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J Reconstr Microsurg 2021; 37(03): 300-308
DOI: 10.1055/s-0040-1722182
Original Article

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review

Amanda Y. Shen
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
,
Sarah Lonie
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
,
Kaiyang Lim 
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
,
Hannah Farthing
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
,
David J. Hunter-Smith
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
3   Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
,
Warren M. Rozen
1   Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
2   Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
3   Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
› Author Affiliations
Funding None.
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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

Note

All authors are in agreement with the content of this manuscript. This manuscript has not been published previously and is not under consideration elsewhere.




Publication History

Received: 07 May 2020

Accepted: 04 November 2020

Article published online:
04 January 2021

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