Flap Physiology

Hiew Khee Chun 2018

Introduction Commented [KCH1]:

What is a flap?
16th century Dutch word “flappe”: something that is hung broad and loose, fastened only by one side

Kayser (SRPS 1999): A flap is a unit of skin and other tissues that maintains its own intravascular Commented [KCH2]:
circulation while being transferred from a donor to a recipient site. (Graft does not have own blood Commented [KCH3]: Not always involve skin
supply, relies on blood supply of recipient site.)

Flaps are the essence of plastic surgery. Good understanding and being able to optimize the vascular
physiology of a flap can make the difference between success and failure.

Regulation of flap blood flow

Vascular supply to flaps has 2 components:

 Macrocirculation
o Used to define and design a flap
o Major arterial inflow and venous outflow constitutes foundation for microcirculation
 Microcirculation
o Circulation of blood in the most distal part of the circulatory system, starting from
arterioles
o Flap physiology begins at the level of microcirculation
o Consists of smallest vessels in the circulatory system
 arterioles, capillaries, venules, arteriovenous anastomosis (AVA)
o Functions
 Forms the basis of cellular metabolism throughout the flap
 provide nutrition and oxygen
 carry away carbon dioxide and waste products
 Control/regulation of perfusion
 Thermoregulation
o Innervated by sympathetic fibres directed to
 Arterioles - vasoconstriction
 Precapillary sphincters – involved in nutrient/waste exchange
 AVAs (shunts) – involved in thermoregulation
 E.g. Hypothermia  Opening of AVA  reduced blood flow through
true capillaries (closer to the environment)  Conserve body heat
Precapillary sphincter:
regulates nutritive blood
flow to skin and responds
to locally produced stimuli

Preshunt sphincter:
involved in
thermoregulation, affected
by sympathetic stimuli
from CNS
 Regulation of Cutaneous blood flow
Vasoconstriction Vasodilation
Pain, tissue trauma,
sympathectomy
α-adrenergic

NE (weak) + epinephrine β-adrenergic

Neural Sympathetic Fibres

Serotonergic
Located at AVAs
Stress

Systemic Norepinephrine α-adrenergic

Can vasoactive drugs like
epinephrine noradrenaline be used?

Traumatised Serotonin
platelets thromboxane A2
Humoral leukotriene B2
prostaglandin F2α

Prostaglandin E1
Prostaglandin I2
(prostacyclin)
Anaemia Haemodilution ↑ blood flow histamine
What is the ideal Hb/Hct?
bradykinin
Regulation of Benefit offset by
Rheological ↓O2 delivery
cutaneous blood (Flow)
Flow
Polycythemia
 cell concentration Sickle cells Sludging ↓ blood flow
 plasma viscosity
 RBC aggregation & deformability
 vessel characteristics
Hypercapnia
 Follows Poiseuille’s Law Hypoxia
Metabolic Acidosis
Hyperkalaemia

Local (Autoregulation) Hypothermia

Physical
Hyperthermia
Myogenic reflex To dissipate heat
Triggered by Increased
tissue perfusion to
maintain constant
capillary blood flow

Physiology of vasomotor factors

α1
Noradrenaline
angiotensin II β2
vasopressin Various signal
Endothelin-1 transduction pathways +
thromboxane A2 -
α2
KATP

↓O2 ↓ATP

MLCK – myosin light chain kinase

↑CO2, ↑H+ MLCP – myosin light chain phosphatase
Vascular smooth muscle contraction: An increase in free intracellular calcium can result from either
increased flux of calcium into the cell through calcium channels or by release of calcium from internal
stores (e.g., sarcoplasmic reticulum; SR). The free calcium binds to a special calcium binding protein
called calmodulin. Calcium-calmodulin activates myosin light chain kinase (MLCK), an enzyme that is
capable of phosphorylating myosin light chains (MLC) in the presence of ATP. Myosin light chains are
20-kD regulatory subunits found on the myosin heads. MLC phosphorylation leads to cross-bridge
formation between the myosin heads and the actin filaments, and hence, smooth muscle contraction.

alpha-adrenoceptors

Vascular smooth muscle has two types of

alpha-adrenoceptors: alpha1 (α1) and
alpha2 (α2).

The α1-adrenoceptors are the

predominant α-receptor located on
vascular smooth muscle. These receptors
are linked to Gq-proteins that activate
smooth muscle contraction through the IP3
signal transduction pathway.

Depending on the tissue and type of vessel,

there are also α2-adrenoceptors found on
the smooth muscle. These receptors are
linked to Gi-proteins, and binding of an
alpha-agonist to these receptors decreases intracellular cAMP, which causes smooth muscle contraction.

There are also α2-adrenoceptors located on the sympathetic nerve terminals that inhibit the release of
norepinephrine and therefore act as a feedback mechanism for modulating the release of
norepinephrine.

β2-adrenoceptors

Vascular smooth muscle has β2-adrenoceptors that have a high binding affinity for circulating
epinephrine and a relatively lower affinity to norepinephrine released by sympathetic adrenergic nerves.

Increased intracellular cyclic adenosine monophosphate (cAMP) by beta-2-agonists inhibits myosin light
chain kinase thereby producing relaxation

These receptors, like those in the heart, are coupled to a Gs-protein, which stimulates the formation of
cAMP.

Although increased cAMP enhances cardiac myocyte contraction, in vascular smooth muscle an increase
in cAMP leads to smooth muscle relaxation. The reason for this is that cAMP inhibits myosin light chain
kinase that is responsible for phosphorylating smooth muscle myosin. Therefore, increases in
intracellular cAMP caused by β2-agonists inhibits myosin light chain kinase thereby producing less
contractile force (i.e., promoting relaxation).
Vasomotor effects of hypercapnia, hypoxia, and acidosis:

vasodilatation in response to and hypercapnia

is dependent in part on activation of ATP-
sensitive potassium channels.

vasodilatation during hypercapnia is

dependent in large part on production of NO

Activation of ATP-sensitive potassium

channels produces hyperpolarization and
relaxation of vascular muscle

Hypoxic vasodilation is at least in part mediated by the KATP channels of vascular smooth muscle cells
which open in response to hypoxia-induced decrease in ATP

Anaemia and flap survival:

Hill 2012: The effect of anemia in microvascular reconstruction is controversial, with some reports
suggesting a benefit of normovolemic hemodilution in flaps and skin grafts, based on theory that
decreased viscosity increases cardiac output and thus arterial flow to tissue. This state may also be
deleterious, however, as the decreased viscosity of hemodilution reduces laminar flow, increases
turbulence, and encourages thrombosis. Anemia also decreases oxygen-carrying capacity, which may
contribute to both flap and patient morbidity

SRPS 1999: Increased blood viscosity (hematocrit >45%) may also decrease flow. The effects of
haematocrit were questioned by Kim et al who concluded that normovolemic anemia (hct 19%) had no
significant effect on the survival of pedicled musculocutaneous flaps (experimental study done with 26
pigs, 13 of which exsanguinated to Hct 19%, flap failure rate was the same in both groups).

Velanovich 1988: Reviewed Hb and Hct of 14 successful and 6 failed free flaps, Hb and Hct levels in
clinically acceptable ranges have no effect on free flap survival.

