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Page 10 of 14 Foppiani et al. Plast Aesthet Res 2023;10:53 https://dx.doi.org/10.20517/2347-9264.2022.137

additional therapy. As a result, flaps that may have otherwise been lost can be completely salvaged or only
partially lost instead.

In the pooled patient population, skin necrosis was present in 4% of the patients monitored with
thermography compared to 3% for those monitored with oximetry. Based on our results, oximetry seems to
be marginally better suited for preventing this type of complication. A study by Olsen et al. showed a
cumulative 14% complication rate for non-infectious surgical site complications in 1,799 of their patients
who underwent autologous breast reconstruction . This rate is higher than in either of the sub-groups
[35]
presented in this study and demonstrates the potential benefits that both oximetry and thermography as
postoperative monitoring tools may bring to patients undergoing autologous breast reconstruction. It is also
important to note that Olsen et al. acknowledged a high possibility of under-reporting this type of
complication within their cohort, further strengthening the evidence supporting the implementation of
either of the monitoring tools presented in our paper .
[35]

Additionally, this meta-analysis showed that the overall complication rate for flaps used in autologous
breast reconstruction was 12% for patients monitored with thermography compared to 10% for those
monitored with oximetry. Bennet et al., in a study with a multicenter cohort of 706 patients who underwent
autologous breast reconstruction, showed an overall complication rate of 46.7% with a re-operation rate of
[36]
27.6% . On the other hand, Mehrara et al. showed an overall complication rate of 27.95% in 952 patients
who underwent microvascular breast reconstruction . Therefore, the results of this meta-analysis may show
[1]
better outcomes in terms of overall complications than reported in the literature.

Furthermore, the results of this study showed that thermography prompted a return to the OR in 1% of the
patients compared to 5% for oximetry. A study by Shammas et al. previously showed an overall return to the
OR of 11% and, notably, a 27.8% return to the OR for their sub-patient population who underwent staged
autologous procedures as compared to immediate microsurgical reconstruction . It is interesting to note
[33]
that while the take-back rate in our included studies was lower than in some of the literature, the outcomes
were better than in most of the literature. While no causality can be determined, the monitoring could be
hypothesized to have objectively and accurately identified flaps that required true intervention, leading to
fewer take-backs but also more meaningful take-backs.

While there were no unified postoperative monitoring protocols across the studies, a trend was present.
There was often an emphasis on either continuous or more frequent monitoring during the first 24 h
postoperatively. This trend can be explained by Carruthers, 2019, who describe in their studies that nearly
96% of major complications of microsurgical breast reconstruction occur within those first 24 h following
surgery . These findings highlight the justifiable importance of more rigorous monitoring during this
[29]
postoperative timeframe. Thus, while studies, such as that by Moderhak et al., reported monitoring for up
to 3 months in their cohort postoperatively, the focus of oximetry, thermography, or any postoperative
monitoring method should prioritize this critical 24-hour time period regardless of surgeons’ skills or center
capabilities .
[37]

Of note, Phillips et al. described 19 patients who underwent 30 DIEAP flaps for breast reconstruction and
monitored their patients using mobile smartphone thermography, demonstrating good outcomes .
[21]
Advances such as this are crucial to take into account, as cost efficiency is critical to medical practice. While
some re-usable thermographic cameras can cost up to 20,000 USD, smartphone cameras are more
affordable and can reduce the cost to as low as 200 USD . Additionally, a study by Schoenbrunner et al.
[38]
showed that oximetric monitoring raised the cost of postoperative flap monitoring by 2,000 USD per patient