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presenting for head and neck free flap surgery and breast reconstructive
surgery are fragile cancer patients with a number of dangerous co-morbidities
(5). Hence, pre-operative assessment and investigations play a role for the
risk stratification (6). Although technical issues are prevailing factors, clinical
characteristics also contribute to flap failure (7). The Division of Plastic
and Reconstructive Surgery, University of Southern California, Los Angeles, investigated
a number of non-technical variable in 2015, using the American College of
Surgeons’ National Surgical Quality Improvement Program (NSQIP) database. Univariate
analysis was performed to determine the association of free flap failure with
the following factors: age, gender, ethnicity, body mass index, intraoperative
transfusion, diabetes, smoking, alcohol, American Society of Anaesthesiologists
classification, year of operation, operative time, number of flaps, and type of
reconstruction. Flap loss rate was 4.4%. Operative time was the only
significant independent risk factor, as resulted from the multivariate logistic
regression (8). According the analysis conducted by another
plastic unit, patient’s age is not an independent variable for increased risk in
microvascular reconstruction. However, operative time and reconstruction sites
are associated with higher incidence of complications and ITU admissions (9). Another
important study, held in Toronto in 2016, recognized operative time and smoking
as the independent risk factors for intraoperative complications in
reconstructive breast flap surgery (10).  Several preoperative investigations play
a role in the risk assessment of these patients. Studies revealed how cardiopulmonary
exercise testing (CPET) in complex patients is pivotal to assess the functional
capacity. Many institutions routinely use CPET to design the operation and to
inform patients about risks and benefits of surgery (11). In conclusion, flap
ischemia is a multifactorial event and, according recent literature,
demographics and medical patient’s characteristics such as: age, ethnicity, radiation,
chemotherapy, medical comorbidities, smoking, are not independent risk factors
for surgical complications in microsurgery. Preoperatively, they need to be
assessed to ensure the best perioperative management but intraoperative management
and technical variables may have higher importance for the outcome (12).


Nutrition, preoperative
fasting and preoperative education

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recent evidences, the basic nutritional state should be estimated and optimised:
preoperative quantity of albumin has inverse correlation with wound dehiscence,
pleural effusion, salivary leak, suture removal, fistula (13).  Preoperative fasting should be minimal. In patients
eligible for oral intake, clear solids should be allowed up to 2 hours and
clear fluids up to 6 hours before anaesthesia. (14, 15).  All patients undergoing major head and
neck cancer surgery with free flap and breast reconstructive surgery should be
adequately prepared regarding the surgical journey and evidences suggest they
should receive a systematic teaching. If anaesthetists and qualified health
professionals should share this discussion, is still not clarified, due to
shortage of specifically focused trials (16). In conclusion, the
implementation of a multidisciplinary pre-operative evaluation driven by anaesthetists,
nutritionists, other medical specialists and health practitioners may reduce post-operative
complications deriving from pre-existing conditions (17).


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