RECONSTRUCTIVE SURGERY
Anaesthesia for plastic and
reconstructive surgery
Henry CY Mak
Michael G Irwin
Abstract
Plastic and reconstructive surgery aims to restore normal and functional
anatomy following tissue destruction or impaired wound healing. The tech-
niques required depend on the complexity of the wound, from simple
closure to flap reconstruction. More complicated wounds with large skin de-
fects may need free flap transfer for optimal functional and cosmetic results.
Flap failure is a major potential complication and perioperative anaesthetic
management plays an important role in successful surgery. Factors which
may lead to vasoconstriction must be avoided, including pain, hypothermia
and hypovolaemia. Blood flow is also improved by maintaining an adequate
blood pressure, moderate haemodilution and normocarbia. Free flap failure
occurs mainly during the first three postoperative days. Venous thrombosis
secondary to congestion is more common than arterial obstruction. Prompt
surgical re-exploration is the key to flap salvage.
Keywords Fluid management; free flap; haemodilution; microcirculation;
reconstructive ladder; reconstructive surgery; vasopressor
Royal College of Anaesthetists CPD Matrix: 2A07
Introduction
Plastic and reconstructive surgery aims to restore normal and
functional anatomy following tissue destruction or impaired
wound healing. The abnormality could be congenital, traumatic
or as a result of a disease process such as cancer or infection.
In considering how to close a surgical wound, the plastic
surgeon can ascend the ‘reconstructive ladder’ (Box 1), starting
from the simplest option and ascending to a more advanced one
depending on the complexity of the surgical wound and the
clinical conditions.
The lower rungs of the ladder have limited implications for
anaesthesia, and many simple elective plastic surgery procedures
can be done in an office setting under local anaesthesia with little
or no sedation. Strategies higher up the ladder require more
intervention, in particular split skin grafts require good pain
management for the donor site, preferably using regional anaes-
thesia, for example a lateral cutaneous nerve block in for the
lateral thigh, from where split skin grafts are frequently harvested.
If there are no options for local wound cover, tissue can be
harvested from elsewhere in the body, a technique known as a
Henry CY Mak MBBS is a Trainee in Anaesthesiology at Queen Mary
Hospital, Hong Kong, China. Conflicts of interest: none.
Michael G Irwin MB ChB MD FCAI FRCA FANZCA FHKAM is Head of the
Department of Anaesthesiology of the University of Hong Kong, China.
Conflict of interests: none.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3
Learning objectives
After reading this article you should be able to:
C recognize the reconstructive ladder and the anaesthetic
implications
C describe the physiology of the microcirculation in free flap
surgery and factors which may affect it
C formulate strategies to improve flap survival in free flap surgery
by promoting blood flow
free flap transfer. Any tissue that can be isolated with a suitable
vascular pedicle can be used, and this may include skin, fascia,
fat, muscle, nerve, and bone. It offers the best functional and
cosmetic results, but it also bears a higher risk of flap failure.
Complications can arise due to primary ischaemia at the time of
surgery, reperfusion injury or impaired postoperative blood flow
causing secondary ischaemia.
Intraoperative and postoperative airway management can
also be a concern in reconstructive earenoseethroat and
maxillofacial surgery. In the presence of an upper airway lesion,
the anatomy could be distorted and increase the risk of a difficult
airway. An airway management plan should be formulated with
back-up plans in place. Often the plan may include awake
fibreoptic intubation or even elective tracheostomy. Likewise the
same attention to detail should be directed to extubation and the
possibility of elective postoperative ventilation, particularly in
the presence of oedema or intermaxillary fixation.1 This should
be well communicated with the patient and other members in the
operating team.
Preoperative assessment
Perioperative medical complications increase the economic costs
of microsurgery more than surgical complications. This high-
lights the importance of careful preoperative assessment, espe-
cially for free flap transfer, where the operating time can be
prolonged (e.g. >6 hours).
Both high American Society of Anesthesiologists (ASA)
grading and advanced Charlson grade have been reported as
predictors of postoperative medical complications. Age alone is
not an independent risk factor for postoperative medical or
The reconstructive ladder
9. Free flap transfer (e.g. latissimus dorsi myocutaneous flap)
8. Pedicled flap (e.g. pedicled transverse rectus abdominis
myocutaneous (TRAM) flap)
7. Random pattern flap
6. Tissue expansion
5. Full-thickness skin graft
4. Split-thickness skin graft
3. Delayed primary closure
2. Primary closure
1. Secondary intention
Box 1
136 Ó 2014 Elsevier Ltd. All rights reserved.
 RECONSTRUCTIVE SURGERY
surgical complications. However, medical co-morbidities are
more common in the elderly and tend to increase postoperative
medical but not surgical complications.2 Ischaemic heart dis-
ease and alcohol abuse have been reported as independent
predictors of overall complications following free tissue
transfer.
Diabetes mellitus affects a substantial percentage of the pop-
ulation and increases overall postoperative complications.
Although a large series of transverse rectus abdominis myocu-
taneous (TRAM) flap breast reconstructions showed no signifi-
cant difference in flap survival or complications between those
with or without diabetes mellitus,3 it is prudent to maintain
perioperative normoglycaemia.