Stepanovs 2016 (Review): Patients undergoing microvascular reconstruction are often anaemic from a
combination of iatrogenic haemodilution and acute blood loss. Preoperative anaemia with haematocrit
(Hct) level less than 30% and haemoglobin (Hb) less than 10 g/dl can significantly impact free flap
morbidity (Hill et al., 2012). However, some studies have not confirmed these results (Mlodinow et al.
2013). Haemoglobin and haematocrit levels should be optimised before surgery (Hb > 10 g/dl, Hct > 30
per cent) (Clark et al., 2007).

Mlodinow et al. 2013: Reviewed NSQIP data, 864 samples, anemia (male: Hct < 39%; female: Hct < 36%)
is neither a predictor of free tissue transfer failure nor is it protective

-Large sample, definition of anaemia follows WHO definition, higher threshold than most other studies

Clark et al., 2007: Low preoperative hemoglobin predicted for major morbidity as a continuous variable,
and when dictotomized, a hemoglobin less than 11 g/ dL was a potent predictor of surgical complications
(OR 4.68) and length of hospital stay. We postulate that hemoglobin acts as a surrogate for nutritional
and general health status, since it correlated significantly with low weight and percentage weight loss (p
< .05). Correction of anemia by blood transfusion potentially may have an adverse effect due to increased
blood viscosity (flap failure).

Rossmiller et al. 2010: For patients undergoing free flap surgery, a postoperative transfusion trigger of
hematocrit < 25% (vs <30%) decreases blood transfusion rates without increasing rates of flap related
complications.
Vasoactive drugs:

In recent studies show that administration of vasopressors following flap division does not impact flap
outcomes (Chen et al., 2010; Monroe et al., 2010; 2011). Prospective studies comparing effect of
epinephrine, norepinephrine, dobutamine, and dopexamine demonstrated that both dobutamine and
norepinephrine improved blood flow in free flap skin, with norepinephrine yielding the greatest
improvement (Eley et al., 2012; 2013). After division of the flap, if a vasopressor is needed, it should be
tailored for maintaining blood pressure and flap flow, despite widespread prejudice and information
given in older studies (Louer et al., 2013), helping to avoid excessive fluid administration and interstitial
oedema. Preferable agents are norepinephrine and dobutamine.

Vasoconstriction induced by exogenous NE or by stimulation of adrenergic nerves is associated with

simultaneous release of endothelium-derived NO and PGI2. NE activates alpha2-adrenoreceptors in
andothelial cells to stimulate synthesis and release of NO and PGI2 (vasodilators)

Hypothermia vs Hyperthermia

Hypothermia prolongs tissue ischaemia tolerance, but causes vasoconstriction. Some studies (Thomson
et al., 2009; Liu et al., 2011) report correlation of mild hypothermia with lower rates of flap thrombosis.
However, the majority of reports on humans show that hypothermia is associated with perioperative
complications. It is recommended to maintain ambient room temperature at approximately 24 °C before
patients are in the operating room, and other preventative efforts should be made to avoid hypothermia
(Gardiner and Nanchahal, 2010).

Blood flow regulation in muscle vs skin

Skin Muscle
Capillary density Lower Higher
AV anastomosis/shunts Present (neuronal control) Absent
Neuronal control
-Sympathetic vasoconstriction Most important Less important
Humoral control
-Epinephrine Vasoconstriction Vasodilation
(fight or flight, more perfusion
needed)
Metabolic factors
-Autoregulation Important Most important
(similar to other organs with
high metabolic demand)
Physical factors
-Temperature Important Not important
(muscle not thermoregulatory)
-Myogenic tone Less important More important
 Haemodynamic alterations on flap elevation
 Flap raising disrupts finely balanced equilibrium that regulates blood flow to tissue

Banbury et al described muscle flaps’ triphasic Nutrient vessels &

microcirculatory response to sympathectomy &
denervation (by dividing genitofemoral nerve and sympathetic nerves
assessing the cremasteric muscle flap of 30 rats) severed
 Acute hyperadrenergic phase (0-24 hours) –
vasoconstriction  Loss of sympathetic innervation  spontaneous
First 12 – 18 hours

 Non-adrenergic phase – with significant discharge of vasoconstricting neurotransmitters

vasodilatation
(e.g. norepinephrine)
 Sensitised phase – increased capillary perfusion
and hyperresponsiveness to vasoactive
 Drop in perfusion pressure from physical removal
substances of inflow vessels
 Progressive leukocyte-mediated endothelial injury
Based on these observations it was evident that
microcirculation can be significantly improved by
muscle sympathectomy and somatic denervation
Flow ↓ (especially
Labelled microspheres experiments
(by Palmer, Nathanson, Kerrigan, etc) distal portions)
involving pedicled flaps (basal flow
preserved)
Flow at tip:
 6 - 12 hours: <20%
 1 - 2 weeks: 75%
 3 - 4 weeks: 100%
SRPS 2005 volume 10, number 5, part 2 Microsurgery;
Returning flow John R Griffin MD

Sympathetic Reperfusion injury

12 – 24 hours neurotransmitter
depleted

Microvascular
shutdown
Inosculation from
2 – 3 days flap bed

Tissue necrosis

Flap perfusion
restored
In 1976, Hoopes gave a detailed account of the circulatory events that take place in a pedicled flap
after its blood supply is partially interrupted during elevation and transfer.

•First 6 hours: reduction in arterial blood supply;

Timing of circulatory compromise
decrease circulatory efficiency.
 82.3% in 1st 24 hrs
•6-12 hours: plateau.
0 - 24 •After 12 hours: increase circulatory efficiency;
 95.5% in 1st 72 hours
 Mostly venous in origin
marked congestion and oedema; marked dilation
hours of arterioles & capillaries.  90% of arterial thrombi in 1st 24
hrs-
Important to maintain good MAP
•Improvement in pulse amplitude.
especially 1st day of surgery
•Little or no improvement in circulation during initial 48 hrs.
1-3 •Increase in number and calibre of longitudinal anastomoses. Slow and low flow promotes
•Increase in number of small vessels in the pedicle.
days thrombus formation

Reduce congestion by elevation for

•Progressive increase in circulatory efficiency. 1st 1-2 weeks
•Plateau at day 7.
•Anastomosis between flap and recipient bed present at 2-3 days prevent external compression (e.g.
3-7 and becomes functionally significant at 5-7 days. Surgical drains to prevent
•Increase in size and number of functioning vessels. haematoma, light bandaging)
days •Reorientation of vessels along the long axis of the flap.
Splint limbs to avoid kinking

Prevent tension to pedicle (e.g. use

•Establishment of circulatory function. of brassiere after breast
reconstruction)
•Pulsatile blood flow approaches preoperative level.
1 week
Flap division is safe by 2-3 weeks

•No increase in vascularization.

•Normal arterial pattern.
1-2 •Radioisotope clearance indicates circulatory efficiency surpassing
normal values at 10-21 days returning to normal after 3 weeks.
weeks

•Progressive regression of the vascular system.

•Continuous maturation of anastomosis between flap and recipient
2 weeks site.

•Vascular pattern = preoperative state

•90% of final flap circulation achieved.
•Full development of vascular connection with pedicle and recipient
3 weeks site.

