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Cevallos et al. Plast Aesthet Res 2023;10:30 https://dx.doi.org/10.20517/2347-9264.2023.01 Page 3 of 17

indicated. However, protocols vary significantly between institutions and flap types, and there remains no
national consensus on the frequency or duration of monitoring. Recent discussions have emerged regarding
the necessity of ICU monitoring for free flaps and the utility of monitoring beyond the initial 48 h [26,27] . A
meta-analysis of head and neck microvascular reconstruction indicated that immediate post-operative ICU
care did not lead to a decrease in flap failure or complication rates . Frequent monitoring with hourly flap
[28]
checks in the first 24 h is ideal, and this frequency can be decreased to every 4 h for the subsequent 2-3
days . Shorter intervals, such as 30-minute intervals for the first 24 h, are considered optimal but can be
[29]
time-consuming for surgeons, residents, or nursing staff. Additionally, microsurgical flaps carry the
potential for infection and vascular trauma, which, when combined with manual examination and dressing
[30]
procedures, may result in the development of hematoma and seroma . Nevertheless, the primary objective
of any post-operative monitoring protocol should be to optimize the patient’s recovery and expedite their
return to pre-operative status, thereby reducing hospital length of stay, the risk of infection or deep venous
[27]
thrombosis, and costs of care . Emerging research suggests that the implementation of an enhanced
recovery after surgery (ERAS) program, which incorporates a transdisciplinary comprehensive approach to
peri-operative care, may effectively reduce post-operative complications, shorten the length of stay, and
minimize the need for morphine equivalent dosing . High-volume institutions and greater provider
[31]
experience have been associated with lower rates of flap failure, indicating the beneficial role of
protocols [32,33] . Typically, patients are placed on strict bed rest and “nothing by mouth” for the first 24 h to
prevent mechanical complications and allow for prompt re-exploration, if necessary. Volatile hemodynamic
disturbances are avoided by using appropriate anesthetic/pharmacologic agents [20,34,35] . The use of
anticoagulation remains controversial due to the delicate balance between undesirable bleeding and the risk
[36]
of thrombosis . However, prophylactic administration of heparin can be employed for deep-vein
thrombosis prevention. Aspirin can be given for up to 30 days to inhibit platelet aggregation . Low-
[37]
molecular-weight heparin and aspirin, either alone or in combination, have shown similar efficacy in
reducing macrovascular graft occlusion after surgery . Lastly, patient education about the planned
[36]
monitoring can help to manage their expectations, improve compliance, and enhance both flap outcomes as
[38]
well as the overall patient experience .
Bedside clinical evaluation
The clinical exam remains the cornerstone of flap monitoring after breast reconstruction, offering high
sensitivity and effectiveness in detecting failing flaps without incurring the expenses associated with
advanced monitoring technologies or specialized personnel. The clinical exam comprises four essential
components: color, capillary refill, tension/turgor/swelling, and temperature [Table 1] . Unlike software-
[39]
based techniques, the clinical exam has the capability to discern between adequate inflow (arterial) and
outflow (venous) problems . While not all patients will have a drain post-operatively, checking the drain’s
[39]
functionality, output color, and amount remains an important aspect of the clinical exam.

The effectiveness of the clinical exam relies heavily on the experience of the provider, who may assign
varying importance to specific exam findings. Furthermore, patient-specific factors, such as skin tone and
flap location, can influence findings; color changes, for instance, may be less pronounced in patients of
different races and/or ethnicities [40,41] . The clinical exam has limitations in cases where flaps lack a cutaneous
component (e.g., musculocutaneous flaps and other buried flaps). In such instances, surgeons may opt to
expose a small portion of the flap at the skin surface temporarily to facilitate monitoring. Advanced
monitoring technologies are particularly valuable when the clinical exam yields ambiguous or inconclusive
results .
[42]