Microvascular Anastomoses: A Series of 200 Success Stories

Abstract

Sir: We read with interest the article by Koizumi et al. entitled “Microvascular Anastomoses: A Series of 200 Success Stories” and congratulate them on their 100 percent microvascular success rate in their most recent series.1 Their strategy for microvascular anastomosis is undoubtedly a very good guide. In our department too, experience has accumulated, and their strategy could be expanded to include the following: Complete preparation of both donor and recipient vessels before disconnecting the flap, to stabilize the vessels and to minimize “flap-off” time. The use of supports (e.g., rolled up theater drapes) to stabilize the hands and to reduce undesirable hand movements. Although the skill and technical knowledge required of the surgeon during surgery is undoubted, we contend that it is not the sole factor for microsurgical success.2,3 The physiologic condition of the patient is vital, and we believe that keeping the patient warm, well perfused, and comfortable throughout the perioperative period is crucial. We advocate that microsurgical cases: Are performed by a dedicated microsurgical team to optimize familiarity with equipment and techniques. Are carried out in a warmed operating room (27°C). Maintain a body core temperature at 38°C and core-peripheral temperature difference less than 1°C. Have regional anesthesia available where appropriate, which can continue postoperatively. Dedicated postoperative care is also essential. In a recent review of all (consecutive and unselected) free flaps (n = 2569) carried out in our unit between 1985 and 2008, 327 free flaps were reexplored on 369 occasions.3 In this series, timing of reexploration was significant, with successful reexplorations taking place at a mean ± SE of 19.4 ± 2.5 hours compared with 56.1 ± 10.5 hours for unsuccessful reexplorations (p < 0.001). Our work concurs with other studies, in that the majority of flaps were reexplored in the first 24 hours, with most of these being carried out within the first 6 hours.4,5 The preoperative clinical diagnosis for cause of the failing free flap was correct in over 90 percent of reexplorations. Therefore, the following are adopted in free-flap patients postoperatively: The patient is cared for in a warmed high-dependency care unit, ideally with continued review by the same anesthetist. Initial flap observations are carried out every 15 minutes by experienced nursing staff and continue with hourly observations until 48 hours has passed. Invasive monitoring is removed when it is safe to do so. Urgent surgical intervention is performed if flap viability is in doubt, rather than waiting until the indication is absolute (in our series, 0.4 percent of flap reexplorations were negative, which we believe is acceptable if overall success rates are high3). We believe that a “microsurgical culture” within a unit and availability of appropriate facilities are pivotal to microsurgical success. Patients and their flap(s) should have a period of very close observation postoperatively, with a clinical model of flap monitoring at its core. We also believe that careful perioperative management of the patient (and flap) is as important as the skill of the surgeon in achieving consistently successful free tissue transfer. Richard M. Pinder, M.R.C.S. Robert I. Winterton, M.R.C.S. Mark I. Liddington, F.R.C.S., F.R.C.S.(Plas.) Simon P. Kay, F.R.C.S., F.R.C.S.(Plas.) Department of Plastic Surgery Leeds General Infirmary Leeds, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.