Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. www.PRSJournal.com 70e C lassic vasopressors, such as ephedrine and phenylephrine, are a mainstay of the treat- ment of hypotension under general anes- thesia. During deep inferior epigastric perforator (DIEP) fap cases, many anesthesiologists com- pletely avoid vasopressors because of the theoreti- cal risk of inducing vasospasm, venous congestion, or thrombosis that could compromise fap per fu- sion and lead to failure. The opposing argument is that vasopressors may improve fap per fusion by augmenting mean arterial pressure. Further- more, the routine treatment of DIEP fap vessels with a topically applied vasodilator solution, such as papaverine or nicardipine, before anastomosis may negate any potentially deleterious effects of vasopressors, so the net effect becomes improved fap per fusion by means of increased global mean arterial pressure. In studies of rabbit carotid artery anastomoses 1,2 and porcine gastroepiploic arteries 3 preconstricted with norepinephrine, endothelin-1, or potassium, the topical applica- tion of either papaverine or nicardipine evoked transient concentration-dependent relaxation. Vasopressors were also applied topically to faps in these studies, limiting their generalizability to cases involving intravenous vasopressors. Determining the suitability of vasopressors for treating hypotension during DIEP fap cases is important because, in their absence, anesthesiolo- gists are likely to rely more heavily on intravenous Disclosure: The authors have no financial interest to declare in relation to the content of this article. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003444 Ashley Szabo Eltorai, M.D. Chuan-Chin Huang, D.Sc. Jeffrey T. Lu, M.D. Asako Ogura, M.D., M.P.H. Stephanie A. Caterson, M.D. Dennis P. Orgill, M.D., Ph.D. Boston, Mass. Background: During deep inferior epigastric perforator (DIEP) fap cases, anes- thesiologists commonly avoid intravenous vasopressor administration because of the theoretical concern of inducing vasospasm, thrombosis, or congestion in the vessels of the anastomosis, potentially resulting in poor fap per fusion and ischemia and necessitating revision. In the setting of hypotension, however, vasopressor administration may actually improve outcomes by augmenting fap perfusion by means of increased mean arterial pressure. Methods: The authors reviewed 475 consecutive DIEP fap cases in 333 patients at a single large academic medical center over a 3-year period, addressing potential confounders using univariate analyses. Results: Ephedrine administration was signifcantly associated with decreased risk of intraoperative fap complications (OR, 0.88), including vasospasm, thrombosis, and congestion requiring revision, compared with controls, after controlling for the severity and duration of hypotension. Phenylephrine had no signifcant association with complication rates. Vasopressor administration was not associated with an increased risk of reoperation in the setting of necro- sis within 60 days. Conclusions: Ephedrine treatment for hypotension during DIEP fap cases is associated with decreased intraoperative fap complication rates compared with controls who did not receive vasopressors, whereas phenylephrine has no signifcant association. The common clinical practice of complete abstinence from vasopressors out of concern for worsening DIEP fap outcomes is not supported by this study. (Plast. Reconstr. Surg. 140: 70e, 2017.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. From the Department of Anesthesiology, Perioperative and Pain Medicine and the Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School; and the Harvard T. H. Chan School of Public Health. Received for publication September 29, 2016; accepted January 9, 2017. Selective Intraoperative Vasopressor Use Is Not Associated with Increased Risk of DIEP Flap Complications RECONSTRUCTIVE