Evaluating the Use of Tissue Oximetry to Decrease Intensive Unit Monitoring for Free Flap Breast Reconstruction

Abstract

The postoperative paradigm for microsurgical flaps has historically required intensive unit monitoring. Using tissue oximetry, a fast-track pathway can reduce time spent in an intensive monitoring setting from 24 to 15 hours with significant cost savings and minimal risk of missing a failing free flap.

Inpatient Flap Monitoring after Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: How Long Is Long Enough?

“…Multiple studies have indicated that the majority of flap takebacks resulting from vascular complications occur in the first 24 to 48 postoperative hours after the index operation. 10,13,14 Ricci et al reported that 44% of their complications occurred in the first 4 hours after surgery and 96% occurred in the first 15 hours. 10 Another study by Chen et al showed that 82.3% of flaps with vascular compromise showed signs of circulatory decline within the first 24 hours after free tissue transfer.…”

“…10,13,14 Ricci et al reported that 44% of their complications occurred in the first 4 hours after surgery and 96% occurred in the first 15 hours. 10 Another study by Chen et al showed that 82.3% of flaps with vascular compromise showed signs of circulatory decline within the first 24 hours after free tissue transfer. 15 It is well accepted that early complications tend to be vascular in nature, including pedicle thrombosis, twisting, and spasm, and that most successful salvage attempts are made within the first 24 hours of the initial operation.…”

“…13,16 After this early period, salvage rates for compromised flaps decrease dramatically. 5,7,10,13,15,17 Because early complications are often associated with vascular problems, they are more likely to be correctable and thus warrant closer monitoring. 18 In contrast, late flap failures are less likely to be salvaged because they are intrinsic to the flap and thus do not warrant the same degree of preventative monitoring.…”

“…12,19,20 Multiple published studies have shown that the use of NIRS for continuous flap monitoring leads to earlier detection of microvascular complications and improves flap salvage rates (►Table 5). 3,4,8,10,11,19,20 As early as 2009, a study was published by Keller, which identified specific trends in StO 2 values that could accurately predict flap complications within 1 hour of the occlusive event, before any changes were detectable on Doppler. 3,8 Two years later, Lin et al showed that earlier 20 It is well accepted that this combination of early identification of flap compromise and prompt reoperation results in improved flap salvage rates.…”

“…We have used the NIRS system described earlier for over 10 years to monitor more than 1,500 flaps. Our interpretation of NIRS data has been guided largely by seminal papers that not only outline hard criteria for detecting vascular insufficiency and characteristic StO 2 curves for arterial versus venous issues but also discuss the nuances of such data interpretation [7][8][9][10][11][12]…”