Download PDF
J Reconstr Microsurg 2019; 35(09): 682-687
DOI: 10.1055/s-0039-1693454
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

Katherine H. Carruthers
1   Division of Plastic Surgery, Department of Surgery, West Virginia University, Morgantown, West Virginia
,
Pankaj Tiwari
2   Midwest Breast and Aesthetic Surgery, Gahanna, Ohio
,
Shunsuke Yoshida
2   Midwest Breast and Aesthetic Surgery, Gahanna, Ohio
,
Ergun Kocak
2   Midwest Breast and Aesthetic Surgery, Gahanna, Ohio
› Author Affiliations Funding This study was completed without supporting funds. The authors, Katherine H. Carruthers MD, MS, and Shunsuke Yoshida MD, MS, have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in the manuscript. Pankaj Tiwari, MD, and Ergun Kocak MD, MS, are paid speakers for ViOptix Inc., Fremont, CA.
Further Information

Publication History

27 December 2018

04 June 2019

Publication Date:
21 July 2019 (online)

    Permissions and Reprints

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.

Keywords

flap monitoring - breast reconstruction - tissue oximetry

* Presented at the American Society of Plastic Surgeons Annual Meeting in Chicago, Illinois on September 29, 2018.


 

  • References

  • 1 Shay P, Jacobs J. Autologous reconstruction following nipple sparing mastectomy: a comprehensive review of the current literature. Gland Surg 2018; 7 (03) 316-324
    CrossrefPubMedGoogle Scholar
  • 2 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (03) 579-589
    CrossrefPubMedGoogle Scholar
  • 3 Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013; 29 (01) 51-56
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Chen Y, Shen Z, Shao Z, Yu P, Wu J. Free flap monitoring using near-infrared spectroscopy: a systemic review. Ann Plast Surg 2016; 76 (05) 590-597
    CrossrefPubMedGoogle Scholar
  • 5 Khansa I, Chao AH, Taghizadeh M, Nagel T, Wang D, Tiwari P. A systematic approach to emergent breast free flap takeback: clinical outcomes, algorithm, and review of the literature. Microsurgery 2013; 33 (07) 505-513
    CrossrefPubMedGoogle Scholar
  • 6 Kocak E, Carruthers KH, Knopp MV, Carkaci S, Martin Jr EW, Povoski SP. Image-guided technologies to facilitate the dissection of microsurgical autologous tissue-free flaps. Expert Rev Med Devices 2012; 9 (06) 547-549
    CrossrefPubMedGoogle Scholar
  • 7 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23 (04) 189-197
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (05) 538-543
    CrossrefPubMedGoogle Scholar
  • 9 Keller A. Noninvasive tissue oximetry. Clin Plast Surg 2011; 38 (02) 313-324
    CrossrefPubMedGoogle Scholar
  • 10 Ricci JA, Vargas CR, Ho OA, Lin SJ, Tobias AM, Lee BT. Evaluating the use of tissue oximetry to decrease intensive unit monitoring for free flap breast reconstruction. Ann Plast Surg 2017; 79 (01) 42-46
    CrossrefPubMedGoogle Scholar
  • 11 Pelletier A, Tseng C, Agarwal S, Park J, Song D. Cost analysis of near-infrared spectroscopy tissue oximetry for monitoring autologous free tissue breast reconstruction. J Reconstr Microsurg 2011; 27 (08) 487-494
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Salgarello M, Pagliara D, Rossi M, Visconti G, Barone-Adesi L. Postoperative monitoring of free DIEP flap in breast reconstruction with near-infrared spectroscopy: variables affecting the regional oxygen saturation. J Reconstr Microsurg 2018; 34 (06) 383-388
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Whitaker IS, Pratt GF, Rozen WM. , et al. Near infrared spectroscopy for monitoring flap viability following breast reconstruction. J Reconstr Microsurg 2012; 28 (03) 149-154
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Zoccali G, Molina A, Farhadi J. Is long-term post-operative monitoring of microsurgical flaps still necessary?. J Plast Reconstr Aesthet Surg 2017; 70 (08) 996-1000
    CrossrefPubMedGoogle Scholar
  • 15 Chen KT, Mardini S, Chuang DC. , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
    CrossrefPubMedGoogle Scholar
  • 16 Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 2003; 41 (01) 16-20
    CrossrefPubMedGoogle Scholar
  • 17 Smit JM, Zeebregts CJ, Acosta R. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2008; 122 (03) 991-992
    CrossrefPubMedGoogle Scholar
  • 18 Cornejo A, Ivatury S, Crane CN, Myers JG, Wang HT. Analysis of free flap complications and utilization of intensive care unit monitoring. J Reconstr Microsurg 2013; 29 (07) 473-479
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Steele MH. Three-year experience using near infrared spectroscopy tissue oximetry monitoring of free tissue transfers. Ann Plast Surg 2011; 66 (05) 540-545
    CrossrefPubMedGoogle Scholar
  • 20 Lin SJ, Nguyen MD, Chen C. , et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (03) 1080-1085
    CrossrefPubMedGoogle Scholar
  • 21 Kagaya Y, Miyamoto S. A systematic review of near-infrared spectroscopy in flap monitoring: current basic and clinical evidence and prospects. J Plast Reconstr Aesthet Surg 2018; 71 (02) 246-257
    CrossrefPubMedGoogle Scholar
  • 22 Varadarajan VV, Arshad H, Dziegielewski PT. Head and neck free flap reconstruction: what is the appropriate post-operative level of care?. Oral Oncol 2017; 75: 61-66
    CrossrefPubMedGoogle Scholar
  • 23 Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ 2001; 322 (7284): 473-476
    CrossrefPubMedGoogle Scholar
  • 24 Koolen PG, Vargas CR, Ho OA. , et al. Does increased experience with tissue oximetry monitoring in microsurgical breast reconstruction lead to decreased flap loss? The learning effect. Plast Reconstr Surg 2016; 137 (04) 1093-1101
    CrossrefPubMedGoogle Scholar
  • 25 Colwell AS, Craft RO. Near-infrared spectroscopy in autologous breast reconstruction. Clin Plast Surg 2011; 38 (02) 301-307
    CrossrefPubMedGoogle Scholar
  • 26 Subramaniam S, Sharp D, Jardim C, Batstone MD. Cost-effectiveness of monitoring free flaps. Br J Oral Maxillofac Surg 2016; 54 (05) 579-583
    CrossrefPubMedGoogle Scholar
  • 27 Canizares O, Mayo J, Soto E, Allen RJ, Sadeghi A. Optimizing efficiency in deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2015; 75 (02) 186-192
    CrossrefPubMedGoogle Scholar
  • 28 Bartlett EL, Zavlin D, Friedman JD, Abdollahi A, Rappaport NH. Enhanced recovery after surgery: the plastic surgery paradigm shift. Aesthet Surg J 2018; 38 (06) 676-685
    CrossrefPubMedGoogle Scholar
  • 29 Astanehe A, Temple-Oberle C, Nielsen M. , et al. An enhanced recovery after surgery pathway for microvascular breast reconstruction is safe and effective. Plast Reconstr Surg Glob Open 2018; 6 (01) e1634
    CrossrefPubMedGoogle Scholar
  • 30 Martinez CA, Reis SM, Rednam R, Boutros SG. The outpatient DIEP: safety and viability following a modified recovery protocol. Plast Reconstr Surg Glob Open 2018; 6 (09) e1898
    CrossrefPubMedGoogle Scholar