RECONSTRUCTIVE

Emerging Paradigms in Perioperative

Management for Microsurgical Free Tissue
Transfer: Review of the Literature and
Evidence-Based Guidelines
Saba Motakef, M.D.
Paschalia M. Mountziaris,
M.D., Ph.D.
Inzhili K. Ismail, M.D.
Richard L. Agag, M.D.
Ashit Patel, M.B.Ch.B.
Loma Linda, Calif.; and Albany, N.Y.
Background: Microsurgical free tissue transfer has become an increasingly
valuable technique in reconstructive surgery. However, there is a paucity of
evidence-based guidelines to direct management. A systematic review was per-
formed to define strategies to optimize perioperative management.
Methods: A systematic review of the literature was performed using key search
terms. Strategies to guide patient management were identified, classified
according to level of evidence, and used to devise recommendations in seven
categories: patient temperature, anesthesia, fluid administration/blood trans-
fusion, vasodilators, vasopressors, and anticoagulation.
Results: A total of 106 articles were selected and reviewed. High-level evidence
was identified to guide practices in several key areas, including patient temper-
ature, fluid management, vasopressor use, anticoagulation, and analgesic use.
Conclusions: Current practices remain exceedingly diverse. Key strategies to
improve patient outcomes can be defined from the available literature. Key
evidence-based guidelines included that normothermia should be maintained
perioperatively to improve outcomes (level of evidence 2b), and volume
replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level
of evidence 2b). Vasopressors do not harm outcomes and may improve flap
flow (level of evidence 1b), with most evidence supporting the use of nor-
epinephrine over other vasopressors (level of evidence 1b). Dextran should
be avoided (level of evidence 1b), and pump systems for local anesthetic
infusion are beneficial following free flap breast reconstruction (level of evi-
dence 1b). Further prospective studies will improve the quality of available
evidence. (Plast. Reconstr. Surg. 135: 290, 2015.)

F
ree tissue transfer has become an indispensable
technique in plastic surgery. The methods nec-
essary for free tissue transfer were not developed
until 1960, when Jacobsen and Suarez described
the anastomosis of blood vessels using an operat-
ing microscope in an animal model. The first free
tissue transfer was subsequently performed in 1972,
when McLean and Buncke1 used a free omental flap
From the Department of Plastic Surgery, Loma Linda Uni-
versity Medical Center; and the Department of Surgery, Di-
vision of Plastic Surgery, Albany Medical Center.
Received for publication May 9, 2014; accepted June 16, 2014.
Presented at the 2014 Annual Meeting of the American So-
ciety for Reconstructive Microsurgery, in Kauai, Hawaii,
January 11 through 14, 2014.
The LOE grades in this article were provided by the authors,
not by the American Society of Plastic Surgeons.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000839
to reconstruct a scalp defect. Early flap failure rates
approached 40 to 50 percent,2 but advances over
time have resulted in success rates of 90 to 99 per-
cent.3–9 Although rare, total flap failure and even par-
tial flap loss can have devastating consequences.
A number of modifiable factors in the peri-
operative period have the potential to influence
outcomes in free tissue transfer. To date, there has
been a paucity of reliable evidence to guide peri-
operative management, resulting in a variety of
practices implemented by microsurgeons that are
often not entirely evidence-based. This motivated
the authors to identify the best available evidence
to improve outcomes and minimize complications
Disclosure: The authors have no financial inter-
est or commercial association with any of the sub-
ject matter or products mentioned in this article.

290 www.PRSJournal.com
Volume 135, Number 1 • Perioperative Management for Free Flaps
and to establish evidence-based guidelines to direct
perioperative management for free tissue transfer.
METHODS
A systematic literature review of the PubMed
database was performed using the following
search algorithm: ((free tissue transfer) OR (free
flap) OR (microsurgery)) AND ((perioperative
management) OR (anesthesia) OR (tempera-
ture) OR (fluids) OR (vasodilator) OR (vaso-
pressor) OR (anticoagulation) OR (analgesia)).
Article selection was limited to English language
articles between May of 1953 and March of 2014.
