BACKGROUND:
There is a current push in plastic surgery to advance evidence based medicine. While several ethical and financial barriers exist, the greatest barrier to level I evidence is in generating power in light of low free flap failure rates. Much of our practices are driven by “conventional wisdom” which is handed down from mentors to fellows. In this paper we explore the oxymoron that there is evidence to support controversy in microsurgery.
METHODS:
A systematic literature search was performed on PubMed examining outcomes in microsurgery practice with regard to preoperative patient selection, intraoperative technique, and postoperative protocols. Papers were categorized into level of evidence based on American Society of Plastic Surgeons Level of Evidence Scale (I randomized control trial(RCT)/systematic review(SR), II lower level RCT/SR, III retrospective cohort/case control, IV case series, V expert opinion). Studies were excluded based on the following 1) not catalogued on PubMed, 2) lack of discernable or clear methodology, 3) <30 patients.
RESULTS:
A total of 153 papers were reviewed. The majority of these papers were level III/IV evidence. One paper presented level I evidence. Fifteen papers were level II. Pre operative factors that were analyzed were: age, diabetes, obesity, smoking, radiation, multiple medical co-morbidities, peripheral vascular disease, and hypercoagulability. Intraoperative considerations that were analyzed were: microsurgery suture technique, use of vein grafts, 1 vs. 2 veins, use of anastomotic devices, and anesthetic considerations. Post-operative factors that were included were: anticoagulation protocols, dangling protocols and monitoring. While there is a paucity of high level data to support microsurgery theory, we show the existing data that supports these issues in microsurgery practice.
CONCLUSIONS:
There is a paucity of high level evidence in microsurgical literature. Most of practices appear to be based on low level evidence, training, and personal preferences. Future research efforts may be focused on developing trials to discern optimal evidence-based microsurgical practice that incorporates cost-effective, efficient, patient centered outcomes in reconstructive surgery.