Free flap reconstruction

# OPERATION NOTE — Free flap reconstruction

Date: 19/05/2026Elective
Primary surgeon: Mateusz Gładysz, Consultant Plastic and Hand Surgeon
Assistant: [Registrar Dr ____ / Fellow Dr ____]
Anaesthetist: [Dr ____]    Anaesthetic: GA
WHO Surgical Safety Checklist: Sign-in / Time-out / Sign-out — completed.

## Diagnosis / Indication

- Soft-tissue defect of [SITE] following oncologic resection.
- Plan: Free Anterolateral thigh (ALT) flap reconstruction.

## Consent

Risks: bleeding, haematoma, infection, flap failure (total / partial), need for re-exploration, anastomosis revision, donor-site morbidity (scar, contour deformity, sensory change, lateral femoral cutaneous nerve neuropraxia), DVT / PE, prolonged immobility, scar, ongoing rehabilitation. Discussed with patient.

## Antibiotics / VTE prophylaxis

Cefazolin 2 g IV at induction; continued 24 h post-op. Mechanical VTE prophylaxis intra-op; pharmacological enoxaparin once haemostasis satisfactory.

## Recipient site preparation

- Defect [____] cm × [____] cm at [SITE]; tissues missing: skin / subcutis / muscle / bone / dura / mucosa as documented.
- Debridement to healthy bleeding edges; tumour clearance margins per frozen section (if oncologic).
- Recipient vessels identified: artery [facial / superficial temporal / radial / anterior tibial / posterior tibial / DIEA / thoracodorsal / internal mammary] — calibre [___] mm; vein [paired venae comitantes / external jugular / cephalic] — calibre [___] mm.
- Heparinised saline (10 IU/mL) irrigation; vessels assessed for spasm and flow; clip applied proximally for later anastomosis.
- Pedicle route planned and tunnel created where required.

## Flap harvest — ALT (Anterolateral Thigh)

- Pre-op Doppler used; perforator(s) marked at the midpoint of a line from ASIS to superolateral patella.
- Patient supine with knee slightly flexed.
- Medial skin incision first; subfascial dissection identifies septocutaneous / musculocutaneous perforator(s) from descending branch of lateral circumflex femoral artery (LCFA) in vastus lateralis / rectus-vastus intermuscular septum.
- Perforator chosen: [___] mm calibre, musculocutaneous; intramuscular dissection performed.
- Pedicle dissected proximally to source on descending branch of LCFA — final pedicle length [___] cm; artery [___] mm, paired venae [___] mm.
- Lateral skin incision completed; flap raised on perforator(s); harvested as fasciocutaneous — dimensions [___] × [___] cm.

## Microsurgical anastomosis

- Operating microscope (×10–25). Heparinised saline irrigation.
- Recipient artery prepared; adventitia trimmed; lumen inspected.
- Arterial: end-to-end to [vessel] using 9-0 nylon interrupted simple sutures (8–10 sutures depending on calibre).
- Venous: end-to-end with 3.0 mm Synovis GEM Coupler (lot/serial sticker attached).
- Release of clamps in sequence venous → arterial; flap re-perfused; capillary refill, colour, turgor, bleeding from edges and Doppler signal confirmed.
- Anastomosis times: arterial ischaemia → reperfusion [___] min; total ischaemia [___] min.
- Patency confirmed by strip-empty-refill test and audible Doppler signal post-perfusion.

## Flap inset

- Flap orientated to defect; trimmed to size.
- Inset in layers: deep dermal 3-0 Vicryl; skin 4-0 nylon / staples.
- Implanted Cook–Swartz Doppler (20 MHz) probe placed on venous limb; lead exit marked.
- External skin paddle exposed for clinical observation.
- Two suction drains placed away from pedicle.

## Donor closure

- ALT donor closed primarily in layers (deep fascia 2-0 Vicryl; subcutaneous 2-0 Vicryl; skin staples). STSG to donor if width >8–9 cm.

## Findings

- Single dominant musculocutaneous perforator identified; pedicle length adequate; flap perfused well at completion.

## Estimated blood loss

[___] mL.

## Complications

Nil intra-operative.

## Count

Swabs / needles / instruments — confirmed correct.

## Post-op plan

- HDU / dedicated flap-monitoring ward.
- Flap observations: colour, capillary refill, turgor, temperature, Doppler signal — every 30 min × 4 h, then 1 h × 24 h, 2 h × 24 h, 4 h thereafter for 5 days.
- Head of bed 30°; affected limb elevated; warm room (≥24 °C); avoid pressure on pedicle.
- IVF 1.5–2 mL/kg/h aiming UO ≥0.5 mL/kg/h; Hb ≥80 g/L; avoid vasoconstrictors where possible.
- Aspirin 100 mg daily from day 1 × 4 weeks (per local protocol); VTE prophylaxis with enoxaparin once haemostasis satisfactory.
- Antibiotics: cefazolin 8 g/day for 24 h then stop unless contamination.
- Early hand therapy / physiotherapy referral as relevant.
- Photography on POD 1, 3, 5.
- Concerning flap signs (pale, mottled, congested, loss of Doppler) → urgent surgeon review; theatre re-exploration within 2 h.

## Signature

Mateusz Gładysz, Consultant Plastic and Hand Surgeon — 19/05/2026