Nursing Monitoring of Microsurgical Free Flaps: Identifying and Addressing Knowledge Gaps

2020 ◽  
Vol 36 (09) ◽  
pp. 673-679
Author(s):  
Shawna R. Kleban ◽  
Scott C. Ogley ◽  
Joshua C. MacDavid ◽  
Joshua J. Goldman ◽  
Ashish Francis ◽  
...  
Keyword(s):  
Free Flap ◽  
Test Scores ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Knowledge Gaps ◽  
Educational Session ◽  
Nursing Experience ◽  
Before And After ◽  
Service Training ◽  
Microsurgical Free Flaps

Abstract Background Microsurgical free flaps require careful monitoring to detect early signs of compromise. At many hospitals, nursing staff provides the majority of postoperative monitoring of free flap patients and it lies within their responsibility to alert physicians of a failing free flap. The aim of this study is to identify knowledge gaps in the monitoring of microvascular free tissue transfer in both novice and experienced nurses and to provide appropriate education to address these gaps. Methods This was a pre- and postintervention study. An initial pilot survey was administered to identify knowledge deficiencies. A nursing educational session on free flap physiology and monitoring was then designed to address these deficiencies. An 18-question multiple choice quiz was administered before and after the educational session. Pre- and post-test scores were compared based on nursing experience. At 6 months, the participating nurses completed a survey rating their confidence with free flap patient care as a result of the educational session. Results A total of 72 nurses completed the in-service training course and quiz. The average quiz score increased from 61.9 to 89.3% after the in-service (p < 0.001). There was no correlation between precurriculum test scores and nursing experience as referenced by total number of years in the profession (r s = –0.038, p = 0.754). The follow-up survey showed that prior to the course 38% of respondents reported little or no confidence caring for free flap patients, decreasing to 6% after the course (p < 0.05). Conclusion Based on the results of this study, nursing knowledge of capillary refill, venous congestion, and basic microsurgical free flap physiology is inadequate. With implementation of a teaching in-service curriculum highlighting these key areas of deficiencies, nurses improved both their understanding and confidence levels, regardless of their level of experience.

scholarly journals Use of the Anterolateral Thigh in Cranio-Orbitofacial Reconstruction

2011 ◽  
Vol 2011 ◽  
pp. 1-6 ◽  
Author(s):  
William J. Parkes ◽  
Howard Krein ◽  
Ryan Heffelfinger ◽  
Joseph Curry
Keyword(s):  
Free Flap ◽  
Case Series ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Loss ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Anterolateral Thigh ◽  
The Many ◽  
Soft Tissue Loss

Objective. To detail the clinical outcomes of a series of patients having undergone free flap reconstruction of the orbit and periorbita and highlight the anterolateral thigh (ALT) as a workhorse for addressing defects in this region. Methods. A review of 47 patients who underwent free flap reconstruction for orbital or periorbital defects between September 2006 and May 2011 was performed. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. The ALT subset of the case series was the focus of the data reviewed for this paper. Selected cases were described to highlight some of the advantages of employing the ALT for cranio-orbitofacial reconstruction. Results. 51 free flaps in 47 patients were reviewed. 38 cases required orbital exenteration. The ALT was used in 33 patients. Complications included 1 hematoma, 2 wound infections, 3 CSF leaks, and 3 flap failures. Conclusions. Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The ALT provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.

Elastic Wrapping of Lower Extremity Free Flaps during Dangling Improves Microcirculation and Reduces Pain as well as Edema

2019 ◽  
Vol 35 (07) ◽  
pp. 522-528 ◽  
Author(s):  
Jonas Kolbenschlag ◽  
Alexandra Ruikis ◽  
Lisa Faulhaber ◽  
Adrien Daigeler ◽  
Manuel Held ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Oxygen Saturation ◽  
Microvascular Reconstruction ◽  
Reconstructive Procedure ◽  
Hemoglobin Content ◽  
Edema Formation ◽  
The Impact