•All vessels decreased in diameter.

•Few remaining newly formed vessels.
4 weeks
Metabolic changes in flap elevation
 Tissue ischaemia  anaerobic metabolism
o ↓ O2
o ↓ Glucose – consumption increased in proportion with ischaemia (in ischaemic yet
viable tissue), peaks around day 3, return to normal by day 7
o ↓ ATP
o ↓ superoxide dismutase (protective against superoxide particles) - consumed in
converting superoxide to oxygen in a tissue-protective mechanism

o
o ↑ CO2
o ↑ lactic acid
o ↑ Prostacycline, thromboxane
o ↑ toxic superoxide radicles
*Most of these parameters are reflected on blood investigations like ABG, important to ensure
sufficient nutrition and ventilation support for patients

 Detrimental effects of toxic superoxide radicles

o
o Direct cytotoxic effects
o Triggers local acute inflammation, adherence and accumulation of leukocytes
endothelial injury  microvascular shutdown
 Free radicals also play an important role in hematoma-related flap necrosis
o Hemoglobin and iron catalyse the chemical reactions that lead to the production of
highly destructive free radicals, in particular the hydroxyl radical (•OH)
o Fe2+ + H2O2 → Fe3+ + OH− + •OH (Haber-Weiss reaction).

Ischaemic reperfusion injury

Definition: tissue damage triggered by ischaemia, as a consequence of exposure to a re-established
vascular supply i.e. reperfusion.

Pathophysiology

o Ischaemia
o ↓ O2  anaerobic metabolism
o Oxygen debt and cellular energy depletion → various biochemical alterations (including
atypical build-up of cytoplasmic metabolites and malfunction of membrane transport
systems).
o Changes are injurious at the cellular level in a manner directly proportional to the duration
of ischaemia.

Reperfusion
The re-establishment of normal vascular supply can incite continued and intensified tissue injury
caused by reactive oxygen intermediates (eg. superoxide anion radicals, hydrogen peroxide and the
hydroxyl radical) and tissue neutrophil accumulation.

Important features of the mechanism of ischaemic-reperfusion injury:

1. Production of reactive oxygen species via:

i. Xanthine dehydrogenase / xanthine oxidase enzyme system (by the endothelial cells).

 During prolonged ischemia, adenosine triphosphate (ATP) is catabolised stepwise to

hypoxanthine, with concomitant increase in cytosolic (intracytoplasmic) Ca2+.
 At the same time, a cytosolic protease is activated by intracellular Ca2+ and it converts
xanthine dehydrogenase to xanthine oxidase.
 During reperfusion, the xanthine oxidase generates superoxide (O2•) by univalent reduction of
molecular oxygen in the presence of hypoxanthine.
 The unstable O2• forms H2O2 spontaneously by dismutation.


 Furthermore, the unstable O2• also interacts with H2O2 in the presence of a transition metal
(e.g., iron) to form the most potent cytotoxic hydroxyl radical (OH•) through the Haber–Weiss
(Fenton) reaction - Fe2+ + H2O2 → Fe3+ + OH− + •OH

ii. Neutrophilic nicotinamide adenine diphosphate (NADPH) and myeloperoxidase (MPO)

enzyme system (by the activated neutrophils).

Interventions to address ROS

1. Free radical scavengers e.g. allopurinol, superoxide dismutase, iron chelating agents
2. Hyperbaric oxygen therapy
2. Neutrophil influx.
Recruitment of neutrophils during reperfusion if a multistep process in which the formation of ROS
contributes to chemotaxis and activation of adhesion molecules that lead to neutrophil infiltration.

Process of neutrophil extravasation is a three-step process:

 Rolling – reduces their speed and stimulates endothelial contact.

 Firm adhesion to endothelium.
 Transmigration.

Activated neutrophils cause injury in the ischaemia-reperfusion by:

1. Direct endothelial injury → loss of vascular integrity, oedema, haemorrhage and thrombosis.
2. Microvascular occlusion and further ischaemia resulting from adherence and accumulation of
aggregates of neutrophils within vessel lumen.
3. Producing large amounts of O2• via neutrophilic nicotinamide adenine diphosphate (NADPH)
oxidase system, and these O2• dismutates yield high concentration of H2O2 and OH•,causing
tissue damage (“Respiratory burst”)
4. Myeloperoxidase (MPO), which is unique and abundant in neutrophils, catalyzes the conversion
of H2O2 to hypochlorous acid (HOCl), a potent cytotoxic oxidizing agent (H2O2 + Cl− + H+ →
HOCl + H2O).

Counter-argument against role of neutrophil in I-R injury: Several studies demonstrated that I-R injury
occurs in absence of neutrophil induced in laboratory settings.

Agents that inhibits action of leukocytes and mediated I-R injury

1. Sulfatide: binds to P- and L-selectin, which play important roles in the initiation of neutrophil–
endothelial interactions.
2. monoclonal antibodies against neutrophil–endothelium adhesion molecules:
 attenuated ischemia–reperfusion induced skin necrosis in animal studies.
 attenuated arteriolar vasoconstriction induced by I-R injury
3. Mechlorethamine: alkylating agent for chemotherapy, depletes neutrophil by ~95%
 significantly reduced necrosis in pig latissimus dorsi muscle flaps subjected to 5 hours of
warm ischemia and 48 hours of reperfusion

Insufficient evidence for routine clinical use

3. Arachidonic acid

Lipo/cyclooxygenase =
enzymes that oxygenate
arachidonic acids

+O2
+O2 leukotriene B4, a potent
chemoattractant, which can
induce superoxide anion
generation and degranulation in
neutrophils

a potent vasodilator, a potent vasoconstrictor

inhibitor of platelet & induces platelet
aggregation & increase aggregation
capillary permeability

Intervention

Anti-inflammatory agents: aspirin, COX inhibitors, NSAIDs, steroids

TXA2 synthase inhibitor: dazoxiben (did not show to improve flap survival in rabbits)

? LOX/leukotriene inhibitors: no studies done

4. Depletion of nitric oxide (NO).

Reperfusion injury causes destruction of nitric oxide synthase activity

NO protects tissues by:

 regulating the vascular tone,

 inhibition of leucocyte aggregation and adhesion,
 inhibition of leucocyte adhesion to endothelium,
 free radical scavenging,
 maintaining normal vascular permeability,
 inhibition of smooth muscle proliferation,
 strengthening the immune system and
 stimulation of endothelial cell regeneration.

Decrease in NO concentration causes:

 Vasoconstriction.
 Capillary plugging by neutrophils.
 Thrombus formation in the microcirculation.

Intervention

Nitrosoglutathione (GSNO): induces inducible nitric oxide synthase (iNOS), exogenous nitric oxide (NO)
donor. Demonstrated to improve flap survival in animal studies.
5. Intracellular Ca2+ overload

At reperfusion, the
rapid washout of the
extracellular H+
reactivates the NHE-1

 In sustained ischemia, mitochondrial ATP synthesis ceases and glycolysis ensues net
breakdown of ATP and an accumulation of lactate and intracellular H+
 Build-up of intracellular H+ activates the Na+/H+ exchange isoform-1 (NHE-1) antiporter,
extrusion of H+ and accumulation of intracellular Na+ to restore intracellular pH.
 Elevation of intracellular Na+ concentration  ↑ in intracellular Ca2+ by activation of the Na+/
Ca2+ exchanger Ca2+ influx.
 cytosolic Ca2+ will be overloaded significant uptake of Ca2+ from the cytosol to the
mitochondria  mitochondrial Ca2+ overload depolarization of mitochondria  impairs
ATP synthesis  in cell necrosis
 At reperfusion, the rapid washout of the extracellular H+ reactivates the NHE-1 further
extrusion of intracellular H+, further accumulation of intracellular Na+  further cystolic Ca2+
overload through Na+/Ca2+ exchange.

