The few days after the procedure are critical and monitoring the free flap is mandatory not only for the safety of the flap but also for the patient. Case report noninvasive free flap monitoring using eulerian video magnification yuanfangliu,christophervuong,paulcharleswalker,nathanielraypeterson, jaredchristianinman,pedroalcantaraandradefilho,andstevechoonsunglee department of otolaryngologyhead and neck surgery, loma linda university medical center, loma linda, ca, usa. Free flaps with skin paddles were filmed in the operating room with manipulation of their pedicles. Meaning institutions may monitor head and neck free flaps with decreased resident burden while maintaining good flap outcomes. An evolution of communication in postoperative free flap. Evaluating an observation protocol article pdf available in journal of wound care 101. A multicenter comparison of 398 flaps using clinical monitoring, microdialysis, and the implantable doppler probe. Recent advances in postoperative free microvascular flap.
The majority of free flaps can be directly visualized, and vitality of the flap can be assessed simply by checking the colour of the tissue, turgor, capillary refill and bleeding. Good communication consists of providing and receiving information efficiently and correctly. Used for monitoring blood flow in vessels intraoperatively and following reconstructive. We investigated the nursing and resident house staffs experience and confidence with physical exam for flap monitoring. Current approaches to free flap monitoring ce article. Although complications are inevitable in a percentage of patients, it is good postoperative care and monitoring that determines the success or failure of the reconstruction and also permits early salvage of a failing free flap. Vascular supply for the new area, or flap, is obtained via anastamosis with vessels at new site. The present analysis revealed a potential benefit for the id probe in the postoperative monitoring of free tissue transfers. Free flap head and neck surgery the ottawa hospital.
Free flaps are rarely noted to fail when the patient is still in the operating room. Intraoperative free flap monitoring using indocyanine. Noninvasive free flap monitoring using eulerian video. Postoperative care and monitoring of the reconstructed. Pdf flap monitoring after head and neck reconstruction.
Pdf nursing monitoring and management of free flaps and. Reconstruction of head and neck patients using free tissue transfer is perhaps the most challenging of areas in the human body. For more precise and rapid notification of free flap status between staff members after surgery, the authors used a smartphone and mobile mes. Evidence for postoperative monitoring of microvascular free flaps. The overall flap complication rate has been reported as 2836%, with a flap takeback rate of 525%. Eulerian video magnification evm can enhance subtle changes in videos to reveal what was once invisible to the naked eye. Postoperative free flap care when considering free. Although clinical observation is the gold standard, the ideal free flap monitoring device has not been identified. Flap monitoring after head and neck reconstruction. Also, a consecutive series of 38 patients with free flaps were monitored using physical examination, external doppler, implantable arterial and venous.
The authors increased the flap survival rate from 96. An evolution of communication in postoperative free flap monitoring. Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. To be effective, changes in perfusion need to be recognized quickly to correct any treatable problems. For all free flaps, the blood supply is reconstituted using microsurgical techniques to reconnect the artery brings blood into the flap and vein allows blood to flow out of the flap.
The free flap failure rate has been significantly reduced, but free flap loss still occurs and remains a costly disaster. Patient is cleared to ambulate short distances with physical therapy and nursing staff while monitoring vitals. Because of the low failure rate, plethora of monitoring techniques, and diverse surgeon training, it would be difficult to demonstrate a clinically relevant advantage of any one of these techniques over another. Laserinduced fluorescence of indocyanine green is a new method for assessing tissue perfusion. Blood flow can be monitored continously or periodically as required.
Thermography is a one avenue that can be used for flap design and monitoring. This is a non randomized prospective study of subsequent patients undergoing head and neck cancer resections and free flap reconstruction. Pdf this study evaluated the postoperative freeflap monitoring frequency protocol used in a maxillofacial unit for patients receiving. Free flap reconstruction monitoring techniques and. Monitor surgical flap until discharge vioptic andor doppler monitoring 9. In order to establish the currently preferred protocols, a survey was conducted among micro. Breast reconstruction with free flap procedure cpt 19364 preoperative phase education in surgical clinic.
Individual techniques for the postoperative monitoring of free flaps vary considerably. In microsurgery, the successful salvage of free tissue transfer is dependent on the rapid decision to return to the operating room. They were selected to have their free flap planning done with a thermal. Postoperative monitoring of free flaps in autologous breast reconstruction. This required a clinician to monitor the flap s physical characteristics for colour, turgor, swelling, capillary refill time, temperature, bleeding characteristics after a pin prick or a combination of these approaches 1,3. Postoperative care of the flap patient nursing protocol. A free flap breast reconstruction uses your tissue called autologous to create a new breast. Clinical pathway free flap head and neck surgery tes ts treatments medications activity nutrition specialist consults patient teaching discharge planning postop day 1 morning bloodwork oxygen saturation monitoring cardiac monitoring doppler flap check cuffed tracheostomy tube, cuff. Using a smartphone and mobile messenger application jin hee hwang, m. Tissue oximetry free flap monitoring in the head and neck ahmed m. Tissue is taken from your belly, back, thigh, or buttock. With the development of smartphones and highspeed mobile data networks, photos and videos can be captured and shared in a realtime fashion, and it is especially suitable for postoperative free microvascular flap monitoring.
