Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, e135

CORRESPONDENCE AND COMMUNICATION

Early detection of inflow problems
during free flap monitoring using
digital tympanic thermometers
Dear Sir,
Free flap monitoring remains a contentious issue for many
with clinical assessment being the most effective technique. On reflection, regular monitoring is the actual key to
early detection of clinical problems. Although venous
congestion is the more common problem, it is arterial
thrombosis that is often easily