Saving a free flap with close clinical postoperative monitoring

Prompt detection of circulatory compromise allows for earlier exploration of the vascular anastomosis and for potential salvage of the failing flap before an irreversible no-reflow phenomenon occurs.2 In the no-reflow phenomenon, the initial hyperemia (increased amount of blood) that results from restoration of blood flow to tissue after prolonged ischemia is followed by gradual decline in perfusion until there is almost no blood flow.5 Thus, the outcome of flap salvage is related to the intensity of flap monitoring and the timing of flap failure presentation. Because most flap complications occur within the first 72 hours postoperatively, some researchers recommend close monitoring during that time.2 We have found that close monitoring of the flap in an intermediate care unit for the first 48 hours has allowed early detection of flap failure and hence increased rates of salvageable flaps. In head and neck defects, salvage reconstruction is a challenge because of patients' existing comorbidities and history of chemoradiation. [...]since the patient has undergone a previous flap procedure, the surgical bed is contaminated and vessels for anastomosis are depleted.