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Current Approaches to Free Flap Monitoring

Albert H. Chao, MD
Susan Lamp, BSN, RN, CPSN

There are several approaches to monitoring free flaps

Postoperative monitoring of free flaps remains an essential
postoperatively, including physical examination, labora-
component of care in patients undergoing microsurgi-
tory testing, and the use of medical devices. Oftentimes,
cal reconstructive surgery. Early recognition of vascular
more than 1 method is employed to enhance the ability
problems and prompt surgical intervention improve the
to detect a vascular problem. Each method of monitor-
chances for flap salvage. Physical examination remains
ing has its own advantages and disadvantages (discussed
the cornerstone of free flap monitoring, but more recently,
later), which generally determines which methods are
additional technologies have been developed for this
used in a given case. Irrespective of which monitoring
purpose. In this article, current approaches to free flap
methods are used, the duration and frequency of free flap
monitoring are reviewed.
monitoring remain generally the same and are based on
what is known about how and when free flap vascular
compromise occurs:
1. Duration. Free flap vascular problems typically oc-
INTRODUCTION cur during the first 3 postoperative days (Chao,
Free flap surgery involves the transfer of a patient’s own Meyerson, Povoski, & Kocak, 2013). Accordingly,
tissue from a donor site to a recipient site, which is typi- free flaps are generally monitored starting imme-
cally the site of a defect. The donor site usually has a diately postoperatively until at least day 3, and in
distant location with respect to the recipient site, and some cases for additional days depending on the
therefore in order to physically transfer tissue while main- nature of the procedure (e.g., difficulty) and sur-
taining its viability, that tissue’s vascular supply must be geon preference (Chen et al., 2007).
divided at the donor site, and then reconnected through 2. Frequency. The likelihood of salvaging a failing
the creation of anastomoses at the recipient site. Like free flap improves if the delay between the onset
other types of vascular anastomoses, such as in cardiac of a vascular problem and surgical intervention to
surgery, thrombosis can occur, which threatens free flap correct that problem is reduced (Kroll et al., 1996).
survivability. Without surgical intervention, vascular com- Excessively long delays before intervention occurs,
promise will eventually progress to irreversible and total during which the flap is ischemic, can result in
loss of the free flap. On the contrary, with early identi- partial or total flap loss. For this reason, free flaps
fication and prompt intervention, many failing free flaps are typically monitored frequently (every 30–60
can be salvaged, which underscores the importance of min), especially during the first few days postop-
postoperative flap monitoring. eratively, to identify vascular compromise as soon
as possible so that action can be taken.
Free flaps are performed in both academic centers and
nonacademic centers. The setting where specific types
Albert H. Chao, MD, is Assistant Professor in the Department of Plastic
of free flaps are performed relates largely to the periop-
Surgery at Ohio State University and a board-certified plastic surgeon with erative and postoperative care required, as well as the
specialty training in microvascular surgery. His clinical practice focuses nature of patients who undergo these procedures. Pa-
on oncologic reconstruction and microsurgery, and his research interests
include patient outcomes and the role of technology.
tients undergoing free flap breast reconstruction generally
Susan Lamp, BSN, RN, CPSN, has been a plastic surgery nurse for
tend to be healthy and, aside from flap monitoring, re-
the past 20 years working with the Department of Plastic Surgery at the quire few, if any, additional specialty services. Therefore,
Ohio State University Wexner Medical Center. She currently serves on the these cases are frequently performed in academic and
PSN Journal Editorial Board and the Plastic Surgical Nursing Certification
Board.
nonacademic hospitals alike. The other major group of
The authors report no conflicts of interest.
cancer patients who often require free flap reconstruc-
Address correspondence to Albert H. Chao, MD, Department of Plastic
tion are patients with head and neck tumors. In contrast,
Surgery, The Ohio State University, 915 Olentangy River Road, Suite 2100, these patients tend to have more numerous and signifi-
Columbus, OH 43212 (e-mail: [email protected]). cant medical comorbidities, as well as additional consid-
DOI: 10.1097/PSN.0000000000000037 erations such as airway, nutrition, and speech. For these

