Inpatient Flap Monitoring after Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: How Long Is Long Enough?

Abstract

Background There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies. Methods The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate. Results A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2–13.6 hours). In the series, the flap failure rate was 0.66% (n = 2). Conclusion All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.

Exploring personalized postoperative non-invasive tissue oximetry in DIEP flap breast reconstruction

“…Previous studies used monitoring windows with varying durations, mostly between 24 and 48 h postoperatively [1,17,22]. A recent study by Carruthers et al showed that microvascular issues become visible during clinical evaluation in the initial 23 h following reconstructive surgery [23], suggesting that a 24-h time window should be adequate. These results in combination with the results of the current study suggest that continuous postoperative monitoring of the DIEP flap with the use of tissue oximetry for longer than 24 h would not provide additional important information and therefore a timeframe of 24 h of continuous postoperative tissue oximetry monitoring could be justified.…”

The False Positive Rate of Transcutaneous Tissue Oximetry Alarms in Microvascular Breast Reconstruction Rises after 24 Hours

“…Other groups have also suggested this optimal time point as well in their institution's experiences with tissue oximetry. [21][22][23] Tissue oximetry facilitated timely takeback in 5 of 9 patients. The other 4 patients had clear clinical signs of flap compromise in the PACU.…”

Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße

“…Ein engmaschiges postoperatives Monitoring der Lappenplas tik sollte für 24 Stunden durchgeführt werden -idealerweise auf einer intensivmedizinisch betreuten Station. Dies beinhaltet die klinische und stabdopplerunterstützte Kontrolle [29]. Sollte im Rahmen einer lappenplastischen Revision ein Verlust festzustel len sein, muss eine erneute freie lappenplastische Deckung kri tisch evaluiert und ggf.…”