Indications and contra-indications
Authors: Magnus Balslev Avnstorp MD, Ahmad Makki MD and Thomas Givskov Sørensen
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
- 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
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