RiskStratification Patientspresenting for head and neck free flap surgery and breast reconstructivesurgery are fragile cancer patients with a number of significant co-morbidities(5).

Hence, pre-operative assessment and investigation plays an important rolein the risk stratification (6). Although technical issues aredominant factors, patients and clinical characteristics also contribute to flapfailure (7). The Division of Plastic and Reconstructive Surgery, University ofSouthern California, Los Angeles, investigated a number of non-technicalvariable in 2015, using the American College of Surgeons’ National SurgicalQuality Improvement Program (NSQIP) database. Univariate analysis was performedto determine the association of free flap failure with the following factors:age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes,smoking, alcohol, American Society of Anaesthesiologists classification, yearof operation, operative time, number of flaps, and type of reconstruction. The overallflap loss rate was 4.

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4%. Operative time was the only significant independentrisk factor for flap failure after themultivariate logistic regression (8). Accordingthe analysis conducted by another plastic unit, patient’s age isnot an independent variable for increased risk in microvascular reconstruction.However, operative time, and location of the reconstruction site are associatedwith higher rate of medical complications and ITU referral (9). Anotherimportant study, held in Toronto in 2016, identified the operative time andsmoking as the only independent risk factors for intraoperative complications inreconstructive breast free flap surgery (10).  Several preoperative investigations playa role to assess the risk of patients in flap reconstructive surgery.

Differentstudies revealed that cardiopulmonary exercise testing (CPET) in complexpatients is pivotal to assess the functional capacity. Many studies are ongoingand many centres routinely use CPET to plan the type of surgery, and to informour patients regarding risks and benefits of surgery (11). In conclusion, flaploss is a multifactorial event and, according recent literature, demographics andmedical patient’s characteristics such as: age, ethnicity, radiation,chemotherapy, medical comorbidities, smoking, are not independent risk factorsfor surgical complications. In the preoperative, they need to be assessed toensure the best perioperative management and to reduce medical complicationsbut intraoperative and technical variable may have higher importance for the outcome(12).  Nutrition, preoperativefasting and preoperative education  Accordingrecent evidences, the basic nutritional state should be assessed and optimised:preoperative albumin levels have an inverse correlation with dehiscence,pleural effusion, salivary leakage, cardiac complications, suture removal (13). Preoperative fasting should be minimal.In patients eligible for oral intake, clear solids should be allowed up to 2hours and clear fluids up to 6 hours before anaesthesia.

(14, 15).  All patients undergoing major head andneck cancer surgery with free flap and breast reconstructive surgery should beadequately prepared and informed regarding the surgical journey and evidencessuggest they should receive a structured teaching. If anaesthetists andqualified health professional should play a role together in this discussion, isstill not clarified, due to paucity of high quality studies specificallyfocused on this (16). In conclusion, the implementation of amultidisciplinary pre-operative evaluation conducted by anaesthetists, nutritionists,physiotherapists, other medical specialities, and health practitioner mayreduce post-operative complications arising from pre-existing conditions (17).