Postoperative Monitoring of Free DIEP Flap in Breast Reconstruction with Near-Infrared Spectroscopy: Variables Affecting the Regional Oxygen Saturation

Marzia Salgarello; Domenico Pagliara; Marco Rossi; Giuseppe Visconti; Liliana Barone-Adesi

doi:10.1055/s-0038-1636527

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2018; 34(06): 383-388
DOI: 10.1055/s-0038-1636527

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Postoperative Monitoring of Free DIEP Flap in Breast Reconstruction with Near-Infrared Spectroscopy: Variables Affecting the Regional Oxygen Saturation

Marzia Salgarello

¹Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy

,

Domenico Pagliara

¹Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy

,

Marco Rossi

²Department of Anesthesia, Perioperative Medicine and Pain Therapy, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy

,

Giuseppe Visconti

¹Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy

,

Liliana Barone-Adesi

¹Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart – Policlinico Agostino Gemelli, Rome, Italy

› Author Affiliations

Abstract

Background The timing of surgical reexploration in microanastomotic thrombosis is directly related to the salvage rate of free flap. Near-infrared spectroscopy (NIRS) is a noninvasive technique, which allows a continuous bedside monitoring of flap oxygenation. The current literature is lacking in the assessment of variables able to modify the NIRS monitoring. The aim of this study is to identify patient and flap-related variables that can affect regional oxygen saturation (rSO₂).

Methods We retrospectively analyzed the data obtained from 45 consecutive patients undergoing breast reconstruction with deep inferior epigastric perforator (DIEP) flap. The monitoring device used is the Somanetics INVOS 5100C Cerebral/Somatic Oximeter (Covidien). Baseline measures of demographic–anthropometric variables (age, weight, height, body mass index [BMI]) and flap factors (flap size in grams, skin flap area in square centimeters, perforator number, and perforator size in millimeters) were collected from preoperative and intraoperative assessment. We investigated the linear correlation between mean rSO₂ and BMI, flap size, skin flap area, perforator number, and perforator size.

Results A positive linear correlation between rSO₂ values and skin flap area, perforator number, and perforator size was found. A negative linear correlation between rSO₂ values and BMI and flap size was found. All correlations are statistically significant. Despite the overall negative linear correlation between rSO₂ values and flap size, we observed a bimodal trend: a positive relation up to 800 g, which is inverted above 800 g.

Conclusion The NIRS is a reliable additional tool in free flap monitoring. A careful evaluation should be given to patients and surgery factors that can change the oximetry data.