Additional articles were identified after manual
review of the reference sections of initially iden-
tified articles. The search returned 2794 articles.
Article titles and abstracts were reviewed to iden-
tify articles that addressed factors influencing
flap outcomes, flap complications, and medical
complications. A total of 106 pertinent articles
were selected after applying the inclusion crite-
ria described above. These were scrutinized in
their entirety and graded according to level of evi-
dence10 to define strategies that could guide peri-
operative management (Table 1).11–44
RESULTS
Patient Temperature
Conflicting data exist regarding intraopera-
tive temperature control. A recent study in a rat
model associated hypothermia with higher free
flap survival rates.45 In a retrospective cohort study,
analysis of data from 212 patients correlated mild
hypothermia (36.0° to 36.4°C) with lower rates
of flap thrombosis.46 However, hypothermia has
been associated with perioperative complications
in the majority of studies.11,12,47 In an animal study,
intraoperative hypothermia reduced flap flow and
postocclusive hyperemia.47 Intraoperative hypo-
thermia (minimum core temperature, <35°C) has
also been correlated with perioperative compli-
cations in patients.12 A retrospective study of 156
free flaps correlated intraoperative hypothermia
(average core temperature, <37°C; minimum core
temperature, <34.5°C) with recipient-site infec-
tions, although no difference was noted in flap
thrombosis or failure rate.11
Anesthetic Agents
Various anesthetic strategies have been
described, with most studies focusing on
sevoflurane. Studies have demonstrated that
sevoflurane protects the endothelium from
ischemia-reperfusion injury13–16,18 and primes
human endothelial cell progenitors, promoting
vascular healing.17 In addition, compared with
propofol, administration of sevoflurane results
in a lower capillary filtration coefficient.18
The role of epidural anesthesia combined with
general anesthesia has been evaluated with con-
flicting results. Supplemental epidural anesthesia
reduces cardiac output and mean arterial pressure,
which has been reported to reduce microcircula-
tory blood flow.48,49 However, other studies suggest
that this combined approach is beneficial compared
with general anesthesia alone.19,50,51 In a retrospec-
tive review of lower extremity free flaps, epidural
supplementation of general anesthesia correlated
with a lower rate of microvascular complications
and improved flap survival and overall outcomes.51
Free flap operations under epidural anesthesia
alone have been reported in cases where general
anesthesia was contraindicated.52,53 Several clini-
cal studies have also demonstrated that peripheral
nerve blocks reduce vasospasm and improve perfu-
sion of replanted or revascularized digits.20,21,54,55
Fluid Administration
Existing data correlate high volumes of peri-
operative crystalloid administration with medical
and flap complications.22–24,56–58 In a retrospective
study of 104 free transverse rectus abdominis myo-
cutaneous (TRAM) flaps, patients requiring flap
revision because of anastomotic thrombosis had
received significantly higher fluid volumes during
the original operation.57 High volumes of crystal-
loid administration, either greater than 130 ml/
kg per day or greater than 7 liters during surgery,
have been associated with major medical and flap
complications.22,24 A retrospective review of 354
breast reconstructions indicated that crystalloid
infusion rate is a significant independent predic-
tor of complications.23 The ideal range of crystal-
loid infusion rate in the 24-hour perioperative
period was defined as 3.5 to 6.0 ml/kg per hour.
