Preprocedural Planning
Preoperative planning includes finding the optimal donor site and designing the flap so as to maximize soft-tissue coverage, functionality, and appearance and to minimize complications. Timing should be considered; early (≤ 72 hr) free-flap reconstruction has been associated with a decreased rate of free-flap failures, infection, and additional procedures, though the majority of these procedures are performed in a delayed timeframe. [22] In oncologic cases, the timing of free flap reconstruction should be coordinated with the oncology team, taking into consideration chemotherapy and radiation treatments.
History and physical examination
Preoperative assessment of the patient should include an in-depth review of the patient’s current conditions, past medical history, past surgical history, previous history with anesthesia, and current medications. The social history is important for identifying possible issues with substance or tobacco use, as well as for obtaining a better understanding of the patient’s support network for postoperative care.
The physical examination is used to identify the current defect or to anticipate a presumed defect (in the case of an oncologic procedure). The ability to anticipate the operative defect and plan for appropriate reconstructive repair is imperative for successful restoration of form and function.
Laboratory studies
Because of the possible long operative and fluid shifts associated with microsurgical cases, a complete blood count (CBC), type and screen or type and cross, coagulation panel to rule out either coagulopathy or a hypercoagulable state, and basic chemistries are routinely ordered preoperatively. Electrocardiography (ECG) is also a part of the routine preoperative workup. Additional laboratory studies and tests such as pulmonary function tests may be necessary, depending on the general health and age of the patient.
Imaging studies
Imaging studies are an important part of the preoperative workup for specific defects and reconstructive procedures. However, they are not performed routinely in every case.
Chest radiography is typically part of the routine preoperative workup. Computed tomography (CT) of the head and neck may be useful in understanding the expected defect. In mandibular reconstruction, three-dimensional CT may help visualize the anticipated defect in three dimensions. In lower-extremity reconstruction, angiography is useful for determining the zone of vessel injury and the location of recipient vessels. Lower-extremity angiography is also useful before free fibula harvest in patients who have peripheral vascular disease.
Equipment
Equipment commonly used in microsurgery includes the following:
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Operating microscope
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Microsurgical instruments
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Microsutures (9-0 and 10-0 nylon)
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Vein coupler
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Sterile Doppler device
Patient Preparation
Proper positioning of the patient includes the following:
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Padding of all pressure points
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Prevention of nerve traction or compression
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Placement of a Foley catheter
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Application of sequential compression devices to the legs to prevent deep vein thrombosis
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Sterile preparation of donor and recipient sites, as well as sites as needed for harvesting of vein grafts, nerve grafts, or skin grafts
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Toe-to-thumb transfer.
Tables
Defect Type |
Tissue Defect |
Common Flaps |
Coverage of exposed structures |
Open tibial fractures in distal third of leg |
Latissimus dorsi muscle free flap; gracilis muscle free flap |
Dead space |
Obliteration of maxilla defect after maxillectomy for cancer |
Rectus abdominis muscle free flap |
Tissue defect |
Breast reconstruction |
Transverse rectus abdominis myocutaneous (TRAM) free flap; deep inferior epigastric perforator (DIEP) flap; superior gluteal artery perforator (SGAP) free flap |
Bone and soft defect |
Mandible reconstruction |
Fibula osteocutaneous free flap |
Bone and soft defect |
Infraorbital and maxillary defect |
Parascapular osteocutaneous free flap |
Facial muscle denervation |
Facial paralysis with muscular atrophy |
Gracilis muscle free flap |
Digital amputation |
Thumb amputation |
Great toe composite free flap |
Digestive tract defect |
Esophageal reconstruction |
Jejunum free flap; anterior lateral thigh (ALT) free flap |
