Anaesthesia in Microsurgical Flap Reconstruction: A Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall, the article is well-structured and comprehensive in content, covering several key aspects of anesthesia management in microsurgical flap reconstruction, including hemodynamic control, fluid management, and monitoring techniques. It provides valuable reference for clinical practice. However, there is still room for improvement in the following areas:

1. It is recommended that a sub-section or table be added in the "Results" section to compare different vasoactive agents (e.g., norepinephrine, dopamine, dobutamine) in terms of their effects on flap perfusion, side-effect profiles, and appropriate clinical scenarios.
2. It is recommended to add illustrations to help readers understand.

Author Response

Dear Editor and Reviewers, 
We would like to thank the Editor and the Reviewers for their careful evaluation of our manuscript and for 
their insightful and constructive comments. We have carefully revised the manuscript accordingly, with the 
aim of improving clarity, clinical relevance, and coherence between the objectives, results, and conclusions. 
All changes have been implemented in the revised version of the manuscript. 
Below we provide a detailed, point-by-point response to each comment. 
Review 1 
Overall, the article is well-structured and comprehensive in content, covering several key aspects of 
anesthesia management in microsurgical flap reconstruction, including hemodynamic control, fluid 
management, and monitoring techniques. It provides valuable reference for clinical practice. However, there 
is still room for improvement in the following areas: 
1. It is recommended that a sub-section or table be added in the "Results" section to compare different 
vasoactive agents (e.g., norepinephrine, dopamine, dobutamine) in terms of their effects on flap 
perfusion, side-effect profiles, and appropriate clinical scenarios. 
Response: 
We thank the Reviewer for this valuable suggestion. In response, we have added a dedicated comparative 
table (Table 1) in the Results section summarizing the main vasoactive agents used in free flap surgery, 
including norepinephrine, dobutamine, and dopamine. 
The table highlights their effects on flap perfusion, potential advantages, limitations, and relevant side-effect 
profiles, with the aim of providing clinicians with a practical and easily accessible overview to guide 
intraoperative decision-making. 
2. It is recommended to add illustrations to help readers understand. 
Response: 
We fully agree with this suggestion. A comprehensive graphical abstract has been added to visually 
summarize the key anaesthetic strategies discussed in the review, including haemodynamic optimisation, 
fluid management, vasoactive support, and monitoring tools. 
This illustration is intended to enhance readability and facilitate a rapid understanding of the integrated 
perioperative approach described in the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

