J reconstr Microsurg 2019; 35(07): 529-540
DOI: 10.1055/s-0039-1687914
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

1  Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
Marcus J.M. Ng
2  Yong Loo Lin School of Medicine, National University of Singapore, Singapore
David H. Song
3  Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
Adrian S.H. Ooi
1  Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
› Author Affiliations
Further Information

Publication History

16 October 2018

21 February 2019

Publication Date:
01 May 2019 (eFirst)


Background The use of vasopressors in free flap surgery has traditionally been avoided due to the presumed risk of pedicle vasospasm leading to flap failure. However, there is a lack of strong clinical evidence to suggest that their administration during microvascular surgery is absolutely contraindicated. The aim of this study is to clarify the impact of perioperative vasopressor use on free flap outcomes.

Methods A systematic review was performed of all English-language articles that have compared free flap outcomes between patients who received vasopressors and those who did not. The outcome measures were total flap failure, pedicle thrombosis, and overall flap complications. Meta-analysis was performed using Mantel–Haenszel fixed-effects and DerSimonian and Laird random-effects models.

Results From a total of 130 citations, 14 studies representing 8,653 cases were analyzed. Majority of these did not find any negative effects of vasopressor use irrespective of dose, timing of administration, and method of delivery. Meta-analysis demonstrated that vasopressors were associated with less total flap failure overall (odds ratio, [OR]: 0.71, p = 0.05) and less pedicle thrombosis in head and neck reconstruction specifically (OR: 0.58, p = 0.02). Flap complication rates were similar across all defect types (OR: 0.97, p = 0.81) but appeared to be increased in breast reconstruction (OR: 1.46, p = 0.01).

Conclusion Perioperative vasopressor administration does not appear to be as detrimental to free flap survival as has been previously feared. Their role in optimizing hemodynamic stability may have a more beneficial effect on overall flap perfusion and in minimizing the complications of iatrogenic fluid overload.

Disclosure Statement

The authors have no relevant commercial associations, financial interests, or conflicts of interest to disclose.