Pharmacological agents

Cyclosporin A: binding to mitochondrial cyclophilin inhibits the permeability transition pore

? Calcium channel blocker: demonstrated to be beneficial for rat liver

6. Apoptosis
 Is an actively regulated mechanism of cell death.
 Functions to remove redundant cells and to clean up aged or damaged cells in developed
tissue.
 During reperfusion, ROS cause damage to DNA and mitochondria which are both powerful
inducers of apoptosis.
 Apoptosis contribute significantly to cell death after I-R injury.

Ischaemic preconditioning & delay phenomenon

Definition
Surgical interruption of a portion of the blood supply to a flap at a preliminary stage before transfer

Purpose
 To increase surviving length of a flap
 To improve circulation of a flap and hence diminish the insult of transfer

Procedure
 Flap is mapped out on the donor site
 Incision is made on its 2 longitudinal sides
 Undermine the flap from its bed, keeping the distal end intact
 After a period of time, distal end of the flap is divided
 Flap is transferred to the recipient site

Delay Sequences
Described by Dhar and Taylor 1999:

 Phase 1:
o Initial spasm up to 3 hours
o Gradual dilatation for the next 24 hours
 Phase 2:
o 24-72 hours: increase arterial calibre,
primarily at the choke vessels level
 Phase 3:
o 3-7 days: further luminal dilation and
vessel wall thickening
 Phase 4:
o Day 7 onwards, choke vessels remain
permanently dilated

Mechanism of delay
2 school of thoughts

 Delay conditions tissue to ischaemia:

o Allowing it to survive on less nutrient blood flow than normally needed
 Delay improves or increases vascularity

Likely a combination of both

Five mechanisms of delay phenomenon (Hoopes):

 1. Sympathectomy
2. Acclimatization to hypoxia
3. Vascular reorganization
4. Reactive hyperemia
5. Non specific inflammatory reaction (producing vasodilation)

Anatomical changes
Sympathectomy causes depletion of cathecholamines from the initial procedure itself

 Begins after incision and ending by 30 hours

 Hence, enhanced vascularity from less vasoconstriction due to lack of cathecolamines

Gradual hypertrophy of blood vessels & acclimatization to hypoxia as a result of ischaemic tissue
conditioning from exposure to lower O2 tension or poor circulation

 Vessel enlargement is permanent & irreversible involving

o Multiplication (hyperplasia)
o Elongation
o Hypertrophy of red cells in each layer of the vessel wall
 Maximum effect between 48-72 hours after operation

Vascular reorganization

 Longitudinal reorientation of small vessels parallel to the long axis of pedicles at 1-7 days post
delay

Reactive hyperemia

 Due to increase resistance to venous outflow, and increase in size & number of subdermal
arterial & dermovenous plexuses
 These vessels are toneless, dilated and unable to respond to local changes

Ingrowth of new vessels (neovascularization)

 4 to 5 days post operatively

 Vasodilation & angiogenesis until about day 14

Haemodynamic changes
Overall blood flow increase reached 75 - 90% of normal by the second week

 Vasodilation hypothesis – relaxation in precapillary arterioles of delayed flaps as a result of

o Sympathectomy
o Tissue ischaemia with local arterial dilation
o Inflammation producing vasodilation
o Formation of new collateral vessels or dilation of pre-existing channels

Significantly higher capillary blood flow in delayed random flap

 Increase flow detectable within 2 days of surgical delay

 Increased 100% by D4
 Remained plateau until D14

AV shunts do not have significant role in the pathogenesis of distal skin flap necrosis

 Tissue ischaemia due to vasoconstriction of small random arteries that supply blood to
arterioles in AV shunts

Metabolic changes
Increase glucose consumption & lactate production, with concomitant depletion of glycogen
Im, Su, and Hoopes: higher enzyme activity indicates stepped-up cellular glucose utilization in the face
of an impoverished substrate, suggesting a metabolic adaptation to ischemia. High levels of enzymatic
activity near the tip of delayed flaps

Cohen & colleages: Glucose consumption increased in proportion with ischaemia (in ischaemic yet
viable tissue), peaks around day 3, return to normal by day 7, lending support to the theory that delay
acclimatizes tissue to hypoxia. Flap tolerance to ischemia is influenced by glucose metabolism.

A critical minimal level of tissue glucose is necessary to accommodate metabolic adaptation in the
ischaemic tissue

 Glycolytic enzyme level highest in the first 3 days, supporting the theory that delay acclimatizes
tissue to hypoxia
 Metabolic changes reversible for up to 4 hours
 Ischaemic periods of 12 hours and longer resulted in complete loss of energy reserves

Timing of flap division

 Clinical delay should be lengthened to suit specific anatomy, expected flap viability and
characteristics of recipient site.
 German and associates found that circulation in flaps was re-established earlier than previously
thought.
o Initially divided flaps at 14 days post-transfer.
o Later shortened the interval to 10 days without deleterious effects on flap survival.
 Hauser et al noted that the traditional 3 weeks for division of an inset flap is acceptable in 85% of
patients but is premature in some and excessively long in most.
 Cumulative experience suggests that most flaps can be divided safely at 10 days to 3 weeks.

Flap failure or necrosis

Factors:
 Arterial/venous occlusion
o Venous occlusion:
 Reduction in outflow
 More deleterious than arterial ischaemia
 Common in free tissue transfer
o Thrombosis (Virchow’s triad)
 Caused by low flow state at the level of microcirculation
 Improper flap design
 Ischaemia-reperfusion injury
 Systemic factors affecting microcirculation (hypotension, sepsis,
smoking, vasoconstrictors)
 Physical compression of the flap (improper inset, kinking, haematoma).
 Often originates from site of microvascular anastomosis
 Poor technique: allowing prothrombotic adventitia or media to be
exposed to the luminal blood flow, with subsequent platelet and fibrin
deposition, rather than having a smooth endothelial lining across the
anastomosis
 Exposed endothelium
 Surgical trauma
 causes vasoconstriction and platelet aggregation by means of :
o Nerve ending: Noradrenaline
 o Platelet: TXA2, 5HT2, leukotriene B2
o Endothelial cells: endothelin-1
o RBC (e.g. haematoma): Hb is a potent vasoconstrictor
o ↓ endothelium-derived relaxing factors (e.g. NO, prostacyclin)
o ↑ endothelium-derived relaxing factors (e.g. TXA2, endothelin-
1)