Background Free tissue transfer has become a common and safe reconstructive procedure. However, total or partial flap losses remain a looming threat, especially for lower extremity free flaps due to the gravitational challenge associated with dependency. Thus, the majority of microsurgical centers apply some kind of structured flap training. However, due to the lack of evidence, these differ greatly, for example, in the application of an elastic wrapping during dangling. Therefore, the aim of this study was to assess the impact of an elastic wrapping on free flap microcirculation, edema, and pain during dangling. Methods Standardized dangling was performed from postoperative day (POD) 6 to 9 in 30 patients with microvascular reconstruction of the lower extremity. The first dangling per day was performed without elastic wrapping, followed by another session with 30 mm Hg of elastic wrapping. Tissue oxygen saturation (StO2), regional hemoglobin content (rHb), and blood flow (BF) were continuously measured in the free flap; the circumference of the flap as well as pain was assessed. Results During wrapped dangling, BF as well as StO2 was significantly increased, while rHb was significantly lower on all PODs. Wrapped dangling was rated significantly more comfortable and the girth of the free flaps was significantly less after wrapped dependency when compared with unwrapped dangling. Conclusion Dangling with an elastic wrapping with 30 mm Hg pressure improved flap microcirculation and reduced pain and edema formation.

scholarly journals Cross-Leg as Salvage Procedure after Free Flaps Transfer Failure: A Case Report

2012 ◽  
Vol 2012 ◽  
pp. 1-3
Author(s):  
F. Contedini ◽  
L. Negosanti ◽  
E. Fabbri ◽  
V. Pinto ◽  
B. Tavaniello ◽  
...  
Keyword(s):  
Free Flap ◽  
Latissimus Dorsi ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Lower Leg ◽  
Salvage Procedure ◽  
Soft Tissue Defects ◽  
Vascular Thrombosis ◽  
Flap Failure ◽  
Tissue Defects

Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.

Compromised microvascular free flaps; salvage using Fogarty vascular catheter thrombectomy

2020 ◽  
Vol 13 (12) ◽  
pp. e239251
Author(s):  
Santhosh Rao ◽  
Nitin Kumar Kashyap ◽  
Chinmaya Panda ◽  
Naveen Kumar
Keyword(s):  
Free Flap ◽  
Thrombus Formation ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Transfer ◽  
Microvascular Free Flaps ◽  
Flap Perfusion

Compromised free flap perfusion secondary to thrombus formation is a routinely encountered complication in microvascular free tissue transfer. Various modalities were tried out prophylactically to prevent thrombus formation, and likewise, various methods are tried for salvaging the flap with effective thrombectomy. We present the use of Fogarty vascular catheter for thrombectomy and effective salvage of the flap.

scholarly journals Microsurgical free tissue transfer as avaluable reconstructive procedure in foot reconstruction

2007 ◽  
Vol 40 (02) ◽  
pp. 141-146
Author(s):  
mohamed el-shazly ◽  
mohamed makboul
Keyword(s):  
Free Flap ◽  
Motor Vehicle ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Vehicle Accidents ◽  
Tissue Transfer ◽  
Scapular Flap ◽  
Radial Forearm ◽  
Foot Reconstruction

ABSTRACT Background: owing to the limited soft tissue donor sites in the foot area, the use of microsurgical tissue transfer is frequently becoming mandatory in this area, especially in cases of massive defects due to the common motor vehicle accidents in the territory of upper egypt. free flaps offer a great variety of available tissues to cover larger, multifocal or multistructural defects. they also improve the perfusion of the infected poorly perfused areas.Objectives: in this study, we tried to evaluate foot defects according to their size, shape and site and to determine the general and specific parameters of free tissue transfer to the foot area in concomitance with the patients needs.Materials and methods: eleven patients were included in this study. for each patient, complete history was taken, general and local examination, photographic documentation, laboratory investigations, imaging and other investigations were performed. free flap transfers were applied in all cases as follows: latissimus dorsi flap in five cases, rectus abdominis flap in three cases, scapular flap in one case, gracilis flap in one case and radial forearm flap in one case.Results: nine flaps survived. no infection or donor site complications were recorded. every patient had the optimum free flap as regards the defect size, site, depth, condition, shape, donor site availability and the recipient vessels′ condition.Conclusion: the study of the optimum free flap for foot reconstruction in relation to the defect present and patient conditions is crucial to have significant results.