see file

Comments for author File: Comments.pdf

Comments on the Quality of English Language

minor editing

Author Response

According to the abstract the problem is: 
“In maxillofacial surgery, flap loss remains a major complication and therefore continues to pose a significant 
challenge in the perioperative care of these patients. Anaesthetic management is a determining factor in the 
success of these surgical techniques, due to its role in managing haemodynamic stability and regional blood 
flow.” With the goal, according to the Introduction: “to gather the best practices available in literature, with the 
primary aim of improving intraoperative haemodynamic management of these patients, resulting in improved 
prognosis and survival of the flap and, consequently, of the patient. 
The review does a good job of looking at potential issues leading to vascular problems with blood flow in 
flaps. The emphasis is on strategies to improve flap blood flow as well as monitor the blood flow directly and 
indirectly; and does a good job of summarizing the results of the studies reviewed. 
The Conclusions, however, claim: 
“we have summarized the main data available in the literature, with the aim of providing clinicians with an 
easily accessible tool, as well as advancing new possible strategies for optimising intraoperative 
management. . . combining a more traditional approach with new management algorithms, such as 
intraoperative echocardiography or HPI, to ensure the best possible outcome for these patients. To suggest 
new strategies for free flaps there has to be a problem as well as what is considered success. New 
treatments have to be measured in terms of their potential to solve the problem (at the acceptable level). The 
problem has to be at the clinical Level and relate to loss of function or cost.cFailure of grafts is considered 
the problem. The actual problem has to be the complication(s) due to graft failure with the solution being able 
to reduce complications below the acceptable level. The biomechanisms examined in the review are at a 
lower Level and have to show how they relate to solving the actual clinical problem. 
The Conclusion mentions optimizing the treatment to get the best possible clinical outcome. Neither 
“optimization” nor “best possible outcome” is a worthy or achievable goal, since things can always be 
improved. The goal should be to provide a treatment that solves the clinical problem(s). Once the problem is 
solved there is no need to improve upon it (i.e. no need for “optimization” or “best possible outcome”). 
An example of a design constraint hierarchy for free flaps of the head and neck is as follows (it is likely to be 
somewhat application dependent): 
Level 1 is the clinical outcome. It could have a functional and aesthetic component as well as could be 
overall cost; due to complications from inadequate graft take. This again would be application dependent. 
Although there could be many complications selected, a reasonable one would be enough graft loss to 
require a second graft surgery for over 50% of the graft. Then the actual rateof the problem has to be given 
as well as what an acceptable rate would be (to solve the problem). 
Level 2 is what causes the Level 1 problem. This could be graft necrosis over 50% of the graft within the first 
3 weeks. 
Level 3 is what causes the Level 2 problem. This would be insufficient blood flow (for a sufficient period of 
time) to over 50% of the graft. The design constraint would be the minimum amount of blood flow to the graft 
both spatially and temporally. Level 4 and below are the things measured in the study that affect graft 
healing: could be blood flow from the pedicle or surrounding tissue (it is confusing, since most of the time the 
application is free flaps, but sometimes pedicle grafts are discussed) or within the graft. The major reason 
cited (Level 5) is ischemia reperfusion injury. So there should be some Level 1 problems listed that are 
currently not solved and that the improvements in blood hemodynamics have the potential to solve the Level 
1 problem(s). The study is to determine if the proposed treatments can make the needed improvements. 
It is OK, if the needed improvements are not known, but the next step should be to see, if they have the 
potential to solve Level 1 problems. So, the review has to be problem solving oriented vs. just looking at 
ways to improve outcome (even optimizing it). The review can be to look at best practices (as it does), but 
give the next steps to determine, if these best practices are sufficient to solve problems vs. just improve 
outcomes. This should be reflected in the purpose of the review as well as the interpretation of the results. It 
is fine to concentrate on anesthesia methodology, but not assume it is the only way to solve the problems or 
that it would be sufficient to solve the problem(s). 
Response: 
We sincerely thank the Reviewer for this in-depth and thought-provoking critique, which has helped us to 
substantially refine the conceptual framework of the manuscript. 
We fully acknowledge the importance of framing perioperative strategies in relation to clearly defined clinical 
problems and clinically meaningful outcomes. In the revised version, we have clarified that the primary 
clinical problem addressed by this review is free flap failure and its related complications, which may lead to 
re-operation, prolonged hospital stay, increased costs, and impaired functional and aesthetic outcomes. 
However, as highlighted by the available literature, free flap failure in head and neck reconstruction is a 
multifactorial phenomenon, influenced by patient-related factors, tumour characteristics, surgical technique, 
and perioperative management. Given this complexity, and the absence of universally accepted thresholds 
defining “acceptable” versus “unacceptable” failure rates, the current evidence does not allow anaesthetic 
strategies alone to be presented as a definitive solution to flap loss. 
For this reason, we have deliberately framed our review as problem-oriented but not problem-exclusive, 
focusing on the anaesthesiological domain as one modifiable and clinically relevant component within a 
broader multidisciplinary pathway. We have revised both the Introduction and Conclusions to better 
emphasize that the goal of the reviewed strategies is not abstract “optimisation,” but rather the reduction of 
haemodynamic instability and ischaemia-related mechanisms that are known contributors to flap 
compromise. 
Furthermore, we have clarified that the purpose of this review is to: 
summarize current best practices supported by the literature, 
identify haemodynamic and monitoring strategies with the potential to mitigate known pathophysiological 
mechanisms of flap failure, 
and outline future directions needed to determine whether these strategies are sufficient to translate into 
measurable improvements in clinically relevant outcomes. 
We believe that these revisions better align the manuscript with a clinically grounded, problem-solving 
perspective, while remaining faithful to the scope and limitations of the available evidence.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

see file

Comments for author File: Comments.pdf

Comments on the Quality of English Language

minor editing

Author Response

 

We would like to thank the Reviewer for the careful evaluation of our manuscript. We have revised the manuscript. Below, we address each comment in detail.