Few studies have examined the role of colloids
to replace intraoperative blood loss. In a prospec-
tive, randomized trial comparing 10% hydroxy-
ethyl starch 264/0.45 to 5% albumin in head and
neck reconstruction, hydroxyethyl starch infu-
sions greater than 30 ml/kg per day or greater
than 2 liters overall significantly impaired coagu-
lation.59 Existing data do not support the use of
albumin over synthetic colloids.60
Blood Transfusion
Preoperative hemoglobin values below 11 g/
dl are associated with an increased length of stay
291
 Plastic and Reconstructive Surgery • January 2015

Table 1.  Evidence-Based Recommendations for Perioperative Management for Free Tissue Transfer
Factor LOE Recommendation
Temperature 2b Maintain average temperature >37°C
Minimum core body temperature <34.5°C and average core body temperature <37.0°C each associated
with increased risk of flap infection11
2b Maintain core body temperature >35°C at all times
Core body temperature <35°C at any point during surgery associated with early perioperative complications12
Anesthesia 3b Ideal anesthetic agent unclear; consider sevoflurane
Sevoflurane may have protective effects on the endothelium in the context of ischemia-reperfusion
injury13–16 and may promote vascular healing17
Sevoflurane superior to propofol with regard to its effects on the capillary filtration coefficient18
2b Use supplemental epidural anesthesia for lower extremity free tissue transfer
Epidural supplementation of general anesthesia correlated with improved flap survival and lower rate
of microvascular complications compared with general anesthesia alone19
1b Implement sympathetic blockade for microsurgery involving the digits
Axillary brachial plexus blockade correlated with increased perfusion in replanted digits20,21
Fluids 2b Maintain crystalloid administration between 3.5– and 6 ml/kg/hr in the 24-hr perioperative period
Crystalloid administration >130 ml/kg/day (>5.4 ml/kg/hr) associated with increased major medical
complications22
Extremes of crystalloid infusion associated with increased complications23
2b Crystalloid administration should not exceed 7 liters intraoperatively
Administration of >7 liters of crystalloid during surgery associated with major medical complications and
flap complications24
2b Consider hemoglobin/hematocrit during patient selection
Significantly increased risk for flap failure with hematocrit <30%, hemoglobin <10 g/dl25
2b Restrict blood transfusions to patients with hemoglobin <7 g/dl or who are clinically symptomatic
Intraoperative blood transfusion associated with length of surgery, intraoperative arterial thrombosis,
major surgical/medical complications26
Increased risk for cancer recurrence and increased mortality in patients with oral/oropharyngeal
squamous cell carcinoma receiving 3 or more units of blood perioperatively27
Vasodilators 4 Consider topical, low-dose lidocaine to treat persistent vasospasm
Application of 4% topical lidocaine during and after surgery improved blood flow in patients
with persistent vasospasm28
Vasopressors 2b Use vasopressors when indicated for hypotension; they do not significantly increase flap failure
or complication rates
Vasopressor administration did not affect the rates of reoperation, complete flap loss, partial flap loss,
or fat necrosis in microsurgical breast reconstruction29
Vasopressor administration did not affect flap failure rate or complications in head and neck reconstruction30,31
Vasopressor administration did not affect flap failure rate or complications in upper and lower extremity
reconstruction32
Cumulative dosage and timing of vasopressor administration are not correlated with adverse outcomes29,33
1b Consider norepinephrine and dobutamine for hypotension following free tissue transfer
In a comparison of norepinephrine, dobutamine, epinephrine, and dopexamine administered following
free tissue transfer, free flap skin blood flow increased in a dose-dependent manner with norepineph-
rine and dobutamine, with maximal improvements occurring with norepinephrine; dopexamine and
epinephrine decreased flap blood flow34,35
Dobutamine significantly improved both mean and maximum blood flow through the arterial anastomosis
in patients during head and neck reconstructive surgery36
Although dobutamine and dopamine both significantly increased cardiac output and mean arterial
pressure, dobutamine improved flap blood flow during microvascular TRAM flap procedures37
Anticoagulation 2b Administer aspirin or subcutaneous low-molecular-weight heparin for antithrombotic prophylaxis
No statistically significant difference in the incidence of complications (e.g., bleeding and
thromboembolism, with either aspirin or low-molecular-weight heparin prophylaxis
following oncologic free flap reconstruction)38
Intraoperative, systemic heparin had no effect on the incidence of complications, including microvascular
thrombosis39
1b Dextran should not be used for antithrombotic prophylaxis in head and neck free tissue transfer
Significantly increased incidence of systemic complications with dextran compared with aspirin following
head and neck free flap reconstruction40
Significantly increased flap failure rate in high-risk patients with diabetes mellitus or hypertension
compared with no antithrombotic prophylaxis following head and neck free tissue transfer41
Analgesia 1b Consider continuous local anesthetic infusion by means of pump system for donor-site pain management
following free flap breast reconstruction
Reduced patient-controlled analgesia use, earlier transition to oral narcotics, and better overall pain sat-
isfaction scores with continuous local anesthetic infusion compared with controls following free TRAM
flap breast reconstruction42
4 Consider preoperative gabapentin to reduce postoperative pain and nausea
A single, preoperative dose of gabapentin significantly reduced postoperative pain and nausea,
and analgesic and antiemetic use43
2b Consider ketorolac* for analgesia following lower extremity free flap reconstruction; reduces thrombotic
complications
LOE, level of evidence.