Smoking, while not a significant risk factor for free flap fail-
ure,4 is associated with an increase in wound complications.
Three weeks of smoking cessation preoperatively is required to
reduce wound complication rates. Obesity is associated with
both increased medical and flap complications.
Physiology of blood flow to free flap
If the flow in a blood vessel is laminar, the flow can be predicted
by the HagenePoiseuille equation, which states that flow is
directly proportional to the pressure difference (DP), and the
fourth power of the radius (r), and is inversely proportional to
the length of the vessel (L) and the dynamic viscosity (m).
DPpr 4
Blood flow ¼
8mL
The systemic blood pressure is the main driving force for blood
flow through the flap, therefore the adapted mean arterial pressure
for the patient should be maintained. The vessel radius also has a
significant impact on the blood flow, and vasoconstriction should
be avoided. Hypovolaemia, hypocapnia, hypothermia and pain
can cause vasoconstriction and should be treated accordingly.
Hyperventilation resulting in respiratory alkalosis is associ-
ated with peripheral vasoconstriction, but hypoventilation
resulting in respiratory acidosis can also reduce erythrocytes
deformability and increase catecholamine release, which can
also cause vasoconstriction.
The use of vasopressors to treat hypotension is controversial,
and is generally unpopular among plastic surgeons. Animal
studies have shown that the use of vasopressors can lead to
vasoconstriction in the microcirculation of the free flap but
clinical studies show the use of vasopressor have no effect on
flap survival. One study showed that dobutamine and norepi-
nephrine both improve the flap skin blood flow with maximal
improvement with norepinephrine.5 Dobutamine may improve
blood flow by increasing cardiac output.
Blood viscosity is determined by the haematocrit, in which a
balance is struck between oxygen carrying capacity and blood
flow. The optimal haematocrit is thought to be about 30%. If
the haematocrit increases above 40%, viscosity increases
considerably in the microcirculation which offsets the
increased oxygen carrying capacity and increases the risk of
thrombosis. A recent study on the appropriate transfusion
trigger in free flap transfer surgery suggested that a lower
haematocrit of 25% in contrast to a trigger of 30% reduced the
ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3
number of patients requiring blood transfusion, while not
increasing the rate of postoperative complications.6 Thus the
haematocrit target could be as low as 25e30% but further
studies are required.
Perioperative management for free flap surgery (Table 1)
The perioperative care goal should be to improve free flap sur-
vival and prevent of complications. The exposed skin area can be
large as multiple surgical sites may be involved. This, com-
pounded with the loss of thermoregulation after induction, and
an increase in evaporative water loss from the surgical field, can
lead to the rapid development of hypothermia. The importance of
normothermia in promoting free flap blood flow mandates the
use of body temperature monitoring. Active warming device
such as forced air warming device and/or warming mattress
should be used, and the theatre temperature should be controlled
to reduce the temperature gradient for heat loss. Intravenous and
irrigation fluids should be pre-warmed.
Careful patient positioning and protection of pressure points is
mandatory. Endotracheal intubation is usually preferred for head
and neck procedures, although supraglottic airway devices can
also be used with controlled ventilation for body surface surgery.
Head and neck lesions can distort the airway anatomy and
fibreoptic intubation may be necessary. The nasal route may be
preferred if the presence of an oral tube is likely to obstruct
surgical assess. Reinforced endotracheal tubes are useful if pa-
tient positioning and draping may subject the tube to kinking.
Invasive arterial pressure monitoring can be useful due to the
importance of maintaining the perfusion pressure to the free flap,
and for checking the haematocrit and blood gas analysis. Central
venous assess may be necessary depending on patient’s cardio-
vascular status and the anticipated need for vasopressor and
inotropic support.
Cardiac output monitoring can be considered to help direct
intraoperative fluid management and vasoactive drug use. The
placement of oesophageal Doppler may not be practical in head
and neck surgery due to interference with the operating site. In
such cases, alternative non-invasive cardiac output monitoring
such as using pulse contour analysis is feasible.
Individual risk assessment venous thromboembolism (VTE)
prophylaxis should be undertaken according to the National
Institute for Health and Care Excellence (NICE) guidelines. Thigh
length anti-embolism stockings can be given upon admission to
hospital. Intermittent pneumatic compression is started once the
patient is positioned in the operation theatre. Pharmacological
therapy, subcutaneous low-molecular-weight heparin (LMWH)
prophylaxis can be used if the risk for major bleeding is low.
Evidence from a plastic surgery series showed LMWH signifi-
cantly reduced the rate of venous thromboembolism without a
significant increase in bleeding or haematoma formation versus
mechanical prophylaxis alone.
Volatile anaesthetics as sevoflurane and opioids may atten-
uate ischaemia-reperfusion injury which is hard to avoid
completely in free flap transfer. On the other hand, propofol has
antioxidant and free radical scavenging properties so there is not
enough evidence to support the use of any particular agent.
Metaraminol, phenylephrine and noradrenaline are common
first- and second-line choices to maintain the systemic arterial
137 Ó 2014 Elsevier Ltd. All rights reserved.
 RECONSTRUCTIVE SURGERY

