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Minimizing Clinical Exam In Postoperative Monitoring For Microsurgical Breast Reconstruction
Indiana University Plastic Surgery
2012-02-14
Presenter: Jason Cacioppo
Affidavit:
Director Name: J Coleman
Author Category: Attending
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)
How does this presentation meet the established conference educational objectives?
This presentation examines our experience with tissue oximetry to develop a postoperative protocol that seeks to minimize the role of clinical exams while providing a superior method of assessing flap viability and perfusion. This is a newer technique that allows for a more expeditious management of microvascular complications.
How will your presentation be used by practicing physicians in the audience?
Surgeons will hopefully find utility in this technology not only in managing diep flaps and microvascular breast reconstruction but also in assessing any flap in which perfusion or viabilty needs analysis.
The quest for free flap monitors is nearly as old as free tissue transfer itself and clinical exam has long been accepted as the benchmark. We aim to challenge this statement. Tissue oximetry, also known as Near-Infrared Spectroscopy, is a newer technology that allows for intra-operative as well as post-operative, non-invasive, continuous monitoring of free flaps.
Seventy-seven consecutive microsurgical breast free flaps, mostly DIEP flaps, were examined. We compared 75 flaps monitored by both clinical exam and continuous tissue oximetry. These two tests were then analyzed and compared. False positives, false negatives as well as positive and negative predictive values were calculated for the two monitors.
One false negative was observed in the tissue oximeter arm and no false negatives were noted. Positive predictive value for the tissue oximetry was 100% and the negative predictive value was 98%. Three false negatives were noted in the clinical exam arm with five false positives. Clinical exam eventually coincided with the tissue oximeter but clinical exam lagged.
Five flaps were returned to the OR and salvage rate was 60%. Average lag time from tissue oximetry warning to clinical exam confirmation was eight hours. Fat necrosis was observed in 100% of the flaps taken back based on clinical exam findings. .
Based on these findings, we have modified our practice in microsurgical breast reconstruction. All flaps are monitored with a tissue oximeter and clinical exam is bypassed. Any significant changes in the tissue oximetry readings result in immediate exploration of the flap regardless of its clinical exam.