*Ketorolac is associated with lower rates of microvascular complications following lower extremity reconstruction.44

292
Volume 135, Number 1 • Perioperative Management for Free Flaps
and poor flap outcomes in patients.22 Preopera-
tive hemoglobin values below 10 g/dl are a sig-
nificant predictor of flap failure and thrombosis.25
A recent retrospective review demonstrated
that intraoperative blood transfusion was associ-
ated with higher rates of overall complications,
medical complications, postoperative transfu-
sion, and reoperation.61 In addition, periopera-
tive blood transfusions have a well-documented
association with increased morbidity and mortal-
ity, including head and neck cancer recurrence,
in free flap reconstruction.26,27,62–69 Other studies
have suggested a link between blood transfusions
and wound infections.69,70 This association may be
caused by an immunomodulatory effect of blood
transfusions.71 Transfusion of leukocyte-depleted
packed red blood cells has been attempted, but
this has also been associated with postoperative
morbidity.68 Data suggest that autologous blood
transfusions may be associated with a lower rate of
cancer recurrence in the context of head and neck
cancer surgery.72 However, studies in the context
of breast reconstruction have not demonstrated
any benefit with the use of autologous blood.73,74 A
restrictive transfusion strategy for clinically symp-
tomatic patients or those with a hemoglobin value
less than 7 g/dl is recommended.26
Vasodilators
Numerous vasodilators have shown favorable
effects on flap flow in animal models, including
calcium channel blockers, magnesium sulfate,
sildenafil, ethyl nitrate, botulinum toxin, nitro-
glycerin, prostacyclin analogues, papaverine, and
nicardipine.75–84 However, clinical data remain
limited. In a double-blind, randomized, con-
trolled trial, systemic milrinone did not improve
flap outcomes.85 In clinical studies of nitroglyc-
erin, a single topical application had no effect
compared with controls,86 whereas topical spray
for 1 week postoperatively may have improved
free flap survival in a recent case study.87 Nitro-
glycerin combined with nicardipine has been
shown to reduce vasospasm and improve blood
flow in the context of coronary artery bypass
graft surgery.88,89 In contrast to animal studies,
where 2% lidocaine potentiated vasospasm84 and
20% lidocaine was an effective spasmolytic,90
application of 4% topical lidocaine improved
flap flow in patients with persistent vasospasm.28
Data on topical papaverine are limited; however,
animal studies have demonstrated improved flow
with the administration of topical papaverine
(30 mg/ml) alone or in combination with lido-
caine (2% or 20%).90
Vasopressors
A conservative approach to vasopressors has
been used in clinical studies to balance the risk
of vasoconstriction with the potential benefit of
increased mean arterial pressure and subsequent
improved perfusion pressure across the free
flap.29–31,33,73 Animal studies have demonstrated an
attenuated response to norepinephrine and phen-
ylephrine following surgical sympathectomy.91
Following vasopressor administration, cutaneous
microcirculation actually increased in an amount
proportional to the change in mean arterial pres-
sure in postsympathectomy tissue, whereas flow
in normal tissue was reduced. When the effects
of phenylephrine, dopamine, and dobutamine
were compared in a swine musculocutaneous flap
model, phenylephrine reduced cardiac output
and flap flow.92 Although dopamine and dobuta-
mine increased cardiac output, only dobutamine
increased flap flow. When the effects of nitroprus-
side and phenylephrine on flap flow were evalu-
ated in a porcine model, systemic phenylephrine
caused a 30 percent increase in mean arterial
pressure, whereas heart rate, cardiac output, and
flap flow were unaffected.93
Interestingly, in several clinical studies, intra-
operative vasopressor administration affected
neither the incidence of flap loss nor the rate of
reoperation.29–33 Cumulative dosage and timing
of vasopressor administration showed no correla-
tion with adverse outcomes.29,33 Dobutamine has
