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Mythbusters in Microsurgery: Evaluating Evidence and Debunking Dogma-A Practical Review: Part I
Abdulaziz Elemosho1, Hamid Malekzadeh1, Jude C Kluemper1
1From the Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
Background:
Reconstructive microsurgery has become a cornerstone in the management of complex tissue defects, yet many perioperative practices remain rooted in tradition rather than robust evidence. Persistent complications and variable protocols necessitate systematic evaluation of these dogmas to guide best practices.
Methods:
We conducted a comprehensive literature review of all major databases to identify all studies addressing techniques, perioperative care, monitoring, patient selection, and recovery in reconstructive microsurgery. Relevant studies were assessed and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. When available, meta-analyses and updated systematic reviews were prioritized; individual studies within such analyses were not separately reported to avoid redundancy.
Results:
Eight commonly held perioperative myths were critically appraised. Evidence demonstrates that judicious intraoperative vasopressor use does not increase flap compromise or loss. Perioperative nonsteroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, do not raise the risk of hematoma or thrombosis. Routine therapeutic anticoagulation or dextran use provides no benefit in flap survival and increases bleeding risk. High-dose perioperative steroids are associated with greater flap and wound complications. Extended antibiotic prophylaxis beyond 24 hours postoperatively does not reduce surgical site infections. Negative-pressure wound therapy is safe for free flaps. Most vascular compromises occur within 48-72 hours, supporting step-down monitoring thereafter. Finally, advanced age, diabetes, obesity, or immunosuppression due to solid organ transplantation or other reasons should not preclude patients from getting microsurgical reconstruction.
Conclusions:
Many entrenched perioperative practices in microsurgery lack contemporary evidence. Evidence-based adoption of updated protocols can minimize complications, standardize care, and improve outcomes in reconstructive microsurgery.
Insights
Many reconstructive microsurgery practices lack evidence. This review debunks myths, showing updated protocols like avoiding routine anticoagulation and limiting steroid use improve patient outcomes and reduce complications.
Area of Science:
- Microsurgery
- Evidence-based medicine
- Surgical outcomes
Background:
- Reconstructive microsurgery is vital for complex defects.
- Many perioperative practices lack robust evidence.
- Complications and variable protocols necessitate re-evaluation.
Purpose of the Study:
- Critically appraise common perioperative myths in reconstructive microsurgery.
- Identify evidence-based practices to improve patient outcomes.
- Guide best practices in microsurgical care.
Main Methods:
- Comprehensive literature review of major databases.
- Studies assessed and graded using the GRADE system.
- Prioritized meta-analyses and systematic reviews.
Main Results:
- Intraoperative vasopressor use is safe.
- NSAIDs do not increase hematoma or thrombosis risk.
- Routine anticoagulation/dextran offers no benefit and increases bleeding.
- High-dose steroids increase complications.
- Extended antibiotics beyond 24 hours do not reduce infections.
- Negative-pressure wound therapy is safe for free flaps.
- Vascular compromises typically occur within 48-72 hours.
- Advanced age and comorbidities do not preclude reconstruction.
Conclusions:
- Many perioperative microsurgery practices lack current evidence.
- Adopting updated, evidence-based protocols minimizes complications.
- Standardizing care improves reconstructive microsurgery outcomes.
