate bei nicht metastasierenden Plattenepithelkarzinomen der Haut liegt zwischen 60-80 % (Holtmann et al 2020). (Hölzle et al 2008;Goh et al 2019;Naik et al 2020). Die mikrochirurgische Lappenplastik hat sich auch in der Mund-Kiefer-Gesichtschirurgie etabliert, da diese einen Gewebetransfer und somit eine ästhetische und funktionelle Behandlung von Hart-und…”

“…Typische Fernlappenentnahmestellen in der Mund-Kiefer-Gesichtschirurgie sind das Radialis-Transplantat, das Latissimus dorsi-Transplantat, das Skapula-Transplantat und das Fibula-Transplantat (Hölzle et al 2008;Hölzle et al 2012;Kruse Gujer et al 2013). Katecholaminen in der Mikrochirurgie in den letzten Jahren Thema mehrerer umfangreicher Meta-Analysen (Swanson et al 2016;Goh et al 2019;Naik et al 2020), allerdings ist der Einfluss von Noradrenalin auf freie Lappentransplantate vergleichsweise wenig untersucht (Goh et al 2019).…”

“…Bei großen und langwierigen Operationen, wie zum Beispiel einer Lappentransplantation, ist die perioperative Gabe von Katecholaminen eine gängige Praxis zur Kreislaufstabilisierung (Laux und Rex 2019). Da Katecholamine auch gefäßverengend wirken, wurde lange vermutet, dass die Gabe von Katecholaminen den Erfolg einer Lappenplastik gefährden könnte (Kotsougiani et al 2016;Rose et al 2016;Swanson et al 2016;Chang et al 2017;Anker et al 2018;Goh et al 2019;Rex et al 2019;Naik et al 2020)…”