By L. Scott Levin, MD, FACS

“Preparation is the only shortcut you need.” This is a direct quote from Robert Acland MBBS – a legend, innovator, anatomist, and my dear friend. These words regarding elective microsurgery rang true in 1988–first heard during my fellowship at the Kleinert Kutz Clinic and remain true today. The concepts and details of planning free tissue transfer is an exercise that takes place in other surgical disciplines such as the “pre-operative planning” for joint replacement, osteosynthesis in trauma, and corrective osteotomies.  A few words about free tissue transfer in the upper extremity. While the surgery can be challenging, and requires many steps–all of which must be executed perfectly–awareness of pitfalls can help avoid disasters.

1. Your training dictates your comfort level. It is not a good idea to go to the operating room having never performed a flap that you have selected for the patient. Cadaveric rehearsal is mandatory and working with someone who has experience with the flap is a good way to start.
2. Informed consent is important. Tell patients about failure, the need for takeback, emergent exploration and the need to perform another flap if the first one fails! I say to patients in the clinic: “what I tell you up front is informed consent…….what I tell you after the fact…..is an excuse” “I don’t like to make excuses”. This mantra was taught to me by J. Leonard Goldner, MD.
3. Determine patient position, vessel choices, and monitoring of the flap before the patient is even scheduled for the OR.  Do not figure these things out during anesthesia induction. I wake up in the morning of the case, knowing these variables. Have a primary plan and a secondary plan in mind.

4. Who is helping you? Residents, fellows, partners, surgical technicians, or physician assistants?. Who is doing what part of the case?  Is flap harvest and recipient preparation simultaneous or consecutive? Who is identifying recipient vessels? The vessel preparation is often the most important part of the procedure and requires fastidious technique.

5. The anastomosis should be performed by a surgeon who performs microsurgery routinely.  There is no place for “I have never really done a vein this small under the microscope…….do you mind if I try it?”  The answer should be: “yes-I mind” “Let me know when you have practiced and perfected the technique on a rodent femoral vein……and then you can execute the technique on a patient”

6. Flap insetting is critical. Make sure that the pedicle is not kinked, and that inflow and outflow conduits have slight redundancy. Remember that the flap can swell, resulting in tension or compression on the pedicle. If a skin flap is selected and the entire flap cannot be inset without tension, use a skin graft on the remaining open wound.  Try to get coverage over the pedicle. There is no such thing as taking too much from a donor site, but it is unpleasant to be short of tissue at the recipient site.  A template made out of glove paper or a piece of esmarch is helpful.

By remembering points 1-6 you can stay out of trouble and experience the joy and fulfillment of performing upper extremity microsurgical reconstruction.