Anaes · Plastics and burns anaesthesia
Free flap reconstruction: perfusion-focused anaesthesia
Also known as Free flap reconstruction: perfusion-focused anaesthesia · Microvascular free flap anaesthesia
Exam-exhaustive free-flap anaesthesia for ANZCA Final: flow determinants, normothermia and euvolaemia, vasopressor nuance, shared-airway head and neck flaps, flap observation, and urgent re-exploration pathways.
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Red flags
- Flap survival needs flow, not just MAP number.
- Normothermia and normovolaemia first.
- Avoid hyperventilation and excess viscosity extremes.
- Communicate anastomosis timing.
- Post-op flap checks are time-critical.
Meet the patient
A 58-year-old smoker with oral cancer is booked for resection and a free anterolateral thigh flap — a case that will run ten hours. The microsurgeon asks what mean arterial pressure you will run during the anastomosis. The fellowship answer is not a single number; it is a flow philosophy stated before induction — the goal-directed pilot defined hypotension events as five or more successive minutes with MAP below 65 mmHg.[6]
Microvascular free flaps fail from arterial thrombosis, venous congestion, kinking, haematoma, spasm, and systemic hypoperfusion — taught failure modes, with flap failure low at 3% overall but revision for microvascular compromise at 12% overall in the vasopressor systematic review. Anaesthesia is judged on flow-focused physiology, not a magic MAP number or a drug dogma — and a darkening, swollen flap at 02:00 is a call back to theatre, not a problem for the morning ward round.[4]
References6ShowHide
- [1]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial Lancet, 2008.PMID 18479744
- [2]Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation, 1999.PMID 10477528
- [3]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [4]Ehmidat M, Khalil I, Abuzant R, et al. Pure Alpha Versus Mixed Adrenergic Vasopressors Perioperative Outcomes in Autologous Free Flap Surgery: A Systematic Review and Meta-Analysis. Plast Surg (Oakv), 2026.PMID 42039877
- [5]Larcher Q, Mernier T, Feigna M, et al. Impact of Norepinephrine Use on Free Flap Survival in Breast Reconstructive Microsurgery. Microsurgery, 2025.PMID 39865374
- [6]Philteos J, McCluskey SA, Emerson S, et al. Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study. Health Sci Rep, 2024.PMID 38524770