Therefore, a free flap monitoring protocol is presented, including checking color, temperature, capillary return, and signal from a handheld doppler ultrasonograph in an intraoperatively marked. The use of near infrared spectroscopy nirs for monitoring of free flaps. 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. Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgical reconstructive surgery. The majority of these were for mandibular reconstruction figure 5.
The learning curve is short, thus acquisition of a smartphone and a thermal imaging camera should universally better permit safer free flap designs, provide additional intraoperative management insight, and even be another means for postoperative free flap monitoring. Background monitoring strategies have been developed to address the issue of detecting postoperative free flap ischemia in an effort to permit intervention and flap salvage. After completing this continuing education activity you will be able to. Plastic and reconstructive surgery october 2014 management of intraoperative free flap arterial thrombosis with argatroban in the heparinallergic patient sir. With the aim to rapidly identify a postoperative circulatory problem, some susceptible flaps can be saved by careful clinical monitoring or by various technical monitoring methods. In order to establish the currently preferred protocols, a survey was conducted among micro. Nursing monitoring and management of free flaps and pedicled flapsoutcomes of teaching sessions on flap care.
Because it is a buried flap, it presents a postoperative monitoring challenge. Blood perfusion in a free flap monitored for 16 hours after surgery. Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgi cal reconstructive surgery. This is one type of reconstructive surgery used after a mastectomy. A simple and effective method of monitoring a free skin flap transfer when the flap skin color is white in spite of having a good blood circulation is described. Lovenox 40mg sc in pacu and then daily starting pod 1 until discharge. Your guide to free flap breast reconstruction surgery. The role of the implantable doppler probe in free flap surgery. Therefore, a free flap monitoring protocol is presented, including checking color, temperature, capillary return, and signal from a handheld doppler ultrasonograph in an intraoperatively marked skin area directly over the pedicle. Postoperative monitoring of free flaps is important to minimize the risk of flap failure, but monitoring buried free flaps is difficult because the standard methods of clinical examination and surface doppler monitoring are not possible.
Free flap reconstruction monitoring techniques and. Free implies that the tissue is completely detached from its blood supply at the original location donor site and then transferred to another. Costeffectiveness of monitoring free flaps sciencedirect. Improved freeflap salvage rates2,3 as compared to clinical monitoring alone. Buried free flaps are often monitored using an impl.
Postoperative freeflap monitoring techniques thieme connect. Since the introduction of free tissue transfer in the 1960s, the success rate has improved substantially, currently being 9599% among experienced surgeons. Postoperative free flap care when considering free. Postoperative free flap monitoring in adult patients competency indicators 1st level achieved assessor signature competency indicators. Anticoagulation appears beneficial only in preventing venous thromboembolic. Data were received from 95 centers for the monitoring of 2,825 free flaps performed during 1994. Using a smartphone and mobile messenger application jin hee hwang, m. Current approaches to free flap monitoring request pdf.
It is easy to confirm that the anastomosed vessels are patent or not by visualizing the flap skin color, because erythema will appear after topical application of dinitrochlorobenzene even if skin color is white. Wolff kd 2006 free flap monitoring using simultaneous noninvasive laser doppler flowmetry and tissue spectrophotometry. 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. Nearinfrared spectroscopy nirs is a novel technique for free flap monitoring that has the propensity for early detection of vascular compromise when compared to the current gold standard. Implantable doppler probes for postoperatively monitoring free flaps. 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. Management of intraoperative free flap arterial thrombosis.
For more information on various flap procedures, see flaps. A simple and effective method of monitoring free skin. A free flap breast reconstruction uses your tissue called autologous to create a new breast. In head and neck surgery, where the flaps are often buried and difficult to. Intraoperative free jejunum flap monitoring with indocyanine green nearinfrared angiography. 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. Postoperative monitoring of free flap reconstruction. Anaesthesia for free flap breast reconstruction bja.
