Breast Free-Flap Reconstruction and Flap Monitoring Times for Microvascular Complications: is there a Set Rule? A Retrospective Study from a High-volume Tertiary Centre

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Introduction: Autologous free-flap breast reconstruction accounts for 30% of reconstruction following mastectomy. However there is no consensus regarding immediate post-operative monitoring protocols. We report the time periods and salvage rates for free-flaps which were returned-to-theatre at a high-volume practice. Materials and Methods: The prospectively collected electronic records for patients undergoing breast free-flap reconstruction between January 2015 and August 2019 were reviewed retrospectively. All free-flaps were reviewed by nurses using the standardised hospital protocol until discharge. Primary end-points evaluated include free-flaps which were returned-to-theatre for full free-flap loss, complication type and free-flap salvage. Results: We identified 679 autologous breast free-flap reconstructions. Fifteen (2.2%) were returned-to-theatre for surgery-related complications during inpatient stay. Eight (1.2%) developed microvascular complications; seven (1.0%) were successfully salvaged and we encountered one free-flap loss (0.1%) due to an arterial complication developing 72-hours postoperatively. Six of the eight microvascular complications (75%) occurred within the first 24 hours from surgery. Surgical time in the takeback population was statistically significantly longer than in the non-takeback population (539 minutes vs. 406 minutes, p=0.00585). Conclusion: Majority of microvascular complications occurred within the first 24-hours in our cohort and these were successfully identified and salvaged at our high-volume practice. We believe all free-flaps should be closely monitored in the first 24-hours. Beyond this period, protocols should be suited to each institution based on their patient demographic, facilities available for free-flap monitoring and case-volume.

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