J Reconstr Microsurg 2021; 37(03): 300-308
DOI: 10.1055/s-0040-1722182
Original Article

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review

Amanda Y. Shen
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
,
Sarah Lonie
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
,
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
,
Hannah Farthing
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
,
David J. Hunter-Smith
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
3   Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
,
Warren M. Rozen
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
3   Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
› Author Affiliations
Funding None.

Abstract

Background Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage.

Methods A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention.

Results A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02).

Conclusion Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

Note

All authors are in agreement with the content of this manuscript. This manuscript has not been published previously and is not under consideration elsewhere.




Publication History

Received: 07 May 2020

Accepted: 04 November 2020

Article published online:
04 January 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Kwok AC, Agarwal JP. An analysis of free flap failure using the ACS NSQIP database. Does flap site and flap type matter?. Microsurgery 2017; 37 (06) 531-538
  • 2 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
  • 3 Kucur C, Durmus K, Uysal IO. et al. Management of complications and compromised free flaps following major head and neck surgery. Eur Arch Otorhinolaryngol 2016; 273 (01) 209-213
  • 4 Carney MJ, Weissler JM, Tecce MG. et al. 5000 free flaps and counting: a 10-year review of a single academic institution's microsurgical development and outcomes. Plast Reconstr Surg 2018; 141 (04) 855-863
  • 5 Smit JM, Negenborn VL, Jansen SM. et al. Intraoperative evaluation of perfusion in free flap surgery: a systematic review and meta-analysis. Microsurgery 2018; 38 (07) 804-818
  • 6 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
  • 7 Devine JC, Potter LA, Magennis P, Brown JS, Vaughan ED. Flap monitoring after head and neck reconstruction: evaluating an observation protocol. J Wound Care 2001; 10 (01) 525-529
  • 8 Carruthers KH, Tiwari P, Yoshida S, Kocak E. Inpatient flap monitoring after deep inferior epigastric artery perforator flap breast reconstruction: how long is long enough?. J Reconstr Microsurg 2019; 35 (09) 682-687
  • 9 Weckx A, Loomans N, Lenssen O. Perforator free flaps in head and neck reconstruction: a single-center low-volume experience. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 123 (04) 429-435
  • 10 Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010; 120 (04) 717-723
  • 11 Piwnica-Worms W, Stranix JT, Othman S. et al. Risk factors for lower extremity amputation following attempted free flap salvage. J Reconstr Microsurg 2020; 36 (07) 528-533
  • 12 Ahmad FI, Gerecci D, Gonzalez JD, Peck JJ, Wax MK. The role of postoperative hematoma on free flap compromise. Laryngoscope 2015; 125 (08) 1811-1815
  • 13 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119: 2092-2100
  • 14 Chiu YH, Chang DH, Perng CK. Vascular Complications and Free Flap Salvage in Head and Neck Reconstructive Surgery: Analysis of 150 Cases of Reexploration. Ann Plast Surg 2017; 78 (3 Suppl 2): S83-S88
  • 15 Devine JC, Potter LA, Magennis P, Brown JS, Vaughan ED. Flap monitoring after head and neck reconstruction: evaluating an observation protocol. J Wound Care 2001; 10 (01) 525-529
  • 16 Hyodo I, Nakayama B, Kato H, Hasegawa Y, Ogawa T, Terada A, Torii S. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope 2007; 117 (02) 357-360
  • 17 Mirzabeigi MN, Wang T, Kovach SJ. et al. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130: 579-589
  • 18 Panchapakesan V, Addison P, Beausang E, Lipa JE, Gilbert RW, Neligan PC. Role of thrombolysis in free-flap salvage. J Reconstr Microsurg 2003; 19 (08) 523-530
  • 19 Smit JM, Acosta R, Zeebregts CJ, Liss AG, Anniko M, Hartman EH. Early reintervention of compromised free flaps improves success rate. Microsurgery 2007; 27 (07) 612-616
  • 20 Vijan SS, Tran VN. Microvascular breast reconstruction pedicle thrombosis: how long can we wait?. Microsurgery 2007; 27 (06) 544-547
  • 21 Winterton RI, Pinder RM, Morritt AN, Knight SL, Batchelor AG, Liddington MI, Kay SP. Long term study into surgical re-exploration of the ‘free flap in difficulty’. J Plast Reconstr Aesthet Surg. 2010; 63 (07) 1080-1086
  • 22 Yim JH, Yun J, Jong Lee TJ, Kim EK, Cho J, Eom JS. Outcomes of take-back operations in breast reconstruction with free lower abdominal flaps. Arch Plast Surg 2015; 42 (06) 741-745