Download PDF
J Reconstr Microsurg 2013; 29(01): 051-056
DOI: 10.1055/s-0032-1326741
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

Robert F. Lohman
1   The Departments of Plastic and Orthopedic Surgery, The Cleveland Clinic, Cleveland, Ohio
,
Claude-Jean Langevin
2   The Department of Plastic Surgery, The Cleveland Clinic, Cleveland, Ohio
,
Mehmet Bozkurt
2   The Department of Plastic Surgery, The Cleveland Clinic, Cleveland, Ohio
,
Neilendu Kundu
3   The Department of General Surgery, The Cleveland Clinic, Cleveland, Ohio
,
Risal Djohan
2   The Department of Plastic Surgery, The Cleveland Clinic, Cleveland, Ohio
› Author Affiliations
Further Information

Publication History

07 March 2012

01 June 2012

Publication Date:
12 November 2012 (online)

Also available at
    Permissions and Reprints

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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 6 Hirigoyen MB, Urken ML, Weinberg H. Free flap monitoring: a review of current practice. Microsurgery 1995; 16: 723-726 , discussion 727
    CrossrefPubMedGoogle Scholar
  • 7 Jones NF. Intraoperative and postoperative monitoring of microsurgical free tissue transfers. Clin Plast Surg 1992; 19: 783-797
    CrossrefPubMedGoogle Scholar
  • 8 Furnas H, Rosen JM. Monitoring in microvascular surgery. Ann Plast Surg 1991; 26: 265-272
    CrossrefPubMedGoogle Scholar
  • 9 Jones BM. Monitors for the cutaneous microcirculation. Plast Reconstr Surg 1984; 73: 843-850
    Google Scholar
  • 10 Jones JW, Wiebalck R. Continuous postoperative free-flap monitoring with an EKG-interfaced photoplethysmograph. J Reconstr Microsurg 1992; 8: 61-62
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Jones NF. Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction. Microsurgery 1988; 9: 159-164
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 15 Yuen JC, Feng Z. Monitoring free flaps using the laser Doppler flowmeter: five-year experience. Plast Reconstr Surg 2000; 105: 55-61
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 17 Hartley CJ, Cole JS. A single-crystal ultrasonic catheter-tip velocity probe. Med Instrum 1974; 8: 241-243
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 26 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23: 189-197
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Ferguson Jr RE, Yu P. Techniques of monitoring buried fasciocutaneous free flaps. Plast Reconstr Surg 2009; 123: 525-532
    CrossrefPubMedGoogle Scholar
  • 34 Neligan PC. Monitoring techniques for the detection of flow failure in the postoperative period. Microsurgery 1993; 14: 162-164
    CrossrefPubMedGoogle Scholar
  • 35 Irons GB, Wood MB, Schmitt III EH. Experience with one hundred consecutive free flaps. Ann Plast Surg 1987; 18: 17-23
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar