See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/10576159

Flap monitoring after head and neck reconstruction: Evaluating an

observation protocol

Article  in  Journal of Wound Care · February 2001

DOI: 10.12968/jowc.2001.10.1.26037 · Source: PubMed

CITATIONS READS

24 3,561

5 authors, including:

John Devine Patrick Magennis

Mafraq Hospital - Abu Dhabi Aintree University Hospital NHS Foundation Trust
58 PUBLICATIONS   731 CITATIONS    194 PUBLICATIONS   1,588 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Curricula in OMFS View project

Academic background of OMFS trainees View project

All content following this page was uploaded by Patrick Magennis on 25 June 2014.

The user has requested enhancement of the downloaded file.


Flap monitoring after head and
neck reconstruction: evaluating
an observation protocol
J.C. Devine, FRCS, FDSRCS, Specialist
Registrar;
L.A. Potter, BSc, DipSN, RN, Deputy
Ward Manager;
P. Magennis, FRCSI, FFDRCSI, Specialist
Registrar;
J.S. Brown, MD, FRCS, FDSRCS,
Consultant;
E.D. Vaughan, FRCS, FDSRCS, Consultant;
All at Practice Development Unit,
Regional Services for Maxillofacial
Surgery, University Hospital Aintree,
Liverpool, UK
Fig. 1. A compromised radial
forearm free flap in the mouth
Fig. 2. Vacuum drain causing
venous thrombosis
JOURNAL OF WOUND CARE JANUARY, VOL 10, NO 1, 2001
Journal of Wound Care.Downloaded from magonlinelibrary.com by ${IPAddress} on June 25, 2014. For personal use only. No other uses without permission. . All rights reserved.
RESEARCH
This study evaluated the postoperative free-flap monitoring frequency protocol used in
a maxillofacial unit for patients receiving free-tissue transfer for reconstruction following
orofacial cancer. All free-tissue transfers undertaken in the unit between January 1992
and October 1998 were reviewed retrospectively.
Of the 370 patients evaluated, 46 returned to theatre with compromised free flaps.
The compromise was purely venous in origin in 37 of these cases, arterial in three and
due to a combination of arterial and venous problems in six. Thirty-five of the flaps were
successfully salvaged. On average, the clinical manifestation of the problem occurred
25.5 hours postoperatively. However, there was a significant time difference between
flaps that were salvaged successfully and those that were not: in the salvaged group the
compromise was identified 17.5 hours postsurgery compared with 51 hours for the
unsuccessful group. The timing of the return to theatre following the identification of
the compromise was a significant factor in the success rate: 71 minutes for those
salvaged and 103 minutes for those not salvaged.
It is recommended that flaps are monitored hourly for the first 72 postoperative
hours and observations recorded on a chart.
Free-tissue transfer has Orofacial cancer; Head and neck This article describes a
become the method of reconstruction; Flap monitoring retrospective study that
choice for reconstructing aimed to determine the mon-
defects produced by the ablative treatment of itoring frequency rate most likely to result in
cancer and, less commonly, trauma in the the successful salvage of compromised flaps.
head and neck region. This is a reliable
method of reconstruction, resulting in Flap monitoring methods
improved postoperative function and aes- Flap compromise may be due to arterial or
thetic appearance.1 venous problems or a combination of the two.
It may be necessary to return the patient to It usually manifests as thrombosis or kinking
theatre in the immediate and early postopera- of the feeding vessel (Fig 2), leading to a pro-
tive period if salvage of a compromised free gressive obstruction within the artery or vein.5
flap is required (Fig 1).2 This may occur at any Several devices are available for postoperative
time and can overstretch available resources. monitoring of free flaps. These either provide a
Once tissue ischaemia occurs, there is a finite continuous output of information or assess the
amount of time after which the micro- flap intermittently (Table 1). A full discussion
vasculature is irreversibly damaged and the of these techniques is not possible here but fur-
‘no re-flow’ phenomenon takes place.3 ther information can be obtained from
The consequences of losing a free flap are, Hirigoyen et al.,6 Jones et al.7 and Furuta et al.8
at best, a prolonged hospital stay and delayed The ideal flap monitoring technique allows
recovery and, at worst, significant patient for continuous monitoring. It should also be:
morbidity and even mortality. ■ Reliable
The flap is closely monitored in the post- ■ Reproducible
operative period for the first signs of vascular ■ Easy to interpret
compromise so that a clinical decision to sur- ■ Non-invasive
gically re-explore the flap can be made with- ■ Safe
out delay.4 ■ Inexpensive
525
 RESEARCH