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 reasons, microvascular head and neck reconstruction is PHYSICAL EXAMINATION
generally performed in academic hospitals. Trauma pa-
tients who suffer injuries severe enough to necessitate Traditionally, physical examination findings have been
free flap reconstruction frequently will have sustained the foundation of postoperative free flap monitoring and
other major injuries and thus require multidisciplinary are considered by most microsurgeons to be the gold
care that in many cases is most appropriately provided in standard technique. In general, it is advisable to perform
an academic hospital as well. an initial free flap assessment with a practitioner who
has previously examined the flap to establish a baseline;
otherwise, it may sometimes be unclear whether physi-
POSTOPERATIVE FREE FLAP CARE cal examination findings in a particular case represent
When considering free flap monitoring, a thorough un- something that is normal versus abnormal. In addition,
derstanding of postoperative free flap care is essential, it is important to examine a free flap in the context of a
because it allows the health care practitioner to differenti- patient’s overall condition, to determine whether findings
ate between a true vascular problem that requires surgi- are related to the free flap itself or to a systemic issue.
cal intervention and an issue with the patient that can be
corrected medically or at the bedside. Although there is Capillary Refill
no consensus on postoperative free flap care, there are In a capillary refill assessment, cutaneous blood is ex-
general themes practiced by most microsurgeons. punged from a small area of the free flap, usually by
In general, the free flap patient should be systemi- temporarily applying digital pressure to the flap itself,
cally well perfused, because this is a prerequisite for and then pressure is released to observe the return of
good perfusion of the flap. Related to this, the patient blood flow into that area. This assessment applies only to
should receive maintenance levels of intravenous fluids free flaps with a skin paddle and cannot be performed in
at a minimum, especially if their oral intake has not re- muscle free flaps that have been skin grafted. Typically,
turned to normal. Correspondingly, good urine output capillary refill is described in terms of time (normal 2–3
should be demonstrated, which is reflective of adequate seconds), or whether it is “brisk” versus “delayed.” De-
intravascular volume status; if marginal or low, then ad- layed capillary refill indicates an arterial inflow problem.
ditional volume replacement may be necessary. Patients In contrast, excessively brisk capillary refill indicates a ve-
should also be normotensive, which can be partially de- nous outflow problem, as flap tissues become engorged
termined by comparing their preoperative and postop- with blood due to continued arterial inflow.
erative blood pressures. If there is a history of hyperten-
sion, a blood pressure measurement should be taken
prior to administration of antihypertensive agents, as Color
patients may be relatively hypotensive postoperatively For free flaps that have a skin paddle, the color of the
because of opioid use and other perioperative medica- flap skin should exhibit a pink color similar to the site
tions. Many free flap protocols include warming of the from which the tissue was transferred (Figure 1). This can
patient and room to promote peripheral vasodilation sometimes be a challenging assessment in patients with
and perfusion. darker pigmentation. If the flap skin appears relatively
Pressure on free flaps should always be minimized,
as excessive pressure may impede arterial inflow and/
or venous outflow. Depending on the anatomic site of
the free flap, attention should be paid to patient posi-
tioning to ensure that the patient does not lie or rest
on it, which may particularly be an issue for posteriorly
located free flaps. Surgical dressings should be exam-
ined and confirmed to be not excessively tight, espe-
cially circumferential bandages on extremities that may
be holding a splint in place, as well as surgical bras
in patients who have undergone breast reconstruction.
For extremity free flaps, the involved limb should be
elevated to help control edema, which might otherwise
accumulate and cause pressure on the microvascula-
ture of the flap. Finally, activity restrictions, including
weight-bearing status and range of motion, should be
carefully reviewed, as they may impact pressure or ten- FIGURE 1. A normal-appearing free flap demonstrating a pink color
sion on a free flap. similar to adjacent nonflap tissue.

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 pale (Figure 2), this may signal a problem with the arterial
anastomosis resulting in decreased blood flow into the
flap. On the contrary, if the flap skin demonstrates a pur-
plish discoloration (Figure 3), this may indicate a prob-
lem with the venous anastomosis, with accumulation of
venous blood in the setting of continued arterial inflow.
For free flaps without a skin paddle, which generally
are muscle free flaps that have been skin grafted, color
assessment is performed differently. In these cases, it is
the color of the muscle that is assessed, which should
be red under normal circumstances. Muscle tissue that
appears a pale purple color suggests an underlying vas-
cular problem. Skin grafts placed on muscle free flaps
generally cannot be used as a means of monitoring free
flaps because they have not yet undergone revascu- FIGURE 3. A free flap demonstrating a purplish color that may be
larization during the period of time that monitoring is indicative of a venous outflow problem.
performed.

Temperature turgor that is similar to a patient’s other nonflap tissues.

