Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis

Abstract

Background: Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. Methods: A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. Results: A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). Conclusions: This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.

Fingerstall-type Tissue Oximetry Reduced Anxiety of Nurses in Postoperative Nursing Monitoring of Free Flaps

“…6 There is no universal consensus concerning the ideal flap monitoring method, although such a method would be harmless, rapid, reliable, objective and simple to interpret. 7 Continuous tissue oximetry is useful, but the false positive rate increases significantly from 24 hours postoperatively due to probe malfunction/errors. 2 To obtain the cooperation of nurses, the most important point is to reduce their anxiety and complaints concerning flap monitoring.…”

Comparison of Hyperspectral Imaging and Microvascular Doppler for Perfusion Monitoring of Free Flaps in an In Vivo Rodent Model

“…This is probably due to the high acquisition or follow-up costs of some device-based monitoring methods. In addition, however, some device-based monitoring methods and the measured values also depend on expert interpretation [ 48 ]. Indeed, HSI implementation is associated with high prices, but after a one-time purchase, there are no further follow-up costs, e.g., for disposable probes, and could pay off if the length of hospital stay is shortened through earlier detection of arterial perfusion disorders and more timely salvage surgeries, thereby reducing the overall MFF failure rate [ 49 , 50 ].…”

Free flaps monitoring by Laser-Doppler Flowmetry in head and neck surgery

“…On the other hand, free flaps superiority over pedicled ones almost invariably occurs when dealing with speech and swallowing, even if not at a statistically significant level 16 . However, despite success rates being around 95% or more 3 , flap failure secondary to vascular disturbances remains a major complication that can poten-tially invalidate the morphologic and functional success of the reconstruction, thus leading to higher patient morbidity, prolonged hospital stay and increased healthcare costs 5 . Circulation disturbances leading to flap failure may involve either the flap's arterial inflow, capillary microcirculation, or venous outflow 5 .…”

“…However, despite success rates being around 95% or more 3 , flap failure secondary to vascular disturbances remains a major complication that can poten-tially invalidate the morphologic and functional success of the reconstruction, thus leading to higher patient morbidity, prolonged hospital stay and increased healthcare costs 5 . Circulation disturbances leading to flap failure may involve either the flap's arterial inflow, capillary microcirculation, or venous outflow 5 . Salvage rates of failing free flaps vary with aetiology, flap type and experience, but there is large agreement that early detection of vascular compromise and prompt surgical re-exploration significantly increases the chances of free flap salvage.…”

“…As a consequence, monitoring methods to aid the early recognition of disturbances in flap circulation are critical in performing revision, thus maximising the success of free flap reconstruction. Numerous flap monitoring strategies and technologies exist, which vary in complexity, invasiveness, efficiency and cost 5,6 . Properties of the ideal free flap monitoring technique should be: inexpensive; harmless to both patient and flap; produce rapid, reliable, and objective results; simple to interpret by relatively inexperienced personnel; and applicable to all types of free flaps 6 .…”