Indications and contra-indications

Authors: Magnus Balslev Avnstorp MD, Ahmad Makki MD and Thomas Givskov Sørensen

Introduction

In this chapter you will learn about the indications and contra-indications for microsurgery, and importantly about the pre-operative planning for microsurgery.

Indications for using Microsurgery

Indications for tissue transfer using microsurgical techniques include the following:

• Need to cover exposed vital structures, such as joint surfaces, tendons, essential blood vessels, and bone denuded of periosteum (e.g. in open orthopedic bone traumas)
• Need to restore anatomic shape (e.g. the breast following mastectomy, other oncological surgical treatment or trauma)
• Need to restore function, (e.g. mimical muscles of the face)

Contraindications for using Microsurgery

• Severely ill patient or multiple comorbidities
• Severe psychiatric disease
• Current Smoker
• Current alcohol abuse
• Non-optimized patient with comorbidity such as cardiovascular disease, diabetes mellitus, Raynaud syndrome, scleroderma, collagen vascular diseases, severe non-treated chronic obstructive lung disease (COLD) or ongoing infection

Pre-operative Assessment and preparing of patient

Pre-operative planning:

• Decide your exact criteria needed of the microsurgical flap:
  • Need of a large caliber perforator vessel?
  • Need of large volume tissue transfer?
  • Need of a long perforator?
  • Does the patient have the tissue volume needed at donor site?
• Find the optimal donor site with lowest donor site morbidity
• Design the flap to maximize soft-tissue coverage, functionality and appearance
• Minimize complications on donor site and recipient site.
• Perform CT angiography in several cases preparing and choosing the perforator flap  – to select the best flap perforators
• In oncological cases, the timing of free flap reconstruction should be coordinated, so chemotherapy and radiation treatments do not collide with surgery and healing.
• Always have a plan B and plan C, in case the flap from plan A does not work

Pre-operative preparing/optimization of patient

• Optimizing by healthy and protein rich food intake
• Cessation of smoking at least 6 weeks before and after microsurgery
• Optimizing treatment of comorbidities (Diabetes, cardiovascular, COLD, etc), both pre-operative and post-operative care
• Normalization of electrolytes and hemoglobin
• Blood tests: Blood type, cross match, basic electrolytes
• Electrocardiography

Thrombosis prophylaxis

Prophylaxis against blood clotting must be performed in all Danish patients undergoing microsurgical anastomoses. Following guidelines are to be used:

Pre-operative: Daltesparin 2500 IE sub-cutaneous injection 1-2 hours before surgery

Post-operative: Daltesparin 2500 IE sub-cutaneous injection 12 hours after surgery

Hereafter: Daltesparin 5000 IE sub-cutaneous injection every evening (around 8-9 o’clock PM) for 4 weeks

Pre-operative information to patient

Like every other medical procedure an informed consent from the patient must be obtained. The information should minimally consist of the following:

• Risk of bleeding and re-operation with evacuation of hematoma
• Risk of infection
• Risk of tissue defects
• Risk of flap necrosis or total loss of flap
• Risk of suboptimal cosmetic result (especially for breast reconstruction)
• Further surgical revisions or fat grafting procedures may be required
• The microsurgical procedure may be long, with risk of affecting other organs