■ Able to respond to changes in the micro- Colour

circulation The colour of the flap is scored from 1 to 10,
■ Simple to perform.6 with 1 indicating white/ultra pale, 5 pink and
No method of flap monitoring fulfils all 10 dark purple/black.
these criteria. In the regional maxillofacial unit A flap that has arterial insufficiency will
at University Hospital Aintree, Liverpool, the appear very pale. However, on some donor
sole method of postoperative monitoring is sites, such as the latissimus dorsi, a flap will
flap observation combined with Doppler pulse almost always appear very pale. The presence
surface monitoring of buried or bony flaps. of a pale flap, therefore, does not always sig-
nify a problem.
Flap observations Venous engorgement is suspected when a
Observation and measurement of colour, cap- flap changes from pale pink to blue-purple.
illary refill time, temperature, consistency of Colour change is not always uniform
texture and Doppler signal are recorded on a throughout the flap: some parts can appear
‘flap chart’ (Fig 3). This provides an instant normal while one area may seem discoloured.
visual record of any change in the underlying Staff at the regional maxillofacial unit draw
trend.4 Due to the subjectivity of such obser- a diagram of the flap on the chart and record
vations, at the shift change-over nursing areas of varying colour separately (for exam-
observers should agree on baseline flap obser- ple, area A, area B). Any change in the normal
vations against which any observed changes area is noted. Although venous compromise
in colour, capillary refill time, consistency of a free flap may manifest suddenly as an
and temperature can be measured. The chart abrupt colour change,7 it is usually an insidi-
components are discussed in detail below. ous process lasting for one to two hours,
causing clinical uncertainty and frustration. It
Fig. 3. The flap chart can be difficult to observe flap colour if there
is any bruising, which may occur when the
Name: DoB: Ward: No.: flap is raised, inset or subject to hourly scrap-
ing with a tongue depressor. To minimise
Consultant:
observation difficulties, staff do not needle-
puncture the skin paddle when assessing flap
Flap type: (Please circle) Donor site: (Please circle)
Intra-oral/external/fashiocutaneous Right radial forearm/Left radial forearm
viability as this risks damaging the vascular
Composite/myocutaneous Latissimus dorsi/pexi major pedicle and causing generalised bruising. It is
Other:________________________________ Other:_____________________________________ generally possible to distinguish venous
engorgement from bruising as bruised tissue
Date does not blanche when pressed.
Time
Initials
Capillary refill time
Colour 1
White 2 Capillary refill is assessed by the momentary
3 application and removal of a tongue depres-
4 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ sor to the flap surface, measuring the time it
Pink 5 ✔ takes for blood to flow back to the flap sur-
6 ✔ face. In a well-perfused flap, capillary refill
7 ✔ ✔ ✔
8
should take one to three seconds. Inadequate
Purple 9 arterial flow results in prolonged capillary
Black 10 refill time, usually more than five seconds.
Capillary No blanch ✔ ✔ ✔ ✔ Venous outflow obstruction results in brisk
refill <3 secs ✔ capillary refill, usually less than one second.
3 secs ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ A very engorged flap may not visibly blanche
>3 secs
due to instantaneous refill.
No refill
Texture Spongy
Soft ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Temperature
Firm ✔ ✔ Temperature measurement is not a reliable
Hard indicator of viability in intra-oral flaps as the
Temp Cold flap usually assumes the core temperature of
Cool ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
Warm ✔ ✔
the oral cavity. Surface temperature recordings,
Hot such as thermo-electric thermometer, infrared
Doppler Pulse thermometry or thermography measurements,
Present are used to assess adequacy of tissue perfusion.
Not present
Although surface temperature recordings are
Comments:
continuous, they tend to be inconsistent in the
head and neck due to a wandering baseline