been shown to significantly improve flap flow.36,37
Prospective studies comparing epinephrine,
norepinephrine, dobutamine, and dopexamine
postoperatively demonstrated that both dobu-
tamine and norepinephrine improved free flap
skin blood flow, with norepinephrine yielding
the greatest improvement.34,35 In contrast, dopex-
amine and epinephrine decreased flap flow.34
Anticoagulation
The most commonly used regimens to prevent
anastomotic thrombosis include dextran, aspirin,
and heparin. In a prospective, randomized trial,
dextran had no effect on flap survival but signifi-
cantly increased the incidence of systemic compli-
cations compared with aspirin.40 In a retrospective
review of 1351 free flaps, dextran did not affect
flap survival compared with no antithrombotic
prophylaxis, but did significantly increase the rate
of flap failure in high-risk patients.41
Both systemic and topical antithrombotic
prophylaxis with heparin has been described.
Although animal studies of topical heparin have
293
 Plastic and Reconstructive Surgery • January 2015
demonstrated benefit,94–96 a large prospective clin-
ical study concluded that topical irrigation had no
effect on flap outcomes.6 Similarly, intraoperative,
systemic heparin had no effect on the incidence
of complications, including microvascular throm-
bosis.39 However, postoperative subcutaneous
heparin has been shown to significantly decrease
the incidence of microvascular thrombosis.6
With the exception of dextran, clinical studies
comparing various anticoagulation regimens have
shown equivalent reductions in the incidence of
complications, including anastomotic thrombo-
sis and flap loss.38,97–100 A blinded, randomized,
phase II trial of intraluminal irrigation with either
human tissue factor pathway inhibitor or heparin
indicated equivalent efficacy in preventing throm-
botic complications.101 A retrospective review of
combination prophylaxis with subcutaneous hep-
arin and aspirin indicated that the rates of compli-
cations, including hematoma formation and free
flap failure, were equivalent to published data
using other anticoagulation regimens.38
Analgesia
Several analgesic agents have shown benefit in
free tissue transfer. A recent clinical study demon-
strated significantly reduced postoperative anal-
gesic and antiemetic use in patients receiving a
single preoperative dose of gabapentin.43 Another
study suggested that ketorolac reduces thrombotic
complications in lower extremity free flaps.44 In
a prospective, randomized, double-blind trial of
free TRAM flap breast reconstruction patients, a
continuous infusion pump system delivering bupi-
vacaine resulted in significantly reduced patient-
controlled analgesia narcotic use, an earlier
transition to oral narcotics, and improved overall
pain scores.42 Similarly, donor-site nerve block with
bupivacaine following abdominal free flap breast
reconstruction also reduced postoperative patient-
controlled analgesia narcotic use.102 A recent retro-
spective cohort study noted a significantly shorter
length of stay, lower narcotic use, and fewer epi-
sodes of perioperative nausea and vomiting for
patients receiving a transverse abdominis plane
block following free flap breast reconstruction.103
DISCUSSION
Of the numerous modifiable factors in the
perioperative period, we identified seven for which
sufficient evidence exists to generate guidelines
for free tissue transfer. Patient core temperature
should be carefully controlled in the periop-
erative period because of a correlation between
294
hypothermia and complications. Patients are
widely exposed for prolonged periods during sur-
gery, predisposing them to hypothermia. In addi-
tion, anesthesia can disrupt thermoregulation.
Patient temperature should thus be monitored
closely. If preventative measures are not in place,
hypothermia may occur in as many as 50 to 90 per-
cent of surgical patients.104 We recommend main-
taining core body temperature above 35°C at all
times (level of evidence 2b) (Table 1) and main-
taining average temperature above 37°C during
free tissue transfer (level of evidence 2b) (Table 1).