 Insufficient distal vascularity

o Flap raised larger size than can be supported by supplying vessels
 Perfusion pressure drop-off at sufficient distance from pedicle vessels
 Ischaemia is greatest at the point furthest removed from the vascular pedicle
o Vasoconstriction of supplying vessels  inadequate end-flow
 Proximal portion has reduced blood flow due to sympathectomy,
catecholamine release, and local response to injury  inadequate distal
perfusion
 Vasospasm from surgical manipulation
 Composition – e.g. comparing skin vs muscle flaps:
o Skin flaps: less blood flow, but also less metabolic requirement, more tolerant to longer
ischaemia duration
o Muscle flaps: early hyperaemic phase during reperfusion maintains a significant blood
flow to all regions, including the area of the flap that is destined for necrosis; skin has
marked decreased flow rates

NO-REFLOW PHENOMENON

No-reflow phenomenon: point at which it is not possible to re-establish nutrient inflow despite
reperfusion.
This phenomenon is the result of ischaemia-induced reperfusion injury (IIRI). Three pathogenic
mechanism in development of no-reflow phenomenon:

1. O2 free radicals causing damage in the endothelial and parenchymal cells.

2. Cell membrane damage allowing Ca2+ influx, resulting in intracellular overload and cell death
3. Change in AA metabolism – synthesis of more vasoconstricting and thrombotic TXA2 by platelet,
and less vasodilating and anti-thrombotic PGI2 by the endothelium.

May in 1978 did a study on circulatory changes in free epigastric flap in rabbits.

 All flaps survived up to 4 hours of ischaemia.

 The ischaemia induced several cellular changes:
o Swelling of the endothelial and parenchymal cell.
o Narrowing of the capillary lumen.
o Intravascular aggregation of blood cells.
o Leakage of IV fluid into the interstitial space → oedema.
 4-8 hours of ischaemia: reversible changes.
 After 12 hours of ischaemia: irreversible changes.

Therapeutic interventions to improve flap survival

Therapeutic intervention to improve flap viability:
1. Physical factors
2. Pharmacologic factors

Physical Factors
Advantage Disadvantage
Moist edges Increased surviving portion of flap (Sasaki et al). Excessive moisture
causes maceration
Moist Diminishes depth of tissue loss.
environment Increase flap survival by ↓ desiccation of
ischaemic tissue (McGrath).

Temperature Hypothermia is protective against the injury Hypothermia induces

effects of ischaemia and reperfusion by reducing vasoconstriction
neutrophil accumulation and neutrophil-
mediated tissue injury.

Cooling ischaemic tissue → ↓ metabolic rate and

prolongs period of ischaemia eg: Digits up to
days.
Muscle: 2 hours at 34°C or 5 hours at 26°C
Preconditioning A process whereby tissue is subjected to a brief Multiple procedures
period of nonlethal ischaemia.
Can be done by
 selective pedicle ligation if more than one
axial pedicle exists
 or by repeated courses of pedicle clamping
Confers a resistance to damage by subsequent
prolonged ischaemic events.

Induces a biphasic protection against

 ischemic/reperfusion injury following the initial
preconditioning event:
 an initial strong protective stimulus that last
2 to 3 hours
 followed by a less powerful prolonged
stimulus lasting 48 to 96 hours

Exact mechanism of action is unknown. Theories:

 Alteration in blood flow.
 ↓ Tissue metabolism.
 Selective loss of certain nonessential cellular
functions.
 ↓ Levels of oxygen derived free radicals.
 Release of endothelium-derived relaxing
factors → vasodilation and improved distal
blood flow.

Mounsey
- To enhance muscle flap survival and sustain
normothermic ischaemia, muscle flap is
subjected to intermittent periods of global
ischaemia followed by reperfusion.
Finding : ↑ flap survival at 30 minute intervals.
musculocutaneous flaps fair significantly better
after preconditioning but not skin flaps.
Hyperbaric Improves skin flap viability but must be given Increased production of
oxygen immediately post-operatively. oxygen free radicals

Increased survival in rat abdominal flaps treated Insufficient clinical

with hyperbaric air (21% O2) and hyperbaric 100% evidence to support its
O2, but not hyperbaric 8% O2. use

Mechanism of protection:
 ↑ superoxide dismutase activity.
 decreasing the hypoxic insult
 enhancing fibroblast function and
collagen synthesis
 stimulating angiogenesis
 inhibiting ischemia-reperfusion injury
Pharmacologic Agents

Anticoagulants
most surgeons agree that routine use is not necessary. When a second microvascular flap is performed
to salvage a reconstruction following flap failure, systemic anticoagulation is indicated if unfavorable
conditions persist that are not correctable (e.g., radiation tissue injury, severe atherosclerosis, etc.).

Drug Advantages Disadvantages

Dextran Polysaccharide synthesised by bacteria from sucrose. Side effects:
First developed as volume expander. Anaphylaxis – give small test
2 forms depending on molecular weight formulation: dose before administering full
40000 (Dextran 40) or 70000 (Dextran 70) dose

Administered as a continuous IV infusion during flap Pulmonary (especially in

procedure and post-operatively. elderlies) and cerebral oedema

Effects include: Renal failure

↓ platelet adhesiveness
Inhibition of platelet aggregation Adult respiratory distress
↓ blood viscosity → improved blood flow syndrome (ARDS)

Clinical evidence indicate that pre- or postoperative

low-molecular-weight dextran treatment may not be
effective in augmenting free flap viability (Disa et all
2003, Ridha et al 2006).
Heparin Acts in conjunction with antithrombin III to inhibit high rate of haematoma
thrombosis by inactivation of factor X. formation

More effective at preventing venous thrombosis than Animal studies showed LMWH
arterial thrombosis. might decrease risks but not
 demonstrated in human
Investigators from Duke University Medical Center related trials
(1998) report that:
- Both unfractionated and low molecular
weight heparin (LMWH) improved microcirculatory
perfusion
- But only LMWH improved anastomotic
patency while minimizing haemorrhage.

Topical irrigation with heparinised saline widely used

technique in microsurgery – used in concentration of
100U/ml.

Systemic heparin reserved for microvascular

applications when an intraoperative thrombosis
occurs and requires mechanical clearing.
Hirudin Hirudo medicinalis commonly used to relieve venous Persistent bleeding (up to 48
congestion in flaps and replantations. hours).

Beneficial effects of leeches: Aeromonas hydrophilia

1. Injection of hirudin. infection (managed by
- Potent inhibitor of the conversion of fibrin → administration of prophylactic
fibrinogen. antibiotics).
- Does not require antithrombin III for
activation (therefore can be used in Excessive scarring.
antithrombin III deficiency).
2. Potent vasodilator effect.
3. Injection of hyaluronidase.
- Helps spread the hirudin through tissues
4. Mechanical creation of decompressive
venous bleeding through skin.
Thrombolytic Agents
The common thrombolytic agents that have been used successfully in clinical free flaps are
streptokinase, and recombinant tissue plasminogen activator (rtPA). Results are encouraging
however most are small studies