526 JOURNAL OF WOUND CARE JANUARY, VOL 10, NO 1, 2001

Journal of Wound Care.Downloaded from magonlinelibrary.com by ${IPAddress} on June 25, 2014. For personal use only. No other uses without permission. . All rights reserved.
 RESEARCH

lying the pedicle and the characteristic art-

Table 1. Methods of free-flap monitoring erial noise and sound of venous outflow is
Intermittent methods heard. This technique has a high false-
positive rate as the Doppler signal of adjacent
■ Fluorescein dye injected intravenously, ultraviolet illumination or quantitative fluorometry blood vessels is often mistaken for that of the
■ Isotope scans such as technetium 99 pedicle. This can lead to a false sense of secu-
rity, particularly when there is no exterior
While these methods give information about the adequacy of perfusion at a particular time,
segment of the flap to monitor directly.8
they do not provide continuous information allowing early detection of tissue ischaemia

Continuous monitoring techniques Monitoring frequency

How often should these flap observations be
■ Surface temperature recordings using thermo-electric thermometer, infrared
undertaken? There is no clear consensus in
thermometry or thermography: these assess the adequacy of tissue perfusion
the literature as to the most appropriate pro-
■ Transcutaneous measurements of oxygen tension: made by attaching a probe directly tocol. Previously, staff in the unit observed
to the flap surface, these are designed to detect the changes in oxygen tension that can the flap every hour for the first seven post-
precede clinical signs of vascular compromise. An attractive idea but, in practice, problems
operative days. However, this was exhausting
may occur due to factors such as the presence of oedema
for patients, who were uncomfortable with
■ Photo-electric methods: photoplethysmography monitors reflected light from the the frequent and prolonged nature of the
underlying tissue, which varies with intravascular flow. A waveform is produced that can observations. In addition, this frequency was
indicate vessel spasm or occlusion if present
labour intensive and did not constitute the
■ Laser Doppler: measures changes in reflected laser light caused by the motion of red best use of nursing resources.
blood cells in the dermal capillary bed. Apart from direct visualisation of the flap, this is This led to a desire to provide more effective
the best tool for objective monitoring of free flaps nursing care, without delaying the identifica-
New techniques tion of compromised flaps. As part of a larger
study,10 therefore, all flaps from proceeding
Microdialysis: an implantable probe measures tissue metabolites, which change when years were reviewed with the aim of devising
tissue is ischaemic an evidence-based flap observation protocol.

Table 2. Age and sex of the patients with compromised flaps
Mean age (years)
Maximum age (years)
Minimum age (years)
REFERENCES
1. Harrison, D.H., Girling, M., Mott, G.
Experience in monitoring the circulation in
free-flap transfers. Plastic Reconstructive
Surgery 1981; 68: 4, 543-555.
2. Schusterman, M.A., Miller, M.J., Reece,
G.P. et al. A single centre’s experience with
308 free flaps for repair of head and neck
cancer defects. Plastic Reconstructive Surgery
1994; 93: 3, 479-480.
3. Gapany, M. Failing flap. Facial Plastic
Surgery 1996; 12: 1, 23-27.
4. Coull, A., Wylie, K. Regular monitoring:
the way to ensure flap healing. Prof Nurse
1990; 6: 1, 18-21.
5. Jones, N.F. Intraoperative and
postoperative monitoring of microsurgical
free tissue transfers. Clinics in Plastic Surgery
1992; 19: 4, 783-797.
Male (n=29) Female (n=17)
59.6 65.9
88.0 81.0
34.0 48.0
resulting from changes in the ambient temper-
ature caused by factors such as tracheostomy
mist or heat from an overhead light. Neverthe-
less, a cold extra-oral free flap may be an indica-
tor of arterial insufficiency.9
Consistency
The flap should feel soft to the touch. A flap
that is venously engorged may feel firm to
the touch, with little or no give when pal-
pated. However, it should be noted that this
change in texture tends to be a late sign of
vascular compromise and is a less useful indi-
cator of flap vitality.
Doppler assessment
Surface pulse Doppler is used to identify via-
bility when a flap is buried or purely osseous.
It is routinely used for buried or difficult-to-
see flaps, such as on the posterior pharyngeal
wall, or flaps with no muscular or cutaneous
paddle. The probe is placed on the skin over-
Method
All patients who had free-tissue transfer
between January 1992 and October 1998 to
reconstruct head and neck defects were identi-
fied using the Head and Neck Oncology
database. This included patients who returned
to theatre in the immediate and early postop-
erative period due to a compromised flap.
Patient demographic details, medical history,
diagnoses and operative details were recorded.
The duration of the original operation and the
time of return to theatre were noted from the
anaesthetic records. The flap charts provided
information about the signs of the flap com-
promise and when this was first observed.
Clinical findings at re-operation were taken
from the surgical records. Details relating
to flaps that were salvaged or where salvage
was unsuccessful were compared using the
Student’s t test.
Results
Between January 1992 and October 1998, 370
patients had free-flap reconstruction at the
regional maxillofacial unit. During this
period 46 patients (12.4%) returned to the-
atre due to a compromised free flap.
Age and sex
Of the 46 patients with a compromised free
flap, 29 were male and 17 female (Table 2).
The average age was 59 years for the males
and 65 years for the females.

