Free flap monitoring

Close monitoring of the microvascular reconstruction is paramount. This monitoring

by nurses is important to the avoidance and early detection of complications.
Visible inspection, digital palpation and Doppler monitoring of a markedly superficial
pedicle are part of clinical flap assessment. The patient should be inspected for
compression of anything in or around the neck. This includes no gown ties, trach
ties or even ECG wires or IV lines that may create any compression around the neck.
Any sort of compression can lead to early pedical compromise.
Complications and Salvage
Systemic medical complications are common in patients undergoing microvascular
surgery for head and neck cancer and must be aggressively treated. Local
complications to the donor site are specific to each type of free flap. Complications
range from pain, bleeding, and infection to more severe complications, such as
permanent sensory and motor nerve damage and even loss of the donor limb.
Infections under pressure in either natural or surgically treated compartments can
rapidly lead to compression and thrombosis of the already compromised native
vascularity of the extremity. Recipient site complications include hematoma,
salivary fistula, infection, and wound dehiscence.
Most free flap anastomotic ischemic complications occur within the first 48 to 72
hours. Venous anastomotic thrombosis is more common, but if not remedied, both
outflow and inflow can be compromised. Early venous congestion may affect the
more distal monitoring paddle before the main flap paddle, because of the proximity
of the monitoring paddle to the venous anastomosis. Ealry venous congestion
changes in the monitoring paddle should be taken very seriously. Venous
anastomotic thrombosis results in an increased flap turgor, rapid capillary refill with
brisk bleeding of darker blood, and finally, darkening and mottling of the skin
paddle. Venous congestion may present with any or all of these changes, the color
changes usually being a later sign. The artieral pulse can still be felt until the later
stages.
Arterial insufficiency manifests as a profound paleness and coolness, loss of flap
rugor, and absence of any capillary refill or bleeding to pinprick. Usually only a
serous bubble, if anything, arises from a pinprick or cut. The superficial pedicle
pulse is no longer palpable or obtainable by Doppler testing. Observation of
changes in free muscle flaps are more difficult to determine than in fasciocutaneous
flaps.
Neck Dissection Classification
Radical neck dissection is the standard basic procedure for cervical
lymphadenectomy. It includes the removal of all ipsilateral cervical lymph node
groups extending from the body of the mandible superiorly to the clavicle inferiorly
and from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral
anterior belly of the digastric muscle anteriorly to the anterior border of the
trapezius muscle posteriorly. Included are all lymph node groups from levels I
through V, the spinal accessory nerve, the internal jugular vein, and the
sternocleidomastoid muscle. IT does not include the removal of the postauricular
and suboccipital nodes, the periparotid nodes (except for a few nodes located in the
tail of the parotid gland), the perifacial and buccinators nodes, the retropharyngeal
nodes, and the paratracheal nodes.
Indications
The radical neck dissection is indicated for patients with extensive lymph node
metastases with extension beyond the capsule of the node or nodes to involve the
spinal accessory nerve and the IJ vein.
When the modification of the radical neck dissection involves the preservation of
one or more nonlymphatic structure, the procedure is called modified radical neck
dissection.