Current Techniques for Postoperative Monitoring of Microvascular Free Flaps

Abstract

Free tissue transfer (FTT) is used in patients with complicated reconstructive needs; it can provide stable wound coverage, improved aesthetic appearance, and restore functional deficits. Despite the high success rates of free flaps, vascular occlusion is a significant risk leading to flap failure. Many studies have demonstrated that the salvage rate for flaps is inversely related to the time between onset of a vascular problem and its surgical correction. As a result, ongoing postoperative monitoring of free flaps for adequate perfusion is imperative to allow timely and accurate diagnosis of vascular compromise. Close monitoring and prompt notification of the physician if vascular compromise occurs are typically undertaken by first-line nurses. We conducted an integrative literature to identify and evaluate commonly used techniques for monitoring vascular free flaps during the postoperative period. We searched PubMed and Science Direct electronic databases, using the key words: "free-flap" and "monitoring." This article discusses commonly monitoring modalities, along with their advantages and limitations. Whereas large academic institutions may have an experienced nursing staff specifically trained in effective methods for monitoring free flap patients, this situation may not exist in all hospitals where free flap surgeries are performed. We describe techniques that allow easy and timely detection of flap compromise by nursing staff while reducing interuser variability.

Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction

“…Centers of excellence have been created to optimize surgical outcomes in other fields (Birkmeyer, Lucas, & Wennberg, 1999) and could play a valuable role in ensuring optimal outcomes for patients (Birkmeyer et al, 2002), particularly for those undergoing breast microsurgery. For example, the safe delivery of breast microsurgery requires accurate and effective nursing care to monitor for postoperative complications and signs of impending flap failure (Chao & Lamp, 2014; Khatri, Zhang, & Kale, 2017). Staff that is more familiar with such procedures are likely to recognize the gravity of the situation and notify the appropriate contact with greater confidence and efficiency.…”

“…Furthermore, physicians in hospitals losing market share may become increasingly reluctant to perform these procedures, making it difficult for them to reach a plateau on the learning curve” (Albornoz et al, 2014). To combat these external pressures, LV hospitals can implement quality improvement measures and adopt guidelines and care pathways from their HV counterparts to strive for comparable outcomes (Khatri et al, 2017; Share et al, 2011).…”

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods

“…When a problem occurs, it is often within the first 48 h post-surgery. Vascular compromise requiring re-exploration is reported as occurring in 12-17% of cases 4,5 . Timely detection of a flap vascular problem is very important as about 70-80% of flaps can be rescued by remedial surgery if done in time 6 .…”

Measurement of optical reflection and temperature changes after blood occlusion using a wearable device

“…The key reason for flap failure is compromised circulation in the blood vessels due to thrombosis 1 , 6 , 7 , which occurs in one week after the surgery in most cases. Early salvage surgery soon after the compromised circulation event is essential to increase the rescue rate of tissue 8 , 9 . Thus, real time detection of tissue circulation is necessary.…”