JOURNAL OF WOUND CARE JANUARY, VOL 10, NO 1, 2001 527

Journal of Wound Care.Downloaded from magonlinelibrary.com by ${IPAddress} on June 25, 2014. For personal use only. No other uses without permission. . All rights reserved.
 RESEARCH

Clinical findings at re-operation

Fig. 4. Time interval between reconstructive surgery and manifestation The compromise was of venous origin in 37
of compromised flap cases, arterial in three cases and a combina-
12 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– tion of venous and arterial problems in six.

10 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Successfully salvaged flaps Timing of flap compromise
Number of cases

Failed salvaged flaps In this overall group (n=46) the average time
8 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
taken for the problem to manifest was 25.5
6 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– hours. However, there was a significant differ-
ence in timings between the group of patients
4 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
whose flaps were salvaged and where salvage
2 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– had failed (Table 3). Flap problems mani-
fested in the salvaged group 17.5 hours post-
0 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
4 12 20 24 < 48 > 72 operatively, on average, compared with 50.97
hours in the unsuccessful group (p<0.05)
Time (hours) (Fig 4; Table 3).

Timing of return to theatre

Table 3. Timings of the clinical manifestations of compromised flaps The average time taken to re-anaesthetise a
patient in theatre following clinical manifes-
Successful flap Unsuccessful flap tation of symptoms of a compromised flap
salvage (n=35) salvage (n=11) was 71 minutes in the successful group and
Average time (hours) 17.5* 50.97* 103 minutes in the unsuccessful group
(p<0.05) (Fig 5; Table 4).
Maximum time (hours) 168.0 201.67
Flap patency and salvage
Minimum time (hours) 0.5 2.5
Of the 370 free flaps performed for head and
Standard deviation (hours) 31.55 56.7 neck reconstruction during the study period,
*p<0.05 348 were successful (patency rate: 94%.) Of
the 46 patients who returned to theatre with
a compromised free flap, salvage was success-
Fig. 5. Time interval between manifestation of compromised flap and ful in 35 cases (76%).
return to theatre
Discussion
18 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Postoperative monitoring of free flaps is
16 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Successfully salvaged flaps essential to identify and rectify vascular com-
Failed salvaged flaps promise at the earliest opportunity. Clinical
14 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
observation is used at the maxillofacial unit
Number of cases