Administer antibiotics 24 hours after surgery, then dc 10. Free flap monitoring using an implantable doppler probe. The present analysis revealed a potential benefit for the id probe in the postoperative monitoring of free tissue transfers. Despite the complexity and increasing frequency of free flap reconstruction, there is no comprehensive head and neck resource intended for the radiologist. Elimination of environmental effects on temperature. Flap and replant perfusion monitoring microsurgeon. This article provides a framework to facilitate the planning, execution, and monitoring of free flaps. A nursing inservice was created to educate experienced and novice nurses on free flap monitoring and free flap patient care. We sought to evaluate our experience with color doppler ultrasound in the monitoring of gracilis free flap viability in the immediate postoperative. Tissue oximetry free flap monitoring in the head and neck.
Head and neck free flap monitoring remains heterogeneous with respect to technique and frequency of resident flap checks across academic institutions. A simple technique of marking the perforator of a free. Breast reconstruction with free flap procedure cpt 19364 preoperative phase. Free fibula flap accounted for almost twenty percent of the flaps done. Free fibula flap is now considered the gold standard for mandibular reconstruction 17.
The gracilis muscle free flap has become a reliable means for smile reanimation for patients with facial paralysis. Free flap management summary successful free flap management focuses on three areas. P ti o 2 monitoring is a feasible method of free flap monitoring when flap temperature is monitored and maintained close to the core temperature. No one existing noninvasive method has been widely accepted in a clinical setting. Name email organisation country please send me the pdf an flap monitoring. However, a good understanding of the physiology of blood flow both in the systemic circulation and through the free flap will help to make sensible.
Disruption of perfusion to a flap or replant can result in partial or complete tissue loss. Meaning institutions may monitor head and neck free flaps with decreased resident burden while maintaining good flap outcomes. Current approaches to free flap monitoring ceconnection for. Pdf nursing monitoring and management of free flaps and. However, most flaps are being monitored in the icu setting using q1h nursing checks with an external or implantable doppler. Monitoring of a free flap or a perforator flap is important in the immediate postoperative period to alert the surgeon of a vascular event and to enable flap salvage by early intervention.
An evolution of communication in postoperative free flap monitoring. The efficacy of clinical assessment in the postoperative monitoring of free flaps. An 18question multiple choice quiz was administered immediately before and after the course. In 1975, creech and miller outlined the criteria they considered essential for the ideal free flap monitoring device 6,9. Tissue is taken from your belly, back, thigh, or buttock. 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. In microsurgery, the successful salvage of free tissue transfer is dependent on the rapid decision to return to the operating room. Cost equivalence is reached between monitoring and not monitoring only at a failure rate of 15. Although clinical observation is the gold standard, the ideal free flap monitoring device has not been identified. Duke enhanced recovery breast reconstruction with free. Free flap head and neck surgery the ottawa hospital.
Tissue oximetry free flap monitoring in the head and neck ahmed m. Free flap monitoring techniques and frequency jama. The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the transplantation of tissue from one site of the body to another, in order to reconstruct an existing defect. The survey focused on nursing knowledge about free flap monitoring and care. An evolution of communication in postoperative free flap. Good communication consists of providing and receiving information efficiently and correctly. The authors increased the flap survival rate from 96. Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. When other monitoring methods give controversial results or are unavailable, 15 o h 2 o pet technique is feasible in the evaluation of the perfusion of the newly reconstructed free flaps. Close icu monitoring is paramount to early intervention in the event of complications. In order to establish the currently preferred protocols, a survey was conducted among microsurgeons in north america using a mailed questionnaire.
Individual techniques for the postoperative monitoring of free flaps vary considerably. A comparison of external doppler ultrasonography and the implantable doppler probe. Reconstruction of head and neck patients using free tissue transfer is perhaps the most challenging of areas in the human body. Anaesthesia for free flap breast reconstruction there are surprisingly few good randomized controlled trials regarding the best anaesthetic management for patients undergoing free flap surgery.
To be effective, changes in perfusion need to be recognized quickly to correct any treatable problems. Current approaches to free flap monitoring ce article. Monitor surgical flap until discharge vioptic andor doppler monitoring 9. Free flap monitoring protocol zurich open repository and. Recent advances in postoperative free microvascular flap. There were 2 free flaps with a success rate of 99%. Monitoring circulation of flaps and replants postoperatively is critical to success in microvascular surgery. Dynamic infrared thermography and smartphone thermal. Green light photoplethysmography monitoring of free flaps. For more precise and rapid notification of free flap status between staff members after surgery, the authors used a smartphone and mobile mes.
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