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Plastic SurgeryManagement
Free Flap Postoperative Monitoring Protocol
Free Flap Postoperative Monitoring Protocol: Free Flap Postoperative Check → Clinical Examination of the Flap → Any change from the last check, or in do...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Clinical Examination of the Flap
Compare with the previous flap check. Assess colour, capillary refill, temperature, turgor and Doppler signal.
- Pinprick or scratch test if the unit uses it: note the speed and colour of bleeding
- Buried flap: cannot be seen; use the implantable Doppler or other monitor
- Record each check; report any change at once
- Protect the pedicle: no tight or circumferential ties, tapes or dressings over it; position the head or limb as the surgeon orders
03Decision Any change from the last check, or in doubt?
Normal: pink (or matches the donor skin), warm, soft, normal capillary refill, Doppler signal unchanged
- If Yes
04Action Change found: possible arterial or venous compromise
Any of these signs needs the surgeon now.
- Arterial: pale, cool, slow or no capillary refill, little or no bleeding on pinprick, Doppler signal lost
- Venous: dusky, purple or blue, swollen and tense, brisk capillary refill, dark blood on pinprick
- Doppler can stay present in venous congestion: do not be reassured by it
- Any other change, or in doubt: treat as compromise
05Warning Compromise suspected: call the surgeon now
Arterial and venous compromise both need urgent surgical review. Salvage falls quickly with delay. Neck flap with stridor, breathing difficulty or fast-growing neck swelling: also call a medical emergency for the airway now.
- Microsurgery team to review the flap immediately
- Prepare for urgent return to theatre
- Do not start leeches or anticoagulants without the surgeon
06Action While the surgeon comes: bedside measures
Remove compression: loosen dressings and ties; surgeon or medical team releases tight sutures. Check pedicle position.
- Tracheostomy ties: secure the tube another way before loosening; never leave the tube unsecured
- Look for haematoma or a kink from head, limb or body position
- Correct hypotension, hypothermia and fluid deficit
- Keep the patient nil by mouth for theatre
07Decision Surgeon confirms flap compromise?
Surgeon decision after review at the bedside
- If Yes
08Action Surgeon confirms compromise: urgent return to theatre
Surgeon explores the pedicle and anastomoses. Do not delay theatre for bedside measures. When in doubt, the surgeon explores. If theatre is not possible, the surgeon decides on other salvage.
09Decision Venous congestion that surgery did not or cannot correct?
Surgeon decision. Includes venous congestion when theatre is not possible. Not for arterial compromise.
- If Yes
10Action Uncorrected venous congestion: leech therapy (surgeon decision)
Adjunct only. Needs arterial inflow: not for arterial compromise. Do not use if the patient refuses blood transfusion or antibiotic prophylaxis. Start antibiotic prophylaxis against Aeromonas first and continue it during therapy.
- Antibiotic: follow local protocol or ID advice; ciprofloxacin-resistant Aeromonas is reported
- Monitor haemoglobin: blood loss continues and transfusion is often needed
- Surgeon weighs risk: immunosuppression (infection); anticoagulants, bleeding disorder, anaemia (blood loss); hypotension, sepsis, pregnancy or breastfeeding, leech allergy
- Usual course 4-10 days; surgeon decides when to stop. Supply: hospital pharmacy (not ward stock)
11End During leech therapy: continue close flap checks
Flap checks and haemoglobin per surgeon orders. Report fever, cellulitis or worsening congestion to the surgeon at once.
If No12End No uncorrected venous congestion: close monitoring per surgeon orders
Restart hourly flap checks per surgeon orders. Arterial compromise with no surgical option, or a flap that cannot be saved: the surgeon plans the next steps (leeches do not help).
If No13End Surgeon finds no compromise: continue close monitoring
Hourly flap checks per surgeon orders. Any new change: call the surgeon again at once.
If No14End No change: continue monitoring
Hourly checks for at least the first 24-48 h, then per unit protocol to at least 72 h. Check vital signs, temperature and fluid balance with flap checks. Late compromise can occur: report any later change to the surgeon.
Guideline Source
Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review (J Reconstr Microsurg 2021)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No national free flap monitoring standard: follow the operating surgeon's orders and the unit protocol
- Buried flaps cannot be examined clinically and need an implantable Doppler or other monitor
- Most compromise occurs in the first 48-72 h, but late compromise can occur
- Leech therapy is an adjunct decided by the surgeon, not a first-line treatment
Applicable Regions
USAUUKEU
AU: No national standard; follow the unit's microsurgery flap monitoring protocol
UK: No national standard; follow the unit's flap monitoring protocol
US: Hourly nurse flap checks are common in the early postoperative period
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Free Flap Postoperative Monitoring Protocol?
The Free Flap Postoperative Monitoring Protocol is a management clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review (J Reconstr Microsurg 2021).
What guideline is the Free Flap Postoperative Monitoring Protocol based on?
This algorithm is based on Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review (J Reconstr Microsurg 2021) (DOI: 10.1055/s-0040-1722182).
What are the limitations of the Free Flap Postoperative Monitoring Protocol?
Known limitations include: No national free flap monitoring standard: follow the operating surgeon's orders and the unit protocol; Buried flaps cannot be examined clinically and need an implantable Doppler or other monitor; Most compromise occurs in the first 48-72 h, but late compromise can occur; Leech therapy is an adjunct decided by the surgeon, not a first-line treatment. Individual patient factors may require deviation from these recommendations.
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