Since the advent of microsurgery, free-tissue transfer (FTT) has become the goldstandard reconstructive option for bony, soft tissue and combined defects of the head and neck. (1,2,3,4) Even with success rates of 92% and above (1,2,3,4,5,6), there remains a small percentage of cases in which circulatory compromise develops. Early identification of compromise and prompt return to theatre is associated with higher rates of salvage (7,8,9). Here we present a new technique of clinical examination for a particular subset of buried head and neck flaps.
We conducted an independent review of the literature using Medline, PubMed and Q Read performed up to February 2017 using combinations and variations of search terms including “buried free flap”, “free flap clinical monitoring”, “free tissue transfer monitoring” and “salvage free flap”. We also manually searched reference lists of articles, and used institutional access to the University of Melbourne Library.
Monitoring buried flaps within the head and neck presents a unique challenge to the microsurgeon. In this paper, we present a variation of the Acland’s empty-and-refill test (10) which may be used to monitor buried flaps that have venous anastomosis in an end-to-end fashion to the external jugular vein. The EJV can be occluded externally using the clinician’s fingers, and emptied in a inferior direction. Refilling of the vein on releasing the superior occlusion indicates adequate flow from the flap. As is the case when venous doppler monitoring is used, this can be extrapolated to conclude that the arterial supply is also adequate.
We believe that our technique meets nearly all of the criteria for an ideal free flap monitoring technique, as outlined by Creech and Miller (11), and would be a valuable tool in the clinical assessment of this particular subset of free flaps.