Applications of Ultrasound in the Postoperative Period: A Review

Abstract

Background Recent advances in ultrasound technology have further increased its potential for routine use by plastic and reconstructive surgeons.

Methods An extensive literature review was performed to determine the most common applications of ultrasound in the postoperative care of plastic and reconstructive surgery patients.

Results In contrast with other available imaging modalities, ultrasound is cost-effective, rapid to obtain, eliminates the need for ionizing radiation or intravenous contrast, and has virtually no contraindications. In addition to its diagnostic capabilities, ultrasound can also be used to facilitate treatment of common postoperative concerns conveniently at the bedside or in an office setting.

Conclusion This article presents a review of the current applications of ultrasound imaging in the postoperative care of plastic and reconstructive surgery patients, including free flap monitoring following microsurgery, diagnosis and treatment of hematoma and seroma, including those associated with BIA-ALCL, and breast implant surveillance.

Keywords

ultrasound - postoperative - plastic surgery - microsurgery - seroma - breast surgery

Publication History

Received: 31 May 2021

Accepted: 09 November 2021

Article published online:
24 January 2022

• References

• 1 Bui DT, Cordeiro PG, Hu Q-Y, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
• 2 Chen K-T, Mardini S, Chuang DC-C. et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
• 3 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
• 4 Jones NF, Jarrahy R, Song JI, Kaufman MR, Markowitz B. Postoperative medical complications–not microsurgical complications–negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer. Plast Reconstr Surg 2007; 119 (07) 2053-2060
• 5 Urken ML, Buchbinder D, Weinberg H. et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope 2015; 125 (07) 1512-1512
• 6 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
• 7 Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999; 125 (03) 295-299
• 8 Wax MK. The role of the implantable Doppler probe in free flap surgery. Laryngoscope 2014; 124 (Suppl. 01) S1-S12
• 9 Hyodo I, Nakayama B, Kato H. et al. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope 2007; 117 (02) 357-360
• 10 Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 2003; 41 (01) 16-20
• 11 Smit JM, Acosta R, Zeebregts CJ, Liss AG, Anniko M, Hartman EHM. Early reintervention of compromised free flaps improves success rate. Microsurgery 2007; 27 (07) 612-616
• 12 Kucur C, Durmus K, Uysal IO. et al. Management of complications and compromised free flaps following major head and neck surgery. Eur Arch Otorhinolaryngol 2016; 273 (01) 209-213
• 13 Gonzalez J, Gardikiotis I, Ruiz-Moya A. et al. Duplex echography as an adjuvant tool to clinical examination to detect early postoperative free flap vascular compromise. Microsurgery 2021; 41 (02) 109-118
• 14 Shinomiya R, Sunagawa T, Nakashima Y. et al. Monitoring vascular compromise using ultrasound after free tissue transfer. J Ultrasound Med 2020; 39 (06) 1213-1222
• 15 Rosenberg JJ, Fornage BD, Chevray PM. Monitoring buried free flaps: limitations of the implantable Doppler and use of color duplex sonography as a confirmatory test. Plast Reconstr Surg 2006; 118 (01) 109-113 , discussion 114–115
• 16 Safran T, Gorsky K, Viezel-Mathieu A, Kanevsky J, Gilardino MS. The role of ultrasound technology in plastic surgery. J Plast Reconstr Aesthet Surg 2018; 71 (03) 416-424
• 17 Arya R, Griffiths L, Figus A, King D, Ramakrishnan V, Griffiths M. Post-operative assessment of perfusion of Deep Inferior Epigastric Perforator (DIEP) free flaps via Pulsatility Index (PI) using a portable colour Doppler sonogram device. J Plast Reconstr Aesthet Surg 2013; 66 (07) 931-936
• 18 Jacob DD, Kwiecien GJ, Cakmakoglu C, Moreira A. Color duplex ultrasound for localization of vascular compromise in microsurgical breast reconstruction. Plast Reconstr Surg 2020; 145 (03) 666e-667e