Mainly for flap salvage

Drug Advantages Disadvantages

Streptokinase  A nonenzymatic protein derived from group C beta- slowest rate of clot
hemolytic streptococci. lysis among the 3
 Activates adjacent plasminogen by forming a non-
covalent SK-plasminogen activator complex Stimulates antibody
production making
 In flap salvage, injected into arterial side of flap and retreatment difficult.
drained through the venous side to avoid systemic
effects. Higher incidence of
allergic reaction
 Dosage ranging from 50000 – 125000 units.
Urokinase  Urokinase was originally isolated from human urine, In general, many
and it is also present in the blood and in the contraindications and
extracellular matrix of many tissues. side effects
 Activates plasminogen directly by enzymatic action.
Bleeding/haematoma
 Yii et al reported 6 free flaps that were salvaged and is a major concern
2 failed after clinical use of urokinase and tPA for -not only in operative
pedicle thrombosis. site but other organs
as well e.g. ICB, UGIB
 Serletti et al reported 5 cases of venous thrombosis
that were salvaged by revision of the venous
anastomosis followed by intraoperative infusion of
250,000 units of urokinase.
rtPA tPA is a serine protease found on endothelial cells.
rtPA manufactured using recombinant biotechnology
techniques.
Vasodilators/Antispasmodics
α1
Noradrenaline
angiotensin II β2
vasopressin Various signal
Endothelin-1 transduction pathways +
thromboxane A2 -
α2
KATP

↓O2 ↓ATP

MLCK – myosin light chain kinase

↑CO2, ↑H+ MLCP – myosin light chain phosphatase

Drug Advantages Disadvantages

Calcium-channel Diltiazem, nifidepine, nitrendipine, verapamil Systemic
blockers Inhibit Ca2+ influx into the arterial smooth muscles to cause hypotension
vasodilation.
Diltiazem also stimulate release of PGI2 (vasodilator and
antiplatelet aggregation)
Topical nitroglycerin is converted to nitric oxide (NO) – follows cGMP
nitroglycerin – MLCP pathway
(GTN) potent vasodilator with a greater effect on the venous
circulation than on arterial vessels.

Gdalevitch et al.2015: RCT in Vancouver with 165 patients,

demonstrated marked reduction in mastectomy flap necrosis
in patients who received nitroglycerin ointment
Prostaglandins Prostacyclin (PGI2), Prostaglandin E1 (PGE1) high dose
Mechanism: via cAMP – MLCK pathway causes
 vasodilation systemic
 decreases platelet activation hypotension
 impairs the release of cytotoxins from white blood cells yet does not
 Stimulate new vessel formation in ischaemic tissue improve skin
Improved flap survival in animal studies, no large human perfusion
trials, only a few case report/series
Lidocaine Mechanism: inhibition of action potentials via sodium Toxicity
channel blocking in vasoconstrictor sympathetic nerves + NO related to
release anaesthetics
biphasic effect on the microvasculature: contraction at low
concentrations and relaxation at high concentrations

Ricci et al. 2016, Amsterdam: lidocaine or nicardipine as a

substitute for papaverine (during shortage) did not increase
flap loss/re-exploration
 Amrinone inhibit phosphodiesterase  ↑cyclic AMP
Papaverine Opium alkaloid antispasmodic drug, used primarily in the
treatment of visceral spasm and vasospasm
inhibit phosphodiesterase  ↑cyclic AMP
Recent worldwide shortage
Adenosine Mechanisms:
 adenosine binds to adenosine type 2A (A2A) receptors,
which are coupled to the Gs-protein – follows cAMP – MLCK
pathway
 inhibits calcium entry
increase cGMP  increased MLCP
Dipyramidamole Adenosine uptake inhibitor
Increase flap survival in animal studies
Calcitonin gene Potent vasodilator via NO, KATP, cGMP pathway
related peptide Beneficial in animal studies

Free Radical Scavangers

Drug Advantages Disadvantages
Allopurinol  Inhibit xanthine oxidase → ↓ SOR production. Prone to develop
 Mixed outcome in animal studies SJS
Renal failure
Bone marrow
suppression
Superoxide
dismutase
Catalase
2 H2O2 2 H2O + O2
Catalase
Improved flap survival in animal studies
Iron chelating  Fe2+ + H2O2 → Fe3+ + OH− + •OH (Haber-Weiss
agents reaction).
 Inhibit hydroxyl radical (OH) formation
 Reduces haematoma-related flap necrosis.
Anti-inflammatory agents

Drug Advantages Disadvantages

Aspirin  Blocks platelet aggregation and vascular Haematoma/bleeding
thrombosis
 Inhibits platelet derived COX product (TXA2)
at lower doses
 Inhibits endothelial derived COX product (PGI-
2, vasodilator) at higher doses
 Ideal dose thought to be 50 – 100 mg
 Mixed outcome in retrospective studies
NSAIDs  anti-inflammatory Inhibits COX-1, blocks
 antineutrophils agents prostaglandin synthesis 
 reduces flap oedema reduce platelet aggregation
 perioperative
bleeding/haematoma, UGIB
COX-2 Inhibits prostacyclin
inhibitors synthesis  disables
defence of endothelium
against platelet aggregation
 venous clot formation
Steroids Systemic side effects + those
related to COX inhibition

Other agents with potential to affect flap survival

Nicotine
 Vasoconstrictor
 Significantly decreased capillary blood flow, distal perfusion, and flap survival.
 Recommended for patients to stop smoking completely for several weeks before and after
flap surgery.

Caffeine? Chocolate? Vanilla? – no conclusive studies with regards to flap survival

Flap monitoring
Detection of compromised perfusion at an early stage is critical to the ability to intervene, to correct
problems, and to save a flap.

The ideal flap monitoring system should be simple, reliable, reproducible, and sensitive and should
reflect the condition of the entire flap

Flap monitoring
Non-invasive Invasive
Flow Oxygenation Temperature Visual Implantable Injectable
probes agents
Ultrasonography Oximetry Surface Smartphone Microdialysis Fluorometry
temperature digital
technology
Laser doppler Near infrared Dynamic Microvascular Cook-Swarz Contrast-
flowmetry spectroscopy infrared imaging doppler enhanced
(NIRS) thermography ultrasound
Photoplethysmography Visible light Hydrogen Nuclear
spectrophotometry clearance medicine
(VLS)
Sidestream dark field Multispectral Temperature
imaging (SDFI) special frequency
domain imaging
(SFDI)
Luminiscence pH
radiometric oxygen
imaging (LROI)
Oxygen
tension

Bedside clinical monitoring

Clinical parameter Normal Arterial occlusion Venous occlusion
Colour Pink Pale/mottled Dusky/cyanotic
Temperature Warm Cool Cool
Turgor Soft Flaccid Tense
Capillary refill time 1-2 seconds Absent/sluggish Brisk
 Cap. Bleeding on pinprick Slight delay, Delayed, little Immediate, dark red
bright red blood bleeding

Clinical monitoring alone has enabled flap salvage rates of up to 80% and overall success rates of up
to 99%.

Non-invasive, repeatable, and remains the gold standard technique

Limitations:

 Subjective, affected by lighting, skin colour

 Early clinical changes can be subtle
 Requires experience
 Not suitable for buried flaps or flaps without skin pedicle

Blood flow measurement

Doppler principle: wave that strikes a moving object will undergo a shift in frequency proportional to
the velocity of the moving object

Handheld doppler
 low-frequency (8 MHz) continuous-wave probe
 uses reflected sound to pick up pulsatile vessels
 Non-invasive, real time technique which provide information on
blood circulation
 reflects mainly on blood flow in larger vessels and not in the
microvasculature

 Typical arterial signal – triphasic pattern.

