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Foppiani et al. Plast Aesthet Res 2023;10:53 https://dx.doi.org/10.20517/2347-9264.2022.137 Page 11 of 14

with devices costing 8,000-50,000 USD [39,40] . While this implies that the cost of both those types
of monitoring is similar, the newer smartphone-based monitoring could become a compelling cost-
efficient method. Continuing with the discussion of cost efficiency, another important factor to
consider is the economic burden that results from flap complications and flap loss. Complications
associated with autologous breast reconstruction are costly, with median costs for complications at 30
days found to be an additional $7,197 USD and at one year found to be an additional $10,644 USD .
[41]
Therefore, the price of monitoring flap perfusion may ultimately be more cost-effective for the sake of
avoiding eventual flap complications and loss while certainly preventing additional psychological burden
on patients.

Limitations
While this is an original and pioneering study that aims to systematically review and compare the outcomes
and complications of oximetric and thermographic flap monitoring for microvascular flap monitoring, it
does have limitations. Given the specific type of outcome investigated and the paucity of experimental
designs in this domain, it was not feasible to restrict study designs to only randomized controlled trials or
case-control cohorts, resulting in high heterogenicity. The final patient population was thus retrieved largely
from observational studies, which present biases inherent to their design (e.g., underreporting or
information bias, and publication bias) and frequently incomplete data. This is a natural outcome when
venturing into new territory and collecting data from multiple sources. Despite this limitation, our study
represents a crucial first step in understanding the utility of thermography and oximetry for flap monitoring
in microvascular breast reconstruction. Future research can build on our findings by comparing these
monitoring techniques in a larger, more standardized patient cohort, with careful consideration of patient
characteristics and comorbidities to enhance the rigor and precision of the comparison. Another significant
limitation was the lack of consensus on what defines certain complications. For example, flap and skin
necrosis were not reported in terms of area or percentage. Thus, some studies could have considered small
defects while others may have chosen to only count larger areas of necrosis as a reportable complication.
Furthermore, while postoperative monitoring can significantly impact outcomes, surgical experience, the
volume of free flap performed in each institution, and variation in surgical technique can all have a major
impact on complication rates. Lastly, it is important to note that a consensus on a unified cut-off indicating
concern for a threatened flap when using oximetry or thermography should be established. Such a
consensus could decrease heterogeneity within sub-groups and enable a more valid comparison of methods
of breast flap monitoring.

CONCLUSION
Ultimately, this meta-analysis concludes that while oximetry monitoring currently has strong evidence for
improving flap outcomes trends, the current data indicate that further studies may show that more updated,
modern thermography is at least comparable to oximetry in achieving ideal patient outcomes. As of this
systematic review, oximetry seems to be marginally superior to thermography and thus poses whether it
would be valuable to put more resources into investigating thermographic monitoring techniques for
microsurgical breast reconstruction. However, while outcomes themselves would not warrant further
investigation, the emergent low-cost thermographic devices have the potential to improve cost-efficiency.
Finally, this study highlights the importance of flap monitoring following microsurgical reconstruction of
the breast and also encourages further cost analysis comparing thermography and oximetry.

DECLARATIONS
Acknowledgment
We sincerely thank Victor Joao, affiliated with the Universidad De La Republica Uruguay, for his help as the
active librarian for this project. He helped with creating search strategies and gathering the search results for