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The Efficacy of Clinical Assessment in the Postoperative Monitoring of Free Flaps: A Review of 1140 Consecutive Cases

Chubb, Daniel M.B.B.S., B.Med.Sc.; Rozen, Warren M. M.B.B.S., B.Med.Sc., Ph.D.; Whitaker, Iain S. B.A.(Hons.), M.A.(Cantab.), M.B.B.Chir.; Acosta, Rafael M.D.; Grinsell, Damien M.B.B.S.; Ashton, Mark W. M.B.B.S., M.D.

Plastic and Reconstructive Surgery: April 2010 - Volume 125 - Issue 4 - p 1157-1166
doi: 10.1097/PRS.0b013e3181d0ac95
Reconstructive: Trunk: Original Articles

Background: Effective postoperative monitoring of the vascular pedicle to a free flap can potentiate rapid return to the operating room in the setting of compromise, allowing for the potential to salvage the flap. The only ubiquitous method for postoperative monitoring of free flaps is clinical bedside monitoring, but although the use of clinical monitoring may be inferred in large reported series of free flaps, there has been little discussed in the literature of specific clinical outcome measures.

Methods: The authors present their experience with 1140 consecutive cases of free tissue transfer and the use of clinical monitoring as a sole method of monitoring, and subgroup analysis of different recipient sites.

Results: There were 94 take-backs, four of which had no pedicle compromise (false-positives) and there were four false-negatives. The overall flap salvage rate was 62.8 percent and the false-positive rate was 0.4 percent. Subgroup analyses demonstrated statistically significant differences between recipient sites for the false-positive rates: fewer false-positives with breast reconstruction cases (p < 0.05) and significantly more false-positives in the extremity group (p < 0.05). There was an improved flap salvage rate in cases of venous compromise compared with arterial compromise (69 percent versus 51 percent, p = 0.015).

Conclusions: This largest reported series to date provides an outcome-based analysis of postoperative monitoring for free flaps, providing a benchmark standard against which adjunctive monitoring techniques can be compared. Future studies need to be assessed in the context of individual recipient sites, with significant differences in monitoring outcomes between sites.

Parkville, Victoria, Australia; Swansea, United Kingdom; and Uppsala, Sweden

From the Jack Brockhoff Reconstructive Plastic Surgery Research Unit and the Department of Anatomy, University of Melbourne; the Department of Plastic, Reconstructive, and Burns Surgery, The Welsh Centre for Burns and Plastic Surgery, Morriston Hospital; and the Department of Plastic Surgery, Uppsala Clinic Hospital.

Received for publication July 17, 2009; accepted October 2, 2009.

Disclosure: There was no source of financial or other support, or any financial or other relationships, that might pose a competing interest.

Daniel Chubb, M.B.B.S., B.Med.Sc. Jack Brockhoff Reconstructive Plastic Surgery Research Unit; Room E533; Department of Anatomy; University of Melbourne; Grattan Street; Parkville 3050, Victoria, Australia;

©2010American Society of Plastic Surgeons