A free flap that is perfusing normally should exhibit a If a free flap exhibits diminished turgor, this may herald
temperature that is comparable to adjacent nonflap an arterial inflow problem. A related finding in this situa-
areas of the patient. Free flap temperature can be as- tion is increased prominence of rhytids (wrinkles) on the
sessed using either an actual measurement or physical skin paddle of a free flap, which are ordinarily obliter-
examination, although the latter is significantly limited by ated and not visible when a flap is distended by normal
the subjectivity of what constitutes warm versus cool. A amounts of vascular inflow. On the contrary, a free flap
difference of greater than 1°C–3°C (1.8°F–5.4°F) in tem- that is excessively swollen and firm may be experiencing
perature between a flap and adjacent nonflap skin may a venous outflow problem. As with temperature assess-
be indicative of a vascular problem (Chen et al., 2007). ments, it is important to compare flap turgor to adjacent
Temperature assessments tend not to be routinely used in nonflap tissues, as systemic issues can also alter turgor
postoperative free flap monitoring because of the greater (e.g., volume status).
accuracy of other methods discussed in this article.

LABORATORY TESTING
Turgor
The balance between vascular inflow and outflow deter- Techniques of free flap monitoring that involve laboratory
mines tissue turgor. Normally, a free flap should exhibit testing including tissue pH, blood glucose levels, and mi-
crodialysis (Chen et al., 2007; Salgado, Moran, & Mardini,
2009). These methods typically require repetitive invasive
investigations to compare the flap tissues to values mea-
sured earlier in time and/or to systemic tissues. For this
reason, laboratory testing is infrequently used in routine
free flap monitoring.

MEDICAL DEVICES
Multiple types of medical devices have been developed
to aid in the monitoring of free flaps (Smit, Zeebregts,
Acosta, & Werker, 2010). These devices can be broadly
classified into those that monitor the microvascular anas-
tomoses themselves (color duplex ultrasonography, flow
coupler, implantable Doppler) and those that perform an
assessment at a more downstream point, usually at the
external surface of the free flap (acoustic Doppler ultra-
FIGURE 2. A free flap demonstrating a pale color that may be sonography, laser Doppler flowmetry, and near-infrared
indicative of an arterial inflow problem. and visible light spectroscopy).

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 Acoustic Doppler Sonography Implantable Doppler
Acoustic Doppler sonography is one of the most com- The implantable Doppler utilizes the Doppler principle
monly used methods of free flap monitoring and is ordi- applied directly to the site of microvascular anastomosis,
narily combined with physical examination. It employs but unlike the flow coupler, it can be used at both arte-
the Doppler effect, which refers to the phenomenon rial and venous anastomoses. Typically, the device, which
whereby the frequency of a wave changes when its consists of a Doppler probe that is wrapped around the
source and an observer move relative to one another. site of anastomosis, is applied at the conclusion of a free
With acoustic Doppler sonography, a stationary probe flap reconstruction. The implantable Doppler can be ap-
emits ultrasound waves, and the frequency of those plied to the arterial anastomosis, venous anastomosis, or
waves changes as a result of blood flow within the flap. both if two devices are used, and it is, therefore, impor-
The device then generates sound that is proportionate tant to know to which site(s) it has been applied because
to flap blood flow. Ordinarily, upon completion of a free this governs the quality of the signal that is produced.
flap procedure, sites for Doppler monitoring are identi- The probe is attached to a wire that transmits the Dop-
fied and marked with sutures (which can be done for pler signal, which is brought out of the surgical incision
both free flaps with a skin paddle and free muscle flaps and connected to a sound and power source. The device
that have been skin grafted), so that the same sites can then produces auditory output similar to that produced
be evaluated over time. Usually, sites of arterial flow are by acoustic Doppler sonography. Weakening or loss of
marked and assessed and produce a characteristic pulsa- the signal suggests a vascular problem. An important
tile auditory output. In some cases, a venous signal can point regarding the use of the implantable Doppler is that
also be identified, which in contrast produces a constant patient movement can cause the Doppler probe to move
and relatively quieter sound, since venous flow is non- within the patient, which in turn can alter the signal even
pulsatile and slower. Weakening or loss of a previously in the setting of a normal anastomosis. Despite this, any
normal Doppler signal is indicative of a vascular problem. change in the signal warrants thorough flap assessment
and notification of the microsurgeon. After the postopera-
Color Duplex Ultrasonography tive monitoring period, the wire is pulled, which removes
Color duplex ultrasonography is a method of free flap the entire apparatus from the patient.
monitoring that uses ultrasound to directly visualize ves-
sels that have undergone microvascular anastomosis, in- Laser Doppler Flowmetry
cluding their real-time flow. The device consists of an Free flap monitoring devices that utilize laser Doppler
ultrasound probe and a viewing monitor, which can be flowmetry make use of the Doppler effect applied to laser
used in a radiology suite or transported to a patient room. light (rather than ultrasound waves as in acoustic Doppler
Its use requires a radiology technician to operate the de- sonography). A probe is affixed to the surface of the flap
vice, a radiologist to interpret the images, and the micro- using a dressing or sutures, and the probe emits laser light
surgeon to assist in anatomical orientation. For these rea- that experiences a shift in frequency based on the velocity
sons, color duplex ultrasonography is not routinely used of blood flow within the flap. The device reports veloc-
for free flap monitoring. ity measurements in units often abbreviated as LDF (la-
ser Doppler flow meter) units, which vary depending on
both the type of flap and the particular patient. There are
Flow Coupler
currently no standardized criteria for diagnosing vascu-
The venous anastomosis in free flap surgery is commonly
lar compromise using laser Doppler flowmetry. Although
created using a device called a coupler. A coupler is a
many groups suggest that a value greater than 2.0 LDF is
hollow plastic (polyethylene) apparatus onto which the
indicative of a normal free flap, the specific criteria for a
ends of the two veins to be connected are mounted, and
given case will depend on the flap type, device model,
through which venous blood will eventually flow. The
and surgeon preference.
flow coupler (Synovis Micro Companies Alliance, Inc.,
Birmingham, Alabama) is a coupler that is additionally
fitted with a Doppler probe, whose signal is transduced Near-Infrared and Visible Light Spectroscopy
through a wire connected to the coupler. The wire tra- In spectrometry, a source emits light of a specific wave-
verses the surgical wound and exits the incision where it length toward an object (chromophore), and a detector
is ultimately connected to a sound and power source. The measures changes in the reflected light, such as reduction
device then generates a venous Doppler signal that can in intensity. Based on the characteristics of the reflected
be heard continuously, with loss of the signal indicative light and the chromophore, concentrations of the chromo-
of a vascular problem. Prior to hospital discharge, gentle phore can be determined. Free flap monitoring devices
traction on the wire results in disconnection from the cou- that utilize spectroscopy commonly utilize near-infrared
pler, which remains in the patient. light (650–900 nm), which can measure concentrations of

