Postoperative vascular compromise can result from a problem at the anastomotic site, including vessel damage, improperly placed sutures, trauma to the vessel, or atherosclerosis. Systemic factors include decreased blood flow, vascular spasm, and atherosclerosis. External compression such as hematoma, tight skin closure, or a large drain pressing on a vessel can compromise flow. In patients who are to undergo elective microsurgery, angiography at the recipient site is helpful to select healthy vessels. Anastomosis is performed outside the zone of injury, and a patency test is performed after anastomosis to substantiate adequate blood flow. If a healthy vessel is repaired with a technically satisfactory anastomosis, without tension, and if attention is given to meticulous hemostasis, careful skin closure, and nonconstricting dressings, postoperative management will be easy. Surgeons who are less conscientious in these matters will become more familiar with difficult postoperative management problems. With comprehensive postoperative care of the patient, including repeated monitoring with both clinical evaluation and monitoring devices, arterial or venous insufficiency can be detected early. If the cause of the vascular compromise is identified and corrected rapidly, the failing free tissue transfer can often be saved.
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