• 19 Cuthbert R, Deutsch C, Roy A, Stimpson P, Patel H. Postoperative monitoring of the free jejunal flap: use of colour duplex and systematic review of available techniques. Ann R Coll Surg Engl 2018; 100 (06) 485-490
• 20 Schön R, Schramm A, Gellrich N-C, Maier W, Düker J, Schmelzeisen R. Color duplex sonography for the monitoring of vascularized free bone flaps. Otolaryngol Head Neck Surg 2003; 129 (01) 71-76
• 21 Khalid AN, Quraishi SA, Zang WA, Chadwick JL, Stack Jr BC. Color doppler ultrasonography is a reliable predictor of free tissue transfer outcomes in head and neck reconstruction. Otolaryngol Head Neck Surg 2006; 134 (04) 635-638
• 22 Kapoor A, Karmakar M, Roy C, Anand KP. Assessment of perfusion of free flaps used in head and neck reconstruction using pulsatility index. Indian J Plast Surg 2017; 50 (02) 173-179
• 23 Cho M-J, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
• 24 Hood K, Ganesh Kumar N, Kaoutzanis C, Higdon KK. Hematomas in aesthetic surgery. Aesthet Surg J 2018; 38 (09) 1013-1025
• 25 Kaoutzanis C, Winocour J, Gupta V. et al. Incidence and risk factors for major hematomas in aesthetic surgery: analysis of 129,007 patients. Aesthet Surg J 2017; 37 (10) 1175-1185
• 26 Polverini AC, Kruper L. Surgical emergencies in breast surgery. Surg Emerg Cancer Patient 2017
• 27 Wicks JD, Silver TM, Bree RL. Gray scale features of hematomas: an ultrasonic spectrum. AJR Am J Roentgenol 1978; 131 (06) 977-980
• 28 Almasarweh S, Sudah M, Joukainen S, Okuma H, Vanninen R, Masarwah A. The feasibility of ultrasound-guided vacuum-assisted evacuation of large breast hematomas. Radiol Oncol 2020; 54 (03) 311-316
• 29 Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg 2008; 122 (01) 280-288
• 30 Mohammad JA, Warnke PH, Stavraky W. Ultrasound in the diagnosis and management of fluid collection complications following abdominoplasty. Ann Plast Surg 1998; 41 (05) 498-502
• 31 Seretis K, Goulis D, Demiri EC, Lykoudis EG. Prevention of seroma formation following abdominoplasty: a systematic review and meta-analysis. Aesthet Surg J 2017; 37 (03) 316-323
• 32 Colen SR, Shaw WW, McCarthy JG. Review of the morbidity of 300 free-flap donor sites. Plast Reconstr Surg 1986; 77 (06) 948-953
• 33 Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg 2006; 117 (02) 414-430
• 34 Di Martino M, Nahas FX, Barbosa MVJ. et al. Seroma in lipoabdominoplasty and abdominoplasty: a comparative study using ultrasound. Plast Reconstr Surg 2010; 126 (05) 1742-1751
• 35 Di Martino M, Nahas FX, Kimura AK, Sallum N, Ferreira LM. Natural evolution of seroma in abdominoplasty. Plast Reconstr Surg 2015; 135 (04) 691e-698e
• 36 Gokhale S. Sonography in identification of abdominal wall lesions presenting as palpable masses. J Ultrasound Med 2006; 25 (09) 1199-1209
• 37 Stebbins WG, Hanke CW, Petersen J. Ultrasound-guided drainage of a seroma following tumescent liposuction. Dermatol Ther (Heidelb) 2011; 24 (01) 121-124
• 38 Park JE, Nigam M, Shenaq DS, Song DH. A simple, safe technique for thorough seroma evacuation in the outpatient setting. Plast Reconstr Surg Glob Open 2014; 2 (09) e212
• 39 Gioacchini M, Bottoni M, Grassetti L, Scalise A, Di Benedetto G. A simple, reliable, and inexpensive method for seroma drainage. Arch Plast Surg 2015; 42 (03) 361-362
• 40 Klusmann M, Tehrani H. A novel method for seroma drainage. Plast Reconstr Surg 2005; 116 (05) 1577
• 41 Berríos-Torres SI, Umscheid CA, Bratzler DW. et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152 (08) 784-791
• 42 Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg 2012; 147 (04) 373-383
• 43 Kantar RS, Rifkin WJ, Wilson SC. et al. Abdominal panniculectomy: determining the impact of diabetes on complications and risk factors for adverse events. Plast Reconstr Surg 2018; 142 (04) 462e-471e
• 44 Gabriel A, Gupta S, Orgill DP. Challenges and management of surgical site occurrences. Plast Reconstr Surg 2019; 143 (1S Management of Surgical Incisions Utilizing Closed-Incision Negative-Pressure Therapy, 1S): 7S-10S
