Mythbusters in Microsurgery: Evaluating Evidence and Debunking Dogma-A Practical Review: Part II

The first part of this 2-part practical review critically appraised 8 common perioperative practices in reconstructive microsurgery, revealing that several were unsupported by evidence. This second part evaluated the remaining 9 frequently cited dogmas in microsurgical reconstruction.

A comprehensive review of all major databases was performed to identify studies addressing vein grafts, number and sequence of anastomoses, vasodilator selection, flap choice for osteomyelitis, vessel selection in trauma, caffeine use, postoperative mobilization, and showering with drains after surgery. Evidence was synthesized and graded using the GRADE system.

Vein-grafted free flaps demonstrated modestly higher failure rates, but overall high success, particularly when used in complex cases. Dual venous anastomoses provided benefit in high-risk or large flaps, whereas a single vein is sufficient in most limb reconstructions. No clear superiority exists for artery- versus vein-first anastomosis; both are effective if performed correctly. Papaverine is not indispensable, as other agents achieve comparable vasodilation. Muscle flaps are not inherently superior to fasciocutaneous flaps for osteomyelitis. Avoiding "zone of injury" vessels is unnecessary if intraoperative assessment shows good quality, and the use of tranexamic acid is safe as an adjunct to reduce bleeding. Moderate caffeine intake does not compromise flap outcomes, and early mobilization (including discharge) does not increase complications and supports enhanced recovery. Showering under running water 48 hours or more after surgery, with/without drains, does not increase the risk of surgical site infection.

Several dogmas in reconstructive microsurgery lack robust evidence. Adoption of flexible, evidence-based strategies can improve patient outcomes and streamline perioperative protocols.