Fluid overload & anastomosis failure Introduction Free‐tissue transfer has become the standard treatment for autologous breast reconstruction. In breast reconstruction, postoperative complications and the final aesthetic outcomes place a significant emotional burden on the patient. Anatomical and clinical studies have increased the physiological knowledge of flaps used in breast reconstruction. However, although overall free flap success rates are above 95%, thrombosis of the arterial or venous anastomosis is still a dramatic complication, which may lead to flap loss. In contrast to the increased knowledge on flap design, little is known about the anesthetic and perioperative management, which may have an effect on the outcome of microvascular surgery. In 1985, Macdonald proposed that it is important to maintain adequate arterial pressure and cardiac output. It is generally accepted that good perfusion pressure is essential to flap survival.1,2 In addition to general anesthesia, intravenous fluid is administered during surgery. Anesthesiologists attempt to restore vascular volume based not only on clinical signs such as heart rate, arterial blood pressure and urine output but also on calculations of maintenance, third‐space losses and blood loss. It is common practice to use generous amounts of fluid resuscitation since it is believed that modest hypervolaemia reduces the sympathetic tone and therefore dilates the supplying vessels to the flap. In addition, a mild increase in central venous pressure will increase the cardiac output. On the other hand, restricted fluid administration has shown to improve outcome after major surgery.3 The excessive use of fluid therapy may therefore increase the complication rate in reconstructive surgery. The reason for this retrospective study was to analyze perioperative fluid therapy, its effect on hemodynamic parameters and its effect on the outcome of the free‐tissue transfer. Patients and methods One hundred and eight patients were included in this retrospective study. All surgical interventions were performed by experienced plastic surgeons. During the period of this study, the muscle sparing free transverse rectus abdominis myocutaneous (TRAM) flap technique was used for the reconstruction. In this surgical procedure, a small medial part of the rectus abdominis is harvested along with several lateral and medial perforating vessels of the deep inferior epigastric artery. After complete dissection, the flap is divided into four perfusion zones as previously reported.4 All four zones were included in the flap, and the end‐to‐end anastomosis was performed using the internal mammary artery. All patients eligible for breast reconstruction with the muscle sparing free TRAM flap were included in the study regardless of relative risk factors such as smoking, obesity, 27
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