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Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27 Page 9 of 15

[84]
site than from the reconstructive sites where the majority of surgery is performed . STSG donor sites heal
more quickly, with fewer infections, and with less pain with hydrocolloid dressings [e.g., DuoDERM
hydrocolloid (ConvaTec, Princeton, NJ)] compared with non-moist dressings (e.g., sterile gauze). While
other moist dressings [e.g., Tegaderm transparent film (3M Health Care, St. Paul, MN)] lead to slower
healing than hydrocolloid, they also demonstrate superiority over non-moist dressings with respect to
healing and infection rates [85,86] .

The use of prophylactic mechanical drains following neck dissection helps prevent the accumulation of
serosanguinous fluid under skin flaps before hematomas or seromas can develop. Active drains, such as the
Jackson-Pratt (JP), provide low or high levels of negative pressure to remove fluid actively from a cavity.
Compared to passive drains, such as Penrose, active drains facilitate more rapid healing and better
adherence to skin flaps. The often-cited concern that the negative pressure of an active drain compromises a
microvascular anastomosis has not consistently been demonstrated .
[87]

Finally, the use of wound vacuum-assisted closure (VAC) therapy is a safe, established practice in head and
neck surgery that is used to aid in the healing of complex wounds. When administered over skin graft
recipient sites, wound VAC therapy has been shown to increase graft acceptance rates and decrease healing
time compared to conventional wound care . More recently, the immediate use of perioperative wound
[88]
VAC therapy in the neck has been shown to be safe after neck dissection and microvascular anastomosis.
This practice demonstrated lower rates of infection when compared to conventional therapy and was not
[89]
associated with any events of vascular compromise . Additional work is required to determine whether
wound VAC therapy to the neck also demonstrates superiority over more conventional active draining
mechanisms when applied immediately after neck dissection and microsurgery.

Pain management
The use of multimodal analgesia in the postoperative setting has been shown to reduce overall opioid use
and expedite recovery [12,90-92] . Pain regimens consisting of multiple opioid-sparing analgesics, such as
gabapentin, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs), have demonstrated
synergistic effects and enable the reservation of opioids for breakthrough pain alone . Gabapentin, in
[13]
particular, appears to provide a significant ameliorative effect on postoperative pain and analgesic
consumption when administered preoperatively and continued in the postoperative setting [93,94] . Regional
anesthesia through nerve blocks performed pre- and intra-operatively has demonstrated success in reducing
postoperative pain scores without a significant increase in morbidity [95,96] . Notably, however, intraoperative
infusion of long-acting local anesthetics into donor sites after harvest for free flap reconstruction does not
appear to reduce postoperative pain scores . Additionally, the use of longer-acting opioids or those with
[97]
reduced habit-forming potentials, such as methadone or tramadol, decreases overall opioid usage, reduces
postoperative pain, and increases patients’ quality of life [95,98,99] .

Despite widespread beliefs to the contrary, NSAIDs, such as ketorolac, celecoxib, and diclofenac, have been
shown not to increase the risk of postoperative bleeding in surgical patients [100-103] . However, a synergistic
effect between ketorolac and heparin used for venous thromboembolism prophylaxis appears to increase the
risk of bleeding in head and neck patients when used together, despite neither agent increasing the risk
when used alone [104-106] . These findings have been interpreted to caution the concomitant use of NSAIDs and
heparin derivatives and to encourage individualization of the use of NSAIDs based on the analgesic needs
and bleeding risk of the patient .
[8]