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 oxygenated and deoxygenated hemoglobin, which vary CONCLUSION
depending on the degree of blood flow within a flap.
One of the more commonly used free flap monitoring Physical examination combined with acoustic Doppler
devices that utilize near-infrared light spectroscopy is the sonography remains the cornerstone of postoperative free
T.Ox Tissue Oximeter (ViOptix Inc., Fremont, California). flap monitoring. Several medical devices are now avail-
With this device, a probe is affixed to the flap skin paddle able for flap monitoring, many of which provide continu-
with an occlusive dressing. Usually, two criteria are used ous data related to flap perfusion and therefore serve to
to diagnose vascular compromise: a 20-point drop within supplement traditional flap monitoring approaches. An
a 1-hour period or an absolute reading less than 30. The understanding of how these devices work can assist in
device can be set to alarm when these criteria or other their usage and interpretation in postoperative free flap
user-specified criteria are met. Because the measurement monitoring.
will vary depending on the specific location on the flap,
REFERENCES
this site is usually chosen at the conclusion of a free flap Chao, A. H., Meyerson, J., Povoski, S. P., & Kocak, E. (2013). A
procedure, and that same site is used to assess the flap review of devices used in the monitoring of microvascular free
during the postoperative period so that both the current tissue transfers. Expert Review of Medical Devices, 10, 649–660.
measurement and overall trends can be obtained. When Chen, K. T., Mardini, S., Chuang, D. C., Lin, C. H., Cheng, M. H., &
Lin, Y. T., et al. (2007). Timing of presentation of the first signs
assessing a free flap whose reading has changed, the of vascular compromise dictates the salvage outcome of free
probe dressing should be inspected, as moisture under flap transfers. Plastic and Reconstructive Surgery, 120, 187–195.
the dressing or migration of the probe can also affect the Kroll, S. S., Schusterman, M. A., Reece, G. P., Miller, M. J., Evans, G.
R., & Robb, G. L., et al. (1996). Timing of pedicle thrombosis
reading. In addition, excessive ambient light can alter de- and flap loss after free-tissue transfer. Plastic and Reconstructive
vice function, and therefore the probe should be covered Surgery, 98, 1230–1233.
except when examining the flap. Salgado, C. J., Moran, S. L., & Mardini, S. (2009). Flap monitoring
A relatively newer device is T-Stat (Spectros, CA), and patient management. Plastic and Reconstructive Surgery,
124, e295–e302.
which uses visible light (475–600 nm) spectroscopy. Smit, J. M., Zeebregts, C. J., Acosta, R., & Werker, P. M. (2010).
However, there are currently no established criteria for Advancements in free flap monitoring in the last decade: A criti-
diagnosing vascular problems with T-Stat. cal review. Plastic and Reconstructive Surgery, 125, 177–185.

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