Microsurgical reconstruction during the early puerperium

A transverse rectus abdominis musculocutaneous free flap was electively performed for reconstructing the cutaneous cover in a patient during the early puerperium (12 hr after delivery). This flap was chosen because of the natural expansion achieved by pregnancy, and because it would cover the entire area to be reconstructed. During surgery, considerable vasodilation and continuous bleeding were encountered, as well as severe spasm of the arteries and veins both in the flap pedicle and at the recipient site. This spasm eased when local papaverine was used, and blood flow was interrupted but recurred as soon as the artery or vein had contact with the patient's blood. The administration of systemic papaverine caused dilation of flap and recipient vessels, but also of uterine vessels, with severe hemorrhage. Under such circumstances, the systemic use of papaverine was interrupted and systemic oxytocin was administered, with subsequent decrease in tissue perfusion and necrosis of the transplanted flap.