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Background and Aims Compared to general anesthesia, regional anesthesia (RA) with sedation is safer for elderly patients with comorbidities, especially for long-duration procedures. Our institution established an Integrated Care Pathway (ICP) for advanced skin cancer, managing 102 cases over the last four years. Among them, 79 underwent surgical excision. Reconstruction required free flap in 20 cases and regional flap in 46. All patients received targeted RA techniques. We report a case series of four elderly and fragile patients who underwent free flap reconstruction under targeted blocks and mild sedation.
Methods Four patients with skin cancer underwent wide excision and reconstruction. 1- latissimus dorsi muscle flap: combined erector spinae plane, deep- serratus plane, and pecto-serratus plane blocks. 2- vastus lateralis flap: spinal anesthesia 3- superficial circumflex iliac perforator flap: spinal anesthesia These flaps were transferred to the parieto-occipital, fronto-temporal, and temporo-auricular regions, with the superficial temporal used as recipient vessels. Combination of supratrochlear, supraorbital, auriculotemporal, occipital nerves, and cervical plexus block allowed to manage the recipient site. 4- lateral arm flap: axillary brachial plexus block Transferred to the dorsum of ipsilateral hand with anastomoses to the dorsal branch of the radial artery and cephalic vein.
Results mean age was 82.8 years; mean operative time was 4h47’. No patient required transfer to the intensive care unit; no flap loss was observed. Mean time to discharge was 4.5 days.
Conclusions Free flap transfer under RA is advisable for fragile patients, avoiding intensive care and hastening recovery and discharge. Thorough planning, tailored RA and collaboration between surgeon and anesthesiologist are crucial.