• 45 Gottlieb M, Avila J, Chottiner M, Peksa GD. Point-of-care ultrasonography for the diagnosis of skin and soft tissue abscesses: a systematic review and meta-analysis. Ann Emerg Med 2020; 76 (01) 67-77
• 46 O'Rourke K, Kibbee N, Stubbs A. Ultrasound for the evaluation of skin and soft tissue infections. Mo Med 2015; 112 (03) 202-205
• 47 Chau CLF, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol 2005; 60 (02) 149-159
• 48 Ozseker B, Ozcan UA, Rasa K, Cizmeli OM. Treatment of breast abscesses with ultrasound-guided aspiration and irrigation in the emergency setting. Emerg Radiol 2008; 15 (02) 105-108
• 49 Clemens MW, Brody GS, Mahabir RC, Miranda RN. How to diagnose and treat breast implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg 2018; 141 (04) 586e-599e
• 50 Ramos-Gallardo G, Cuenca-Pardo J, Rodríguez-Olivares E. et al. Breast implant and anaplastic large cell lymphoma meta-analysis. J Invest Surg 2017; 30 (01) 56-65
• 51 Gidengil CA, Predmore Z, Mattke S, van Busum K, Kim B. Breast implant-associated anaplastic large cell lymphoma: a systematic review. Plast Reconstr Surg 2015; 135 (03) 713-720
• 52 Clemens MW, Horwitz SM. NCCN consensus guidelines for the diagnosis and management of breast implant-associated anaplastic large cell lymphoma. Aesthet Surg J 2017; 37 (03) 285-289
• 53 Adrada BE, Miranda RN, Rauch GM. et al. Breast implant-associated anaplastic large cell lymphoma: sensitivity, specificity, and findings of imaging studies in 44 patients. Breast Cancer Res Treat 2014; 147 (01) 1-14
• 54 Carr LW, Roberts J, Mericli AF, Liu J, Arribas EM, Clemens MW. Breast implant imaging surveillance among U.S. plastic surgeons: U.S. Food and Drug Administration recommendations versus clinical reality. Plast Reconstr Surg 2020; 145 (06) 1381-1387
• 55 Stivala A, Rem K, Leuzzi S. et al. Efficacy of ultrasound, mammography and magnetic resonance imaging in detecting breast implant rupture: a retrospective study of 175 reconstructive and aesthetic sub-pectoral breast augmentation cases. J Plast Reconstr Aesthet Surg 2017; 70 (11) 1520-1526
• 56 U.S. Food & Drug Administration. Guidance Document: Breast Implants - Certain Labeling Recommendations to Improve Patient Communication. Published September 29, 2020. Accessed November 30, 2021 https://www.fda.gov/regulatory-information/search-fda-guidance-documents/breast-implants-certain-labeling-recommendations-improve-patient-communication
• 57 Chung KC, Malay S, Shauver MJ, Kim HM. Economic analysis of screening strategies for rupture of silicone gel breast implants. Plast Reconstr Surg 2012; 130 (01) 225-237
• 58 U.S. Department of Health and Human Services. About the Epidemic. Published February 19, 2021. Accessed November 30, 2021 https://www-hhs-gov.proxy.library.vanderbilt.edu/opioids/about-the-epidemic/index.html
• 59 Long EA, Johnson SP, Valmadrid A, Wormer BA, Drolet BC, Perdikis G. Plastic surgery patient expectations for postoperative opioid prescriptions. Ann Plast Surg 2020; 84 (6S, Suppl 5): S437-S440
• 60 Demsey D, Carr NJ, Clarke H, Vipler S. Managing opioid addiction risk in plastic surgery during the perioperative period. Plast Reconstr Surg 2017; 140 (04) 613e-619e
• 61 Joshi GP, Kehlet H. Postoperative pain management in the era of ERAS: an overview. Best Pract Res Clin Anaesthesiol 2019; 33 (03) 259-267
• 62 Barker JC, Joshi GP, Janis JE. Basics and best practices of multimodal pain management for the plastic surgeon. Plast Reconstr Surg Glob Open 2020; 8 (05) e2833
• 63 Momoh AO, Hilliard PE, Chung KC. Regional and neuraxial analgesia for plastic surgery: surgeon's and anesthesiologist's perspectives. Plast Reconstr Surg 2014; 134 (4, Suppl 2): 58S-68S
• 64 Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2010; 105 (06) 842-852
• 65 Salviz EA, Sivrikoz N, Ozonur A. et al. Ultrasound-guided bilateral thoracic paravertebral blocks as an adjunct to general anesthesia in patients undergoing reduction mammaplasty: a historical cohort study. Plast Reconstr Surg 2017; 139 (01) 20e-28e
