Modern Flap Monitoring Protocols Reduce the Time Needed for Inpatient Flap Monitoring
Katherine H. Carruthers, MD, MS1, Pankaj Tiwari, MD2, Shunsuke Yoshida, MD, MS2, Ayaz Shaikh, MD2, Ergun Kocak, MD, MS2.
1West Virginia University, Morgantown, WV, USA, 2Midwest Breast & Aesthetic Surgery, Gahanna, OH, USA.
The monitoring of free tissue flaps after microsurgical breast reconstruction has become the standard of care. However, the methods and duration of flap monitoring vary greatly between institutions and practitioners. In recent years, several noninvasive flap monitoring technologies, such as tissue oximetry with near-infrared spectroscopy, have been introduced and incorporated into flap monitoring protocols alongside the more traditional techniques of external Doppler and clinical examination. While many of these technologies have not been shown to definitively improve flap outcomes, they have been shown to reduce the time it takes to detect impending flap compromise. Given the growing trend across healthcare to perform increasingly complex procedures in less acute, lower cost settings, we set out to determine if the routine implementation of a flap monitoring protocol utilizing noninvasive flap monitoring technologies could reduce the overall time needed for inpatient flap monitoring.
METHODS: The medical charts of all patients who underwent microsurgical breast reconstruction with free deep inferior epigastric artery perforator (DIEP) flaps over 24 consecutive months by three surgeons in a single practice were reviewed. For all cases, preoperative computed tomography angiography (CTA) was used for surgical planning and flap design. Postoperatively, all flaps were monitored according to a protocol that included tissue oximetry with noninvasive near-infrared spectroscopy. The primary endpoints evaluated included any unplanned return to the operating room during the initial seven days after surgery, time to takeback, and flap loss or salvage rate.
In the study period, a total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. A total of 14 patients were brought back to the operating room during their initial hospitalization. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues and 9 of the reconstructed breasts (3.0%) were taken back for non-vascular issues such as hematoma. Of patients who were brought back for microvascular issues, all 5 (100.0%) of the takebacks occurred within the first 14 hours and none occurred after that time point. Of flaps that were reexplored for potential vascular compromise, all were salvaged. In the series there were two flap losses, one occurred intraoperatively and the other occurred eight days postoperatively, after the patient was discharged, making the overall flap failure rate for this series 0.66% (n=2).
Advances in flap monitoring technologies have reduced the time that it takes to detect microvascular flap compromise. In this series, all of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt takeback and flap salvage. The results of this study bring into question the need for more lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable when modern flap monitoring protocols are utilized for select patients following microvascular breast reconstruction.
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