Comment 1

Although much improved it still is claiming potential strategies to “optimize the procedure” and obtain the “best possible outcome for patients”. In general, it should be clearer on what we know and what we don’t know and how do we get to solving clinical problems vs. “improving or optimizing outcomes”.

Response:
We fully agree with this comment and have revised the manuscript to remove language implying “optimization” or “best possible outcomes.” Throughout the Introduction and Conclusions, we have replaced these expressions, such as potential improvement, clinically meaningful improvement, and reduction of complications to acceptable levels (see the revised manuscript).

In addition, we have explicitly clarified the distinction between established evidence and areas of uncertainty. The revised Conclusions now focus on how anesthetic strategies may contribute to addressing defined clinical problems rather than on optimizing outcomes in a general sense (see the revised manuscript).

Comment 2

The Introduction should state that there are many flap procedures that lead to unsatisfactory outcomes (also it is still unclear if it is only free grafts or pedicle grafts [which is the definition given]). The purpose of the review is to look at current best practices in anesthetic management to improve intraoperative haemodynamic management to improve graft take; with the long term goal of reducing complications to an acceptable level for these procedures.

Response:
We have revised the Introduction to explicitly acknowledge that unsatisfactory outcomes are not limited exclusively to free flaps. This uncertainty is now clearly stated early in the Introduction. Moreover, we have reformulated the stated aim of the review. 

Comment 3

The justification for looking at anesthetic management is fine. Since it is application specific and there are no generalizable acceptable values, and no specific cases were given, the Conclusions need to give a clearer picture of where we go from here. Instead of optimization, the strategies presented have to show what type of improvement is possible in intraoperative haemodynamic management to improve graft survival; which may also be application dependent.

Response:
We appreciate this important clarification. In response, we have revised the Conclusions to explicitly acknowledge the lack of generalizable haemodynamic targets and the application-specific nature of intraoperative management. We now emphasize that future efforts should focus on defining acceptable outcomes and evaluating whether the achievable haemodynamic improvements are sufficient to address specific clinical problems (see the revised manuscript).

 

 

 

Comment 4

The Conclusion can be similar, without saying “optimization or best possible outcomes”. It has to end with where we go from here. It can be bottom up, top down, or a mix.

Response:
We have revised the Conclusions in line with this recommendation.

Specifically, we describe a top-down approach that begins with defining acceptable clinical outcomes for specific applications and then identifies the haemodynamic requirements and strategies needed to achieve them, as well as a bottom-up approach that evaluates the haemodynamic effects of individual interventions and tests their ability to solve defined clinical problems. 

Author Response File: Author Response.pdf

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

The revision did a good job of addressing the concerns and modifying the text, in the Abstract, Introduction, and Conclusions.

 

Still some “optimization” in the results section:

“From an anaesthesiological standpoint, it is therefore crucial to implement perioperative strategies aimed at optimising the patient’s haemodynamic status during surgery. Below, we summarise the main approaches described in the literature”.

 

Figure  1 caption:

“A schematic overview of all the strategies for haemodynamic optimisation in flap surgery that are discussed throughout this article.”

Comments for author File: Comments.pdf

Comments on the Quality of English Language

minor editing

Author Response

Comment 1: The revision did a good job of addressing the concerns and modifying the text, in the Abstract, Introduction, and Conclusions. Still some “optimization” in the results section: “From an anaesthesiological standpoint, it is therefore crucial to implement perioperative strategies aimed at optimising the patient’s haemodynamic status during surgery. Below, we summarise the main approaches described in the literature”.

Response 1: We thank the Reviewer for this helpful comment.
We have revised the wording in the Results section to avoid the term “optimisation” and to better reflect the concept of haemodynamic support and control rather than ideal optimisation.

Comment 2: Figure 1 caption: “A schematic overview of all the strategies for haemodynamic optimisation in flap surgery that are discussed throughout this article.”

Response 2: The caption of Figure 1 has been modified as requested.