12 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– because it produces the most consistent

results and relies on the visual senses of expert
10 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
professionals to note colour, capillary refill
8 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– and tissue texture. Surface Doppler pulses are
6 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– occasionally used to assess internal vessels on
instruction from the microsurgeon.
4 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– These study findings do not provide
2 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– evidence to support the use of hourly flap
observations for seven days. Indeed, successful
0 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– salvage is not often achieved after 72 hours.
30 60 90 120 150 >150
Flap salvage is more likely if the vascular com-
Time (minutes) promise manifests early in the postoperative
period and there is a rapid return to theatre.
This in turn underlines the vital importance
Table 4. Mean time of return to theatre following the decision to of having rapid access to theatre at all times.
re-explore the flap This study highlights the efficacy of simple
flap observation, which can be carried out by
Successful flap Unsuccessful flap trained and experienced nurses without the
salvage salvage
need for expensive supplementary monitoring
Number of minutes 71 103 devices. The limiting factor of such a flap-
monitoring regimen is the risk of variation in
p<0.05 observer interpretation. However, practition-
ers in a dedicated clinical set-up who deal with

528 JOURNAL OF WOUND CARE JANUARY, VOL 10, NO 1, 2001

Journal of Wound Care.Downloaded from magonlinelibrary.com by ${IPAddress} on June 25, 2014. For personal use only. No other uses without permission. . All rights reserved.

6. Hirigoyen, M.B., Urken, M.L., Weinberg,
H. Free flap monitoring: a review of current
practice. Microsurgery 1995; 16: 11, 723-726.
7. Jones, B.M., Sanders, R., Greenhalgh, R.M.
Monitoring skin flaps by colour
measurement. Brit J Plastic Surgery 1983; 36:
1, 88-94.
8. Furuta, S., Hataya, Y., Ishigaki, Y.,
Watanabe, T. Monitoring the free radial
forearm flap in pharyngo-oesophageal
reconstruction. Brit J Plastic Surgery 1997; 50:
1, 40-42.
9. Kroll, S.S., Schusterman, M.A., Reece, G.P.
et al. Timing of pedicle thrombosis and flap
loss after free-tissue transfer. Plastic
Reconstructive Surgery 1996; 98: 7,
1230-1233.
10. Devine, J.C., Brown, J.S., Magennis, P.,
Vaughan, E.D. Analysis of surgical
re-intervention in 60 cases of free-flap
compromise in head and neck
reconstruction. J Cranio-Maxillofacial Surgery
1998; 26: (Suppl 1), 39.
■ We would like to thank Jean
Speake, Audit Co-ordinator for her
help in the organisation of the
study. Thanks are also due to
Richard Hancock from the depart-
ment of medical illustration, Univer-
sity Hospital Aintree, Liverpool, UK
Journal of Wound Care.Downloaded
View publication stats from magonlinelibrary.com by ${IPAddress} on June 25, 2014. For personal use only. No other uses without permission. . All rights reserved.
RESEARCH
a large caseload may rapidly gain the experi-
Table 5. Summary of findings
ence needed to recognise the subtlest changes
early in their development. Finally, there must
Thirty-one out of 35 salvaged flaps were
be a clear line of communication between
re-operated on within 24 hours of noticing
nursing and medical staff based on mutual that the flap was compromised
trust of each other’s clinical judgement.
Of the four flaps salvaged after 24 hours,
Conclusion three were arterial in origin, manifesting as
Practice at the unit has changed as a result of spontaneous haemorrhage
the study. Hourly flap observations are
Only one flap with a venous problem was
undertaken and recorded for 72 hours only
salvaged after 24 hours (50 hours)
on the specially designed flap chart. A flap
check is then performed after routine blood Only five flaps re-operated on within 24 hours
pressure and pulse measurements have been were not salvaged
undertaken (Fig 3).
It is our overwhelming clinical impression Flaps that were salvaged deteriorated
that, in the 18 months since the introduction significantly earlier than those on which
salvage failed
of the flap-observation protocol, patients have
been less tired and more comfortable in the Once a decision was made to re-operate,
postoperative period and specialist nursing salvaged flaps were returned to theatre at a
time has been put to more appropriate use. significantly faster rate than those on which
There has also been no deterioration in the salvage failed
overall free-flap patency rate over this period.
Ongoing development and review of the Head Flap salvage rate was 76%
and Neck Oncology database has led to the
Overall vascular patency rate was 94%
continual evaluation of current practice to
ensure successful free-flap management. ■