Keywords

DIEP flap - NIRS monitoring - variables in NIRS monitoring

Full Text

References

References
1 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
2 Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999; 52 (02) 104-111
3 Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg 2009; 63 (02) 222-230
4 Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg 2008; 122 (03) 702-709
5 Nahabedian MY. Secondary operations of the anterior abdominal wall following microvascular breast reconstruction with the TRAM and DIEP flaps. Plast Reconstr Surg 2007; 120 (02) 365-372
6 Vanschoonbeek A, Fabre G, Nanhekhan L, Vandevoort M. Outcome after urgent microvascular revision of free DIEP, SIEA and SGAP flaps for autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1598-1608
7 Vijan SS, Tran VN. Microvascular breast reconstruction pedicle thrombosis: how long can we wait?. Microsurgery 2007; 27 (06) 544-547
8 Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg 1999; 104 (01) 97-101
9 Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013; 29 (01) 51-56
10 Chae MP, Rozen WM, Whitaker IS. , et al. Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg 2015; 74 (05) 621-632
11 Irwin MS, Thorniley MS, Doré CJ, Green CJ. Near infra-red spectroscopy: a non-invasive monitor of perfusion and oxygenation within the microcirculation of limbs and flaps. Br J Plast Surg 1995; 48 (01) 14-22
12 Thorniley MS, Sinclair JS, Barnett NJ, Shurey CB, Green CJ. The use of near-infrared spectroscopy for assessing flap viability during reconstructive surgery. Br J Plast Surg 1998; 51 (03) 218-226
13 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23 (04) 189-197
14 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (05) 538-543
15 Pelletier A, Tseng C, Agarwal S, Park J, Song D. Cost analysis of near-infrared spectroscopy tissue oximetry for monitoring autologous free tissue breast reconstruction. J Reconstr Microsurg 2011; 27 (08) 487-494
16 Lin SJ, Nguyen MD, Chen C. , et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (03) 1080-1085
17 Akita S, Mitsukawa N, Tokumoto H. , et al. Regional Oxygen Saturation Index: a novel criterion for free flap assessment using tissue oximetry. Plast Reconstr Surg 2016; 138 (03) 510e-518e
18 Kagaya Y, Ohura N, Kurita M, Takushima A, Harii K. Examination of tissue oxygen saturation (StO2) changes associated with vascular pedicle occlusion in a rat Island flap model using near-Infrared spectroscopy. Microsurgery 2015; 35 (05) 393-398
19 Ozturk CN, Ozturk C, Ledinh W. , et al. Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction. Microsurgery 2015; 35 (02) 123-128
20 Visconti G, Tomaselli F, Monda A, Barone-Adesi L, Salgarello M. Deep inferior epigastric artery perforator flap donor-site closure with cannula-assisted, limited undermining, and progressive high-tension sutures versus standard abdominoplasty: complications, sensitivity, and cosmetic outcomes. Plast Reconstr Surg 2015; 135 (01) 1-12
21 Cina A, Salgarello M, Barone-Adesi L, Rinaldi P, Bonomo L. Planning breast reconstruction with deep inferior epigastric artery perforating vessels: multidetector CT angiography versus color Doppler US. Radiology 2010; 255 (03) 979-987
22 Chen Y, Shen Z, Shao Z, Yu P, Wu J. Free flap monitoring using near-infrared spectroscopy: a systemic review. Ann Plast Surg 2016; 76 (05) 590-597
23 Koolen PG, Vargas CR, Ho OA. , et al. Does increased experience with tissue oximetry monitoring in microsurgical breast reconstruction lead to decreased flap loss? The learning effect. Plast Reconstr Surg 2016; 137 (04) 1093-1101
24 Gravvanis A, Tsoutsos D, Karakitsos D, Iconomou T, Papadopoulos O. Blood perfusion of the free anterolateral thigh perforator flap: its beneficial effect in the reconstruction of infected wounds in the lower extremity. World J Surg 2007; 31 (01) 11-18
25 Cornejo A, Rodriguez T, Steigelman M. , et al. The use of visible light spectroscopy to measure tissue oxygenation in free flap reconstruction. J Reconstr Microsurg 2011; 27 (07) 397-402
26 Kyle B, Litton E, Ho KM. Effect of hyperoxia and vascular occlusion on tissue oxygenation measured by near infra-red spectroscopy (InSpectra™): a volunteer study. Anaesthesia 2012; 67 (11) 1237-1241
27 Rubino C, Ramakrishnan V, Figus A, Bulla A, Coscia V, Cavazzuti MA. Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage. J Plast Reconstr Aesthet Surg 2009; 62 (12) 1666-1670
28 Cai ZG, Zhang J, Zhang JG. , et al. Evaluation of near infrared spectroscopy in monitoring postoperative regional tissue oxygen saturation for fibular flaps. J Plast Reconstr Aesthet Surg 2008; 61 (03) 289-296
29 Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol 2007; 56 (06) 901-916 , quiz 917–920
30 Adams F, Jordan J, Schaller K, Luft FC, Boschmann M. Blood flow in subcutaneous adipose tissue depends on skin-fold thickness. Horm Metab Res 2005; 37 (02) 68-73
31 Nguyen-Tu MS, Begey AL, Decorps J. , et al. Skin microvascular response to pressure load in obese mice. Microvasc Res 2013; 90: 138-143
32 Edmonds Jr HL, Ganzel BL, Austin III EH. Cerebral oximetry for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth 2004; 8 (02) 147-166
33 Laflam A, Joshi B, Brady K. , et al. Shoulder surgery in the beach chair position is associated with diminished cerebral autoregulation but no differences in postoperative cognition or brain injury biomarker levels compared with supine positioning: the anesthesia patient safety foundation beach chair study. Anesth Analg 2015; 120 (01) 176-185
34 Casati A, Fanelli G, Pietropaoli P. , et al. Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia. Anesth Analg 2006; 102 (06) 1645
35 Baik N, Urlesberger B, Schwaberger B. , et al. Reference ranges for cerebral tissue oxygen saturation index in term neonates during immediate neonatal transition after birth. Neonatology 2015; 108 (04) 283-286
36 Ricci JA, Vargas CR, Lin SJ, Tobias AM, Taghinia AH, Lee BT. A novel free flap monitoring system using tissue oximetry with text message alerts. J Reconstr Microsurg 2016; 32 (05) 415-420
37 Olenczak JB, Murariu D, Ikeda K, Thiele RH, Campbell CA. Tissue monitoring with three-wavelength light emitting diode-based near-infrared spectroscopy. J Reconstr Microsurg 2016; 32 (09) 712-718