 Venous signal – lower pitched and continuous, varying with
respiratory cycle, easily augmented with gentle pressure on the
flap.

When flap compromised:

 Arterial signal lose normal triphasic pattern, become more “water- hammer”.
 Venous signal is absent or muted, ability to augment venous flow by gentle compression is
lost.

Limitations:

 unable to differentiate from adjacent recipient site vessels

 inability to measure regional perfusion
Laser doppler flowmetry

Principles:

 The laser Doppler technique measures blood flow in the very small blood vessels of the
microvasculature, such as the low-speed flows associated with nutritional blood flow in
capillaries close to the skin surface and flow in the underlying arterioles and venules involved in
regulation of skin temperature.
 The tissue thickness sampled is typically 1mm, the capillary diameters 10 microns and the
velocity spectrum measurement typically 0.01 to 10mm/s.
 The technique depends on the Doppler principle whereby low power light from a
monochromatic stable laser, e.g. a Helium Neon gas laser or a single mode laser diode, incident
(striking) on tissue is scattered by moving red blood cells and as a consequence is frequency
broadened.
Doppler shift: change in frequency between the waves emitted by the transducer and the waves
returning to the transducer after reflection from moving RBCs

ΔF (doppler shift) = Fr - Ft

Light scattering

Light source
Monochromatic – single frequency

Frequency shifts/changes caused by Doppler scattering will then result in a frequency broadening of
the originally monochromatic light.

Wavelengths commonly used in LDF are 633 nm (red) and 780 nm (near-infrared) – better tissue
absorption
Coherence: For interference/light beating to be measured accurately. In order for interference to
occur (photocurrent sensor detects interference patterns of back-scattered light), the coherence
length of the laser must be much longer than the difference in path length for light waves that were
emitted at the same moment

Read more about coherence length and interference: https://entokey.com/physical-optics-2/

Collimated – less spread, more accurate measurement

Interaction with tissue

When light is scattered by a moving object it will be frequency shifted depending on the

 movement of the object

 the direction of the incoming/incident light
 the direction of the scattered light

Due to numerous scattering events as the laser pass through various tissue before hitting RBCs,
incoming laser will have a random direction (hence insensitive to direction of blood flow unlike
doppler USG)

Diffusion of photons within the tissue can be

represented as a series of scattering steps of
types A, B, or C.
Step A represents scattering from a static tissue
element which does not impart any Doppler shift
(the phase shift of this step, φA, is constant). The
distance between static scattering centers |ρ − rj|
will depend on the tissue structure but typically is
∼100 μm.

Step B represents small-angle Doppler scattering

from a moving red blood cell with a phase
shift φβ(t), which varies as Q · vt. The probability
of step B scattering increases with local blood
cell concentration.
Step C represents sequential scattering from two
moving red blood cells and occurs within larger
vessels (>50-μm diam). In this case the velocity
vectors of the two cells are highly
correlated,|𝑣1·𝑣2|∼𝜐21|, although the sign of the
phase terms Q1 · r1(t) and Q2 · r2(t) are random.

Bonner & Nossal 1981

In simple terms (without involving mathematical derivations), doppler shift is increased by the
velocity of each moving particle (reflected by average velocity of RBCs), and the number of
scattering occurred (↑RBC concentration  ↑ number of scattering)
Output
A photodiode receives the photons leaving the tissue and converts them into current.

Light with two different frequencies (Doppler shifted and non-shifted), upon falling on a detector,
establishes a beat frequency in the detector output proportional to the difference in the two
frequencies.

Wave beating in single dimension

The Doppler shifted photons (scattered from moving RBCs) causes an AC current on top of the DC
current from the non-shifted photons (light scattered from static tissue). The frequency spectrum of
the AC current gives information about the Doppler shift and thus the blood perfusion of the tissue.

Speckles generated by light back-

scattered from a particle
suspension. On the right is an
illustration of the fluctuations in
the photodetector intensity
resulting from the dynamic speckle
pattern.

f D is the Doppler-shifted fraction of

all detected photons

To extract the flux and concentration of the moving blood cells, one must measure the power
spectrum of the detector’s current fluctuations.

The scattering from a tissue matrix with a sufficiently small volume of blood (dynamic scatterers) will
result in a signal that is produced mainly by interference of Doppler-shifted light with non-Doppler
shifted light (beating), a situation called heterodyne. (homodyne signal = signal generated by the
photodetector is from only Doppler-shifted light, a situation that occurs when the RBC concentration
is sufficiently high)

Perfusion estimates
 The concentration of moving red blood cells (CMBC) and the perfusion (Perf) can be
estimated from the Doppler power spectrum.
 These estimates are not absolute measures but, in a given sample with low red blood cell
(RBC) concentration, CMBC and Perf scale linearly with the RBC concentration and the tissue
perfusion, respectively.
 In LDF, perfusion is proportional to RBC concentration times the average RBC speed.
 o
 where CRBC is the RBC concentration and vRBC the average RBC speed.
 For high concentrations of RBCs (e.g. in reactive hyperaemia) the CMBC and Perf estimates Commented [KCH4]: Anne Humeau 2000
varies nonlinear with CRBC
o while the relationship between perfusion and the average RBC velocity is entirely
linear
o provided that CRBC is constant and the frequency distribution of the photocurrent is
within the bandwidth of the system
 When the concentration of moving blood cells increases, the number of photons that will
interact with more than one moving erythrocyte (multiple scatter) will increase
 This non-linear relationship can cause perfusion to be underestimated when RBC
concentration is high


 BPU is an arbitrary unit
o Volume of tissue sampled~ 0.5 - 1 mm3
o No measure of tissue volume in LDF
o not ml/min/g tissue
 Used to measure RELATIVE changes in perfusion

Blood flow monitoring

 laser Doppler provides an objective reading, but one must not rely on absolute values
 It is important to observe the trend of perfusion values rather than the absolute value
 In the face of venous occlusions, the drop in values is not as abrupt and steep as compared with
arterial occlusion.
 In monitoring difficulties of venous congestion, one must recognize the distinction between a
muscle flap and a flap with a skin component. Interpretation of venous occlusion by clinical
observation is straightforward when one can see abrupt capillary refill and the mottled bluish
appearance of a congested skin flap. With pure muscle flap, clinical observation is not so
straightforward, and the adjunctive measurement of the laser Doppler can be useful.

Heller et all 2001 recommend classifying LDF readings to corresponding actions ie:

1. If the perfusion is within or above the established range, then a normal degree of
observation is justified
2. If the observed flow is somewhat low, on the bases of a table of normal blood flow for the
flap, then a modestly increased level of clinical evaluation is warranted (alert level 1)
3. If the relative flow falls to 40% of the initial flow of that flap and remains low for 30 minutes
or longer, then a more aggressive observation of the flap wound be indicated (alert level 2)
4. If the absolute flow is lower than 0.4 LDF units for 30 minutes, then a maximally aggressive
clinical observation should occur (alert level 3, red alert) and exploration wound be strongly
 considered. This is typically inconsistent with flap viability, regardless of flap type, recipient
site or blood flow history.