Background despite a plethora of monitoring techniques reported in the literature, only a small number of studies directly address clinical relevant end points, such as the flap salvage rate and falsepositive rate. Close icu monitoring is paramount to early intervention in the event of complications. Surgical technique ottie van zyl the radial free forearm flap rfff was one of the first free tissue transfer flaps to be described. Disruption of perfusion to a flap or replant can result in partial or complete tissue loss. Nursing monitoring and management of free flaps and pedicled flapsoutcomes of teaching sessions on flap care. Pdf postoperative monitoring of free flaps in autologous. This continual monitoring will provide an accurate and absolute history of how well the tissue is being perfused. Free flap management summary successful free flap management focuses on three areas.
Dynamic infrared thermography and smartphone thermal. In order to establish the currently preferred protocols, a survey was conducted among microsurgeons in north america using a mailed questionnaire. The use of buried free flaps in head and neck reconstruction makes monitoring particularly difficult, because either the flap does not communicate with the. Monitoring circulation of flaps and replants postoperatively is critical to success in microvascular surgery. It has since become a workhorse for soft tissue replacement in head. Invitedcommentary intraoperativefreeflapmonitoringusingindocyaninegreen yadrankoducic,md. Duke enhanced recovery breast reconstruction with free. Lin, md1 1 beth israel deaconess medical center, divisions of plastic surgery and otolaryngology, harvard medical school, 2 ain shams university, department of otolaryngology objective to assess the effectiveness of continuous. Free flap monitoring and salvage iowa head and neck. Implantable doppler probes for postoperatively monitoring free flaps. In a representative 77yearold female who received a latissimus dorsi. Tissue oximetry free flap monitoring in the head and neck. Perhaps with more experience, someday thermography will be more than just a complementary adjunct in the use of perforator flaps in general.
A new device, the vioptix tissue oximeter odisseytm based on nearinfrared spectroscopy was evaluated in 30 patients undergoing autologous tissue. Recently we could demonstrate that free flap skin temperature is closely related to free flap microcirculation applying temperature assessment and noninvasive continuous combined laser doppler and spectrophotometry. An example of free flap could be a free toe transfer in which the great toe or the second toe is transferred to the hand to reconstruct a thumb. Thermography in the planning and monitoring of free flaps. Your guide to free flap breast reconstruction surgery. Free flaps are regularly used in plastic and reconstructive surgery but have a significant failure rate due to vessel thrombosis in the reestablished arterial or venous circulation. Anticoagulation appears beneficial only in preventing venous thromboembolic. Repeated clinical examinations are commonly used for flap monitoring, but they can be unreliable because of their subjectivity.
Free flap monitoring using an implantable doppler probe. Postoperative freeflap monitoring techniques thieme connect. Indocyanine green fluorescence angiography for free flap. Postoperative monitoring of free flap reconstruction. Free flap monitoring with tstat y the tstat probes are placed post operatively on the surface of the tissue to provide a realtime saturation value that is updated every second. There was no difference in the groups with respect to the rates of complete or partial flap loss, return to the operating room or other complications. Irrespective of which monitoring methods are used, the duration and frequency of free flap monitoring remain generally the same and are based on what is known about how and when free flap vascular compromise occurs. Administer antibiotics 24 hours after surgery, then dc. Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgi cal reconstructive surgery. Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgical reconstructive surgery. Free flap failure rates have decreased to generally less than 4%.
Anticoagulation appears beneficial only in preventing venous thromboembolic events in. In this proof of concept study, we investigated using evm as a novel form of free flap monitoring. Elimination of environmental effects on temperature. The doppler blood flow monitor is designed to provide audible primary and visual secondary feedback of blood flow when connected to cookswartz doppler probes and extension cables.
Free flap monitoring in plastic and reconstructive surgery. Case report noninvasive free flap monitoring using. Measuring sto2 will give you an early indication of change. Data were received from 95 centers for the monitoring of 2,825 free flaps performed during 1994. Improved free flap salvage rates2,3 as compared to clinical monitoring alone. This is one type of reconstructive surgery used after a mastectomy. The role of the implantable doppler probe in free flap surgery. A prospective analysis of free flap monitoring techniques. Current approaches to free flap monitoring ceconnection for. Medical criteria that the md and team will monitor. Traditionally, clinical monitoring of free flaps in the postoperative period was considered to be the gold standard.