Background: Reconstructive microsurgery has become a cornerstone in the management of complex tissue defects, yet many perioperative practices remain rooted in tradition rather than robust evidence. Persistent complications and variable protocols necessitate systematic evaluation of these dogmas to guide best practices. Methods: We conducted a comprehensive literature review of all major databases to identify all studies addressing techniques, perioperative care, monitoring, patient selection, and recovery in reconstructive microsurgery. Relevant studies were assessed and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. When available, meta-analyses and updated systematic reviews were prioritized; individual studies within such analyses were not separately reported to avoid redundancy. Results: Eight commonly held perioperative myths were critically appraised. Evidence demonstrates that judicious intraoperative vasopressor use does not increase flap compromise or loss. Perioperative nonsteroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, do not raise the risk of hematoma or thrombosis. Routine therapeutic anticoagulation or dextran use provides no benefit in flap survival and increases bleeding risk. High-dose perioperative steroids are associated with greater flap and wound complications. Extended antibiotic prophylaxis beyond 24 hours postoperatively does not reduce surgical site infections. Negative-pressure wound therapy is safe for free flaps. Most vascular compromises occur within 48–72 hours, supporting step-down monitoring thereafter. Finally, advanced age, diabetes, obesity, or immunosuppression due to solid organ transplantation or other reasons should not preclude patients from getting microsurgical reconstruction. Conclusions: Many entrenched perioperative practices in microsurgery lack contemporary evidence. Evidence-based adoption of updated protocols can minimize complications, standardize care, and improve outcomes in reconstructive microsurgery.
Elemosho et al. (Wed,) studied this question.