Novel STSG Donor Site for Forearm Flaps: Radial Skin Paddle

2008 ◽  
Vol 139 (2_suppl) ◽  
pp. P31-P31
Author(s):  
Tamer Abdel-Halim Ghanem ◽  
Mark K Wax
Keyword(s):  
Free Flap ◽  
Medical Center ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Patch Repair ◽  
Skin Grafts ◽  
Skin Paddle ◽  
Forearm Skin ◽  
Radial Forearm

Objective Split thickness skin grafts (STSG) harvested from the thigh are often utilized to provide coverage for radial forearm donor sites. To eliminate the morbidity of the thigh STSG donor site, we assessed the feasibility of harvesting the STSG from the radial. Methods Prospective data was collected from patients undergoing forearm free flap reconstruction at a tertiary medical center in a 6-month period. The radial forearm free flap (RFFF) harvesting procedure was modified to incorporate STSG harvest from the paddle site as the first step after arm tourniquet activation. Results There were 27 patients in this cohort, with mean age of 68.2. There were 24 fasciocutaneous RFFF, 2 osteocutaneous RFFF, and 1 ulnar flap. The indications for free tissue transfer were as follows: intraoral defects (n=13), pharyngeal patch repair (n=8), total laryngopharyngectomy (n=1), external skin coverage (n=5). The mean forearm defect was 41.2 cm2 (24–77 cm2). 22 out of 27 skin grafts were non-meshed. Harvesting from the forearm skin paddle was successful in 25 patients (93%). Two patients required a thigh STSG; both patients were octagenerians with frail skin. All the forearm donor sites healed well, except one patient required a later revision procedure for exposed tendon. Conclusions Based on this study, the thigh STSG donor site can be eliminated in 9 out of 10 patients undergoing radial forearm free flaps. This translates to decreased risk of pain, infection, and wound oozing. Older patients with frail skin and atrophied forearm muscles were likely to require a thigh donor site.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

2019 ◽  
Vol 36 (01) ◽  
pp. 032-040 ◽  
Author(s):  
Jacob R. Rinkinen ◽  
Shawn Diamond ◽  
Jonathan Lans ◽  
Curtis L. Cetrulo ◽  
Kyle R. Eberlin
Keyword(s):  
Systematic Review ◽  
Soft Tissue ◽  
Activities Of Daily Living ◽  
Free Flap ◽  
Daily Living ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Ulcer Formation ◽  
Soft Tissue Reconstruction ◽  
Tissue Transfer

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

scholarly journals Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a “natural” appearance using pre-patterned autogenous free flaps

2015 ◽  
Vol 3 ◽  
pp. 1-8 ◽  
Author(s):  
Elliott H. Rose
Keyword(s):  
Free Flap ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Functional Rehabilitation ◽  
Flap Transfer ◽  
Creative Strategy ◽  
The Face ◽  
The Aesthetic ◽  
Autogenous Reconstruction

Abstract The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The “keystone” of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the “piece of a puzzle” into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative “sculpting” is employed both “in situ” at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author’s approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants; advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the “palette” upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a “natural” facial appearance while preserving fluid motions of facial expression.

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

2021 ◽  
Author(s):  
Amanda Y. Shen ◽  
Sarah Lonie ◽  
Kaiyang Lim ◽  
Hannah Farthing ◽  
David J. Hunter-Smith ◽  
...  
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Cochrane Library ◽  
Success Rates ◽  
Reliable Technique ◽  
Free Flap Monitoring ◽  
Vascular Compromise ◽  
Flap Monitoring ◽  
Meta Analyses

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.

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