• 66 ElHawary H, Joshi GP, Janis JE. Practical review of abdominal and breast regional analgesia for plastic surgeons: evidence and techniques. Plast Reconstr Surg Glob Open 2020; 8 (12) e3224
• 67 Fahy AS, Jakub JW, Dy BM. et al. Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Ann Surg Oncol 2014; 21 (10) 3284-3289
• 68 Salibian AA, Frey JD, Thanik VD, Karp NS, Choi M. Transversus abdominis plane blocks in microsurgical breast reconstruction: analysis of pain, narcotic consumption, length of stay, and cost. Plast Reconstr Surg 2018; 142 (03) 252e-263e
• 69 Sforza M, Andjelkov K, Zaccheddu R, Nagi H, Colic M. Transversus abdominis plane block anesthesia in abdominoplasties. Plast Reconstr Surg 2011; 128 (02) 529-535
• 70 Zhong T, Ojha M, Bagher S. et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: a double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg 2014; 134 (05) 870-878
• 71 Ha AY, Keane G, Parikh R. et al. The analgesic effects of liposomal bupivacaine versus bupivacaine hydrochloride administered as a transversus abdominis plane block after abdominally based autologous microvascular breast reconstruction: a prospective, single-blind, randomized, controlled trial. Plast Reconstr Surg 2019; 144 (01) 35-44
• 72 Gürkan Y, Aksu C, Kuş A, Yörükoğlu UH. Erector spinae plane block and thoracic paravertebral block for breast surgery compared to IV-morphine: a randomized controlled trial. J Clin Anesth 2020; 59: 84-88
• 73 Oksuz G, Bilgen F, Arslan M, Duman Y, Urfalıoglu A, Bilal B. Ultrasound-guided bilateral erector spinae block versus tumescent anesthesia for postoperative analgesia in patients undergoing reduction mammoplasty: a randomized controlled study. Aesthetic Plast Surg 2019; 43 (02) 291-296
• 74 Bhan S, Mishra S, Gupta N. et al. A prospective randomised study to assess the analgesic efficacy of serratus anterior plane (SAP) block for modified radical mastectomy under general anaesthesia. Turk J Anaesthesiol Reanim 2021; 49 (02) 124-129
• 75 Ruan QZ, Diamond S, Zimmer S, Iorio ML. Assessing the safety and efficacy of regional anesthesia for lower extremity microvascular reconstruction: enhancing recovery. J Reconstr Microsurg 2018; 34 (04) 293-299
• 76 Soberón Jr JR, Crookshank III JW, Nossaman BD, Elliott CE, Sisco-Wise LE, Duncan SF. Distal peripheral nerve blocks in the forearm as an alternative to proximal brachial plexus blockade in patients undergoing hand surgery: a prospective and randomized pilot study. J Hand Surg Am 2016; 41 (10) 969-977
• 77 Chi D, Chen AD, Lee BT. Comparative effectiveness of transversus abdominis plane blocks in abdominally based autologous breast reconstruction. Plast Reconstr Surg Glob Open 2019; 7: 116-117
• 78 Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016; 41 (05) 621-627
• 79 Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66 (09) 847-848
• 80 Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of PECS II (modified PECS I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012; 59 (09) 470-475
• 81 Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68 (11) 1107-1113
• 82 Tsai H-C, Yoshida T, Chuang T-Y. et al. Transversus abdominis plane block: an updated review of anatomy and techniques. BioMed Res Int 2017; 2017: 8284363
• 83 Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56 (10) 1024-1026
• 84 Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral nerve block of the upper limb: a technical review. J Anaesthesiol Clin Pharmacol 2015; 31 (03) 296-307
• 85 Winter J, McLeod G, Quaife T, Petropolis C. Surgeon-administered ultrasound-guided peripheral nerve blocks in outpatient procedures of the upper extremity. Plast Reconstr Surg Glob Open 2020; 8 (11) e3227
• 86 Bendtsen TF, Nielsen TD, Rohde CV, Kibak K, Linde F. Ultrasound guidance improves a continuous popliteal sciatic nerve block when compared with nerve stimulation. Reg Anesth Pain Med 2011; 36 (02) 181-184
• 87 Dangle J, Kukreja P, Kalagara H. Review of current practices of peripheral nerve blocks for hip fracture and surgery. Curr Anesthesiol Rep 2020; 10 (03) 259-266