A Prospective Analysis of Free Flap Monitoring Techniques: Physical Examination, External Doppler, Implantable Doppler, and Tissue Oximetry

Abstract

No universally accepted method of flap monitoring exists, and several techniques are in use. Repeated physical examination is most popular and is often supplemented with a handheld, external Doppler, and/or implantable Doppler probes; near-infrared spectroscopy is less commonly used. We investigated the nursing and resident house staff's experience and confidence with physical exam for flap monitoring. Also, a consecutive series of 38 patients with free flaps were monitored using physical examination, external Doppler, implantable arterial and venous Doppler probes, and near-infrared spectroscopy. Five patients developed signs of microvascular complications within 3 days of surgery; all were explored and salvaged. Neither the residents nor the nursing staff were universally trained or experienced in flap monitoring by physical exam. In all patients, changes in the appearance of the flap suggestive of a microvascular complication lagged 30 to 60 minutes after the adjunctive monitoring methods indicated that a problem had occurred. Near-infrared spectroscopy was the first warning sign in four of the five patients. Two patients were explored before thrombosis of the anastomoses occurred. Near-infrared spectroscopy may identify early microvascular complications more reliably than physical examination, external Doppler, or implantable Doppler.

Keywords

monitoring techniques - microsurgery - near infrared spectroscopy - external Doppler - implantable Doppler

