Guidelines for post-operative care and monitoring of free flaps

A Free flap is a unit of tissue removed from the original site (donor site) along with its blood vessels to be used for reconstruction of another area (recipient site) in the body.
The procedure of raising a free flap and performing the anastomosis is a technically challenging, long and costly procedure in both financial and physical terms for both the staff and the patient. The few days after the procedure are critical and monitoring the free flap is mandatory not only for the safety of the flap but also for the patient. Accurate monitoring of the flap permits an opportunity for timely return to theatre if the tissues become compromised in the early postoperative period. Previous studies have reported successful salvage rates between 28 and 87.5% and the rates for return to theatres were between 13% and 20%. Compromised circulation is the reason for re-exploration of free flaps in 5-25% of cases. These figures reflect the importance of accurate monitoring of the flap, bearing in mind that the success of flap is always of huge importance for the patient for early recovery, rehabilitation and good quality of life. Any small changes in the flap colour, texture, capillary refill or even temperature can indicate underlying changes that might need emergency re-exploration to avoid the loss of the flap and indeed to provide the best service for the patient. So even small changes need to be reported.
Early detection of vascular compromise can save a flap and might prevent further complications or surgeries. A review of other guidelines was performed before writing up these guidelines to provide the best and safest service that is most suitable to our practice.
These guidelines should be followed for every free flap procedure in the plastic surgery department, unless specifically stated and documented by the surgeon.
It is mandatory for all staff involved in the post operative care of these patients to be aware of these guidelines including all junior doctors and nursing staff. Free flap monitoring is predominantly carried out by the experienced nursing staff, or a junior nurse under supervision. Any changes should be immediately reported to the senior nurse and the junior doctor who will review the flap and report to the on-call team.