Ambient room temperature should be maintained
at approximately 24°C105 before patients are in the
operating room, and other preventative efforts
should be made to avoid hypothermia. One pro-
tocol suggests warming patients before induction,
during surgery, and for 24 to 48 hours afterward
and aiming for a less than 2°C difference between
core and peripheral temperature.106
Balanced general anesthesia is optimal during
lengthy free flap procedures.106 The available data
favor sevoflurane. It exerts protective effects on the
endothelium13–15 and reduces the capillary filtration
coefficient,18 which can reduce flap edema. Admin-
istration of sevoflurane is thus suggested (level of
evidence 3b) (Table 1). Data remain limited, and it
remains unclear to what degree outcomes may be
modified by choice of anesthesia. However, high-
level evidence supports the use of supplemental
regional anesthesia for lower extremity free flaps
(level of evidence 2b) (Table 1) and digit replanta-
tion (level of evidence 1b) (Table 1).19–21,50,51,54,55
A potential complication that may arise during
a free flap operation is microvascular thrombosis,
prompting the use of systemic anticoagulation.
Should this occur with an epidural catheter in
place, this may cause concerns regarding removal
of the catheter postoperatively, or until antico-
agulation is discontinued. To avoid this dilemma,
consideration should be given to using single-
bolus epidurals, with removal of the catheter.
Alternatively, liposomal bupivacaine (Exparel;
Pacira Pharmaceuticals, Parsippany, N.J.) may be
used. This agent provides up to 72 hours of nerve
blockade with a single injection so that the place-
ment of a catheter is not required.
Fluid administration and blood transfusion
are important areas where patient care may be
optimized. Optimal fluid management ensures
proper blood flow and oxygen delivery to the
free flap, reducing perioperative complications.
Although true blood loss during free tissue trans-
fer may be low, prolonged exposure at multiple
surgical sites contributes to substantial insensible
Volume 135, Number 1 • Perioperative Management for Free Flaps
losses. Patients should receive crystalloid solution
to replace preoperative deficits and insensible
losses, colloid for intraoperative blood losses, and
blood to maintain hematocrit.70 Fluid should be
administered to maintain normovolemia.105
A judicious approach to crystalloid adminis-
tration is recommended because data correlate
high volumes of perioperative crystalloid adminis-
tration with medical and flap complications. The
ideal range of crystalloid infusion in the 24-hour
perioperative period is proposed as 3.5 to 6 ml/kg
per hour (level of evidence 2b) (Table 1).23 Crys-
talloid administration should not exceed 7 liters
intraoperatively or 130 ml/kg per day (level of
evidence 2b) (Table 1).22,24 Fluid resuscitation vol-
ume should be guided primarily by the patient’s
clinical parameters, such as blood pressure, heart
rate, and urine output. Surgical blood loss and
insensible losses are also important consider-
ations. In the setting of adequate tissue perfusion,
fluid volume and rate of infusion should fall close
to this range. Because existing data do not sup-
port the use of albumin over synthetic colloids,60
no recommendations on this subject are made.
Hemoglobin and hematocrit should be opti-
mized before surgery (hematocrit >30 percent,
hemoglobin >10 g/dl) (level of evidence 2b)
(Table 1).22,25 Blood transfusions should be per-
formed intraoperatively to maintain hemoglobin
and hematocrit at appropriate levels for adequate
tissue oxygen delivery and perfusion.107–109 How-
ever, because of their association with flap com-
plications, blood transfusions in patients are to be
performed with caution. We thus recommend a
restrictive transfusion strategy for clinically symp-
tomatic patients or those with hemoglobin level
less than 7 g/dl (level of evidence 2b) (Table 1).26
The use of vasodilators and vasopressors
remains an especially controversial area of patient
management. Data regarding the use of vasodila-
tors is limited. Existing clinical data exist only for
intraoperative and postoperative use of topical
lidocaine. This is only level 4 evidence, so further
research is needed. Because of the limited data
available, we recommend papaverine or 4% or
20% topical lidocaine for the treatment of persis-
tent vasospasm (level of evidence 4) (Table 1).