• References

• 1 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: 187-195
• 2 Hidalgo DA, Jones CS. The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases. Plast Reconstr Surg 1990; 86: 492-498 , discussion 499–501
• 3 Kroll SS, Schusterman MA, Reece GP , et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98: 1230-1233
• 4 Whitaker IS, Oliver DW, Ganchi PA. Postoperative monitoring of microvascular tissue transfers: current practice in the United kingdom and Ireland. Plast Reconstr Surg 2003; 111: 2118-2119
• 5 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008; 61: 280-284
• 6 Hirigoyen MB, Urken ML, Weinberg H. Free flap monitoring: a review of current practice. Microsurgery 1995; 16: 723-726 , discussion 727
• 7 Jones NF. Intraoperative and postoperative monitoring of microsurgical free tissue transfers. Clin Plast Surg 1992; 19: 783-797
• 8 Furnas H, Rosen JM. Monitoring in microvascular surgery. Ann Plast Surg 1991; 26: 265-272
• 9 Jones BM. Monitors for the cutaneous microcirculation. Plast Reconstr Surg 1984; 73: 843-850
• 10 Jones JW, Wiebalck R. Continuous postoperative free-flap monitoring with an EKG-interfaced photoplethysmograph. J Reconstr Microsurg 1992; 8: 61-62
• 11 Jones NF. Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction. Microsurgery 1988; 9: 159-164
• 12 Khouri RK, Shaw WW. Monitoring of free flaps with surface-temperature recordings: is it reliable?. Plast Reconstr Surg 1992; 89: 495-499 , discussion 500–502
• 13 Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical free tissue transfers. J Reconstr Microsurg 1986; 3: 39-41
• 14 Thorniley MS, Sinclair JS, Barnett NJ, Shurey CB, Green CJ. The use of near-infrared spectroscopy for assessing flap viability during reconstructive surgery. Br J Plast Surg 1998; 51: 218-226
• 15 Yuen JC, Feng Z. Monitoring free flaps using the laser Doppler flowmeter: five-year experience. Plast Reconstr Surg 2000; 105: 55-61
• 16 Freed D, Hartley CJ, Christman KD, Lyman RC, Agris J, Walker WF. High-frequency pulsed Doppler ultrasound: a new tool for microvascular surgery. J Microsurg 1979; 1: 148-153
• 17 Hartley CJ, Cole JS. A single-crystal ultrasonic catheter-tip velocity probe. Med Instrum 1974; 8: 241-243
• 18 Pinnella JW, Spira M, Erk Y, Freed D, Hartley CJ. Direct microvascular monitoring with implantable ultrasonic Doppler probes. J Microsurg 1982; 3: 217-221
• 19 Jones NF, Rocke AM, Swartz WM, Klein A. Experimental and clinical monitoring of free jejunal transfers using an implantable ultrasonic Doppler probe. Br J Plast Surg 1989; 42: 274-280
• 20 Swartz WM, Jones NF, Cherup L, Klein A. Direct monitoring of microvascular anastomoses with the 20-MHz ultrasonic Doppler probe: an experimental and clinical study. Plast Reconstr Surg 1988; 81: 149-161
• 21 Gottrup F, Firmin R, Rabkin J, Halliday BJ, Hunt TK. Directly measured tissue oxygen tension and arterial oxygen tension assess tissue perfusion. Crit Care Med 1987; 15: 1030-1036
• 22 Hjortdal VE, Hauge E, Hansen ES. Differential effects of venous stasis and arterial insufficiency on tissue oxygenation in myocutaneous island flaps: an experimental study in pigs. Plast Reconstr Surg 1992; 89: 521-529
• 23 Hunt TK, Rabkin J, Jensen JA, Jonsson K, von Smitten K, Goodson III WH. Tissue oximetry: an interim report. World J Surg 1987; 11: 126-132
• 24 Colwell AS, Buntic RF, Brooks D, Wright L, Buncke GM, Buncke HJ. Detection of perfusion disturbances in digit replantation using near-infrared spectroscopy and serial quantitative fluoroscopy. J Hand Surg Am 2006; 31: 456-462
• 25 Colwell AS, Wright L, Karanas Y. Near-infrared spectroscopy measures tissue oxygenation in free flaps for breast reconstruction. Plast Reconstr Surg 2008; 121: 344e-345e
• 26 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23: 189-197
• 27 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: 538-543
• 28 Repez A, Oroszy D, Arnez ZM. Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy. J Plast Reconstr Aesthet Surg 2008; 61: 71-77
• 29 Hirigoyen MB, Blackwell KE, Zhang WX, Silver L, Weinberg H, Urken ML. Continuous tissue oxygen tension measurement as a monitor of free-flap viability. Plast Reconstr Surg 1997; 99: 763-773
• 30 Paydar KZ, Hansen SL, Chang DS, Hoffman WY, Leon P. Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate. Plast Reconstr Surg 2010; 125: 1129-1134
• 31 de la Torre J, Hedden W, Grant III JH, Gardner PM, Fix RJ, Vásconez LO. Retrospective review of the internal Doppler probe for intra- and postoperative microvascular surveillance. J Reconstr Microsurg 2003; 19: 287-290
• 32 Kind GM, Oliva A. Caution with regard to use of the implantable Doppler probe on the internal mammary vein. J Reconstr Microsurg 2008; 24: 71-72
• 33 Ferguson Jr RE, Yu P. Techniques of monitoring buried fasciocutaneous free flaps. Plast Reconstr Surg 2009; 123: 525-532
• 34 Neligan PC. Monitoring techniques for the detection of flow failure in the postoperative period. Microsurgery 1993; 14: 162-164
• 35 Irons GB, Wood MB, Schmitt III EH. Experience with one hundred consecutive free flaps. Ann Plast Surg 1987; 18: 17-23
• 36 Krag C. Experience with transplantation of composite tissues by means of microsurgical vascular anastomoses. II. Late results and comments. Scand J Plast Reconstr Surg 1985; 19: 157-173
• 37 Macnamara M, Pope S, Sadler A, Grant H, Brough M. Microvascular free flaps in head and neck surgery. J Laryngol Otol 1994; 108: 962-968
• 38 Schusterman MA, Miller MJ, Reece GP, Kroll SS, Marchi M, Goepfert H. A single center's experience with 308 free flaps for repair of head and neck cancer defects. Plast Reconstr Surg 1994; 93: 472-478 , discussion 479–480
• 39 Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique. Plast Reconstr Surg 1998; 102: 722-732 , discussion 733–734
• 40 Khouri RK, Cooley BC, Kunselman AR , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102: 711-721
• 41 Kroll SS, Schusterman MA, Reece GP , et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 1996; 98: 459-463