Abstract
Background Microsurgical free tissue transfer has become a reliable technique with success rates
around 99% and around 5% requiring exploration for vascular compromise. Protocols
for flap monitoring between plastic surgery units vary. We aimed to elucidate the
time period when monitoring is crucial for flap salvage.
Methods A systematic search of literature was performed in PubMed, Cochrane Library, Medline,
and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies
with mention of free flap and monitoring or timing or salvage or compromise. Studies
were screened for relevance according to predetermined inclusion criteria. Data was
extracted from included studies relating to flap type, monitoring, timing and reason
for failure, and success of salvage intervention.
Results A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549
(5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654
(3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps
are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none
were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was
venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma
or infection. The proportion of flap failures at various recipient sites was highest
in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs
(5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95%
CI 0.00, 0.02).
Conclusion Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating
rapid detection of vascular compromise, early salvage, and better outcomes. The location
of the flap has implications on its success and certain recipient sites may need particular
attention to improve chances of success.
Keywords
free flap - timing - failure - salvage