Available studies that have evaluated vasopres-
sor use intraoperatively have not noted an impact
on flap outcomes. However, only two studies
have evaluated the specific timing of vasopressor
administration. Because these were retrospective
studies, data on how this affected the technical
difficulty of the dissection are not available. Thus,
the impact of vasopressor use before division of
the free flap remains unclear. Administration of
vasopressors before division of the free flap may
impact the size of the flap perforator and thus the
technical difficulty of the dissection. Until this is
elucidated, we recommend avoidance of vasopres-
sors during dissection of the perforator unless the
clinical situation requires it. We conclude that
vasopressors administered following flap division
do not impact flap outcomes (level of evidence
2b) (Table 1). After division of the flap, if a vaso-
pressor is needed, it should be tailored to the
patient’s clinical picture. However, epinephrine
and dopexamine should be avoided (level of evi-
dence 1b) (Table 1).
Despite widespread reservations regarding
vasopressor use, these data suggest that vasopres-
sors may be preferable to fluids to maintain blood
pressure and flap flow.73 However, in a recent survey
of anesthesiologists, 25 percent preferred crystal-
loid solution as first-line blood pressure manage-
ment, 39 percent preferred colloid as first line,
and 46 percent reported a positive balance of 2 to
5 liters as acceptable.74 Norepinephrine was con-
sidered contraindicated by 46 percent of respon-
dents.74 In a 2012 survey that included members of
the American Society for Reconstructive Microsur-
gery and the American Society of Plastic Surgeons,
fluid administration was the treatment of choice
for hypotension (94.5 percent).110
Data regarding anticoagulation regimens
remain inconclusive. We thus recommend either
aspirin 325 mg orally every day or heparin 5000
IU subcutaneously every day for antithrombotic
prophylaxis (level of evidence 2b) (Table 1).97 No
evidence currently suggests that systemic heparin
is beneficial in the context of free flap surgery
(level of evidence 2b) (Table 1). Because of strong
evidence linking dextran to flap and systemic
complications, we advise against the use of dex-
tran for thromboprophylaxis (level of evidence
1b) (Table 1).40
Our review revealed compelling evidence
for local anesthetics administered by means of a
pump system following free flap breast reconstruc-
tion, and for ketorolac following lower extrem-
ity reconstruction. To our knowledge, neither of
these emerging findings has been incorporated
into common practice. Improving pain manage-
ment protocols based on existing evidence has the
added benefit of improving outcomes by reduc-
ing circulating catecholamines that may, at least in
theory, potentiate vasospasm and vasoconstriction.
Consideration should be given to using continu-
ous infusion pump systems to deliver local anes-
thetics following free flap breast reconstruction
295
 Plastic and Reconstructive Surgery • January 2015
(level of evidence 1b) (Table 1). Consideration
should also be given to preoperative administra-
tion of gabapentin and ketorolac administration
following lower extremity free flap reconstruction
(level of evidence 1b) (Table 1).
A limitation of this work is the relative lack
of prospective randomized trials, suggesting that
further key factors may be identified as more
evidence emerges. Because of the complexity of
these procedures, existing prospective studies
remain small. Because flap failure and complica-
tion rates are so low, larger studies are needed to
achieve the statistical power necessary to tease out
practices that may improve patient care.
CONCLUSIONS
Free tissue transfer has become an increas-
ingly important tool in plastic and reconstructive
surgery. Over the years, meticulous refinements in
techniques, protocols, and instrumentation have
contributed to greatly improved success rates.
However, there remains a relative lack of prospec-
tive studies on which to base recommendations.
In this work, we reviewed the literature to identify
key perioperative parameters and establish evi-
dence-based guidelines. The insights gained from
this work have the potential to improve current
practice and guide future prospective studies of
strategies to further improve free flap outcomes.
Ashit Patel, M.B.Ch.B.
Division of Plastic Surgery
Albany Medical Center
50 New Scotland Avenue, MC-190
Albany, N.Y. 12208
patela6@mail.amc.edu
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