Waveform analysis
J. C. Fischer 1986 – conducted LDF waveform analysis by arterial and venous occlusion of saphenous
island flaps in dogs

Arterial occlusion

 Decreased mean LDF

 Decreased pulsitility, acceleration, deceleration

Venous occlusion

 increased pulsatility.
 decreased mean LDF
 increased acceleration
 no change in deceleration
 more prominent dicrotic notch
Limitations:

 Sensitive to tissue and cable movement

 Site-to-site variation as probe is moved
o Due to variation in tissue optics
 Relative, arbitrary units
o Measurements obtained by LDF are intrinsically of a relative nature.
o Although such measurements are proportional to perfusion, the factor of
proportionality will be different for different tissues.
Photoplethysmography (PPG)
Light-emitting diode (LED) and
photodetector (PD) placement for
transmission- and reflectance-mode
photoplethysmography (PPG).

 A plethysmograph is an instrument for measuring changes in volume within an organ or whole

body (usually resulting from fluctuations in the amount of blood or air it contains).
 A photoplethysmograph (PPG) is a plethysmograph that uses optical techniques
 Similar to SaO2 monitoring, photoplethysmography (PPG) uses reflected spectrographic means
(either green or infrared light) to determine real-time perfusion.
 However, PPG directly measures the flux of red blood cells, rather than a mathematical
derivative of SaO2 flux, which is the technique used by NIRS
 Measures fluid volume by detecting variations in infrared light absorption by the skin.
 Light-emitting diode transmits light into tissue.
 Reflected light from haemoglobin in the dermal capillary RBCs is received by a photo detector
and is analysed as light intensity along a frequency spectrum → Allows means to distinguish
between perfused and nonperfused tissue.
 In extrinsic complications with arterial failure, the waveform disappears.
 Impedance-based PPG involves passing alternating electric current through a cutaneous free flap
and measuring the induced voltage to give a graphical display of pulsatile flow through the flap
and hence a continuous assessment of perfusion.
 Advantages: Rapid and precise method to determine flap ischaemia and differentiate venous
compromise versus arterial compromise.
 Limitations: Depth of measurement only up to 1-2mm.

http://www.mdpi.com/2079-9292/3/2/282/htm (Electronics 2014, 3(2), 282-302;

doi:10.3390/electronics3020282)
Sidestream Dark Field Imaging

 Visualise RBCs at end-capillary bed in real time, independent of the oxygenation status
 Trough illumination of the flap by a central light surrounded by concentrically placed
stroboscopic LEDs
 Easy to use, direct measure of flap blood flow in microcirculation, useful when CRT is difficult to
assess clinically
 a method already widely used in shock patients in intensive care units
 Limitation: Very limited evidence, further study required
Oxygen measurement
Pulse oximetry
 Uses 2 wavelengths of light to distinguish oxygenated and deoxygenated Hb
 No clear advantage over clinical monitoring on basis of flap salvage rate

Near IR Spectroscopy
 Uses IR light to determine percent oxygen saturation of tissue arterial haemoglobin which is not
affected by external factors
 Studies have shown NIRS detects vascular compromise earlier than clinical assessment,
handheld Doppler, and implanted Doppler probes, resulting in high flap salvage rates (94–100%).
 Limitations
o sensors are designed to adhere to the skin paddle using glue or stickers, and
frequent repositioning may be necessary
o only one probe that can be connected to the monitor
o Costly

Temperature
Surface Temperature/Differential surface temperature
Simple, inexpensive, real-time adjunctive method of monitoring – e.g. with thermoelectric
thermometer

Differential temperature: Thermocouple probes are sutured both proximal and distal to the arterial
anastomoses and their temperature difference is recorded.

Limitations:

 Low specificity (75% when optimised) – affected by core temperature, room temperature,
humidity, light, vasomotor responses
 Temperature changes were only significant after 15 hours of flap ischaemia

Dynamic IR thermography
 More commonly recognised for use in perforator selection and flap planning
 Changes in the thermographic image (pedicle hot spot) can precede clinical signs of vascular
compromise in animal models, independently of absolute temperature values that are
influenced by environmental factors.
 A clinical trial using emitted skin surface IR correlated with alteration in capillary blood flow and
haemoglobin oxygenation demonstrating the reliability of this adjunctive method in
postoperative monitoring of free flaps.

Visual
Smartphone digital technology
Digital photography allows surgeons to monitor free flaps remotely, enable rapid communication
between nursing and medical staff, and potentially reduce response time to re-exploration

Hwang and Mun compared the clinical outcome before and after their unit adopted an
instantaneous Internet messaging service to share digital photos of postoperative free flaps. The flap
salvage rate improved (100% vs 50%) and the response time to re-exploration reduced significantly
(1.4 hours vs 4.0 hours). These elements translated to a higher rate of overall flap survival (100% vs
96.2%).

A prospective study by Engel et al reported a significant decrease in the response time using remote
digital photography over “in-person examination” (8 minutes vs 180 minutes).

In 2014 Kiranantawat et al. developed a smartphone application that analyzes digital photos for
colour difference and demonstrated high sensitivity (94%) and specificity (98%) in detecting vascular
compromise.

Limitations: technical issues, cost, misdiagnosis, and confidentiality issues

Microvascular imaging technique

Confocal microscopy, orthogonal polarized light, and magnetic resonance imaging – tested in animal
studies

Limitations: Expensive, impractical for clinical use

Invasive adjuncts
Microdialysis

 Introduce a double-lumen microdialysis catheter into the flap

 Perfusion fluid passed through the catheter that allows low molecular weight substances to
equilibrate across the semipermeable membrane from surrounding extracellular fluid, producing
dialysate
 The dialysate is the analysed for metabolites e.g. lactate, glucose, glycerol, pyruvate
 By measuring the metabolites and calculating ratio, e.g. lactate:glucose, lactate:pyruvate,
detection of ischaemia is more accurate and able to differentiate arterial and venous occlusion
 Metabolic changes have been shown to occur 30-60 minutes after vessel occlusion and
microdialysis

Limitations:

 Most trials showed no benefit, increase false-positive rates

 Insufficient evidence to show improvement in flap salvage

Other invasive probes: tissue pH, tissue oxygen tension, temperature probe, implantable doppler

Injectable agents
Fluorometry

Principle: when vital dyes are administered systematically, they stain skin that is adequately
perfused.

Administered as an IV bolus (15mg/kg).

After 20 minutes, tissue is examined with an ultraviolet lamp.

Limitations:

 Underestimate flap survival.

 Skin blood flow tends to increase with time after flap elevation.
o Fluorescein given 1 hour after flap elevation will assess flap circulation at that time.
o Any subsequent increase in flow within the next 12 hours will contribute to the
increase in flap survival but it will not have been measured by the early
postoperative dye test.
o Can be repeated only every 8 hours.
 Can cause anaphylaxis
 Unfavourable pharmacokinetic
Current Evidence for Postoperative Monitoring of Microvascular Free Flaps - Systematic
review by Chae et al. 2015
5 monitoring techniques have shown any evidence for improvement of flap salvage rates

 Cook-Swartz implantable Doppler

 NIRS
 laser Doppler flowmetry
 quantitative fluorometry
 digital smartphone assessments

Insufficient outcome based studies for most methods