Summary of anaesthetic intervention for free flap transfer surgery

Problem Anaesthetic intervention

Preoperative Assessment of medical conditions Blood pressure control and normoglycaemia.

Smoking cessation
Upon admission Venous thromboembolism (VTE) risk Consider VTE prophylaxis
assessment
Induction General anaesthesia causes peripheral Temperature monitoring
vasodilation, increases heat loss and causes Fluid replacement
relative intravascular hypovolaemia
Tissue resection Large surgical site, potential for heat and fluid Use of active warming device to maintain
loss normothermia
Flap harvest Flap in ischaemia while removed from its
original blood supply
Flap reperfusion Possible ischaemia-reperfusion injury, with Maintain an adequate blood pressure, may
release of vasoconstrictive substances use vasoconstrictor/inotropes if necessary
At risk for flap oedema due to lack of Reduce blood viscosity, target haematocrit
lymphatic supply 25e30%
Limit crystalloid fluid use
Emergence Cough and straining increase venous pressure Aim for smooth emergence
Recovery Hypothermia, shivering and pain can cause Ensure normothermia, good analgesia
vasoconstriction
Postoperative care Highest risk for flap failure within first 3 days Continue strategies to maintain good flap
perfusion and minimize flap oedema. Flap
monitoring to detect signs of flap failure

Table 1

pressure. However, no safe therapeutic range nor an ideal blood
pressure target has been established. Clinical judgement and
careful titration is necessary to avoid excessive vasoconstriction
which can be detrimental to flap survival. If an inotrope is
required, dobutamine may be the preferred option.
Upon emergence, coughing and retching can increase venous
pressure, compromising flap perfusion. The use of remifentanil
and dexmedetomidine can help smooth emergence as described
in other surgeries and their use is also likely to be beneficial in
free flap surgery.
Fluid therapy and free flap surgery
A free flap initially is devoid of lymphatic drainage, and thus is
highly susceptible to tissue oedema, which could predispose to
venous thrombosis and flap failure. In addition the free flap
capillary endothelium is likely damaged leading to increased
vascular permeability. High-volume crystalloid fluid adminis-
tration has been shown to be an independent risk factor for
increased flap oedema and thrombosis due to a pro-coagulant
effect.7 When crystalloids are administered rapidly, the mecha-
nism for increased coagulability may result from a dilutional
effect resulting in an imbalance between circulating pro- and
anti-coagulant factors. Therefore, crystalloids should be used
cautiously and limited to the replacement of preoperative deficits
and intraoperative insensible losses. This increased coagulability
is not seen with colloid solutions and, therefore, they are a better
choice when plasma volume expansion is required. Hydrox-
yethyl starch (HES) was the colloid of choice as it can decrease
blood viscosity and gives greater plasma expansion when
compared to gelatine based products. However in 2013 the
Pharmacovigilance Risk Assessment Committee (PRAC) of the
European Medicines Agency (EMA), the US FDA and the Cana-
dian authorities issued cautions on the use of HES in critically ill
patients and those with severe sepsis, renal and liver insuffi-
ciency. Further studies are now required to determine the safety
of HES solutions in comparison with other colloid solutions in
this subgroup of patients.
Postoperative care
The general principle of good postoperative care applies. These
include maintaining normothermia, normal blood pressure, a
haematocrit of 25e30%, satisfactory urine output, and good pain
control.
In particular, shivering should be avoided, as it can increase
myocardial oxygen consumption and can cause peripheral
vasoconstriction. External warming, pethidine, alpha-2 agonists
or sedation may be required to stop shivering.
Excellent analgesia is required to prevent the release of cate-
cholamines and the vasoconstrictor response to pain. This can be
achieved by continuous regional block infusion which also has
the advantage of sympathectomy, or by intravenous patient-
controlled analgesia.
Many anaesthetists keep patients with head and neck free
flaps sedated and ventilated post-operatively. This was thought
to protect the free flap and was also partly due to the extended
length of the procedures. However, studies have shown that
immediate postoperative extubation does not increase the inci-
dence of flap or wound-related complications, and may actually

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 138 Ó 2014 Elsevier Ltd. All rights reserved.
 RECONSTRUCTIVE SURGERY
increase postoperative pulmonary complications.8 Therefore,
early extubation should be considered if possible.
Postoperatively the patient may be managed in an intensive-
care or specialized high-dependency unit, with staff fully trained
in flap monitoring, in order to promptly detect a change in flap
status allowing re-exploration and salvage. Many units conduct
hourly clinical flap observation for 3 days. Some use adjuncts
such as hand-held Doppler or implantable Doppler ultrasonog-
raphy for assistance. Venous thrombosis is reported to be over
twice as common as arterial thrombosis in causing free flap
failure. Once a compromise of the flap has been suspected,
prompt re-exploration is the key to salvage. A 8 Petrar S, Bartlett C, Hart RD, MacDougall P. Pulmonary complications
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FURTHER READING
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Br Med J 2006; 332: 710e2.
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thetic practice for head and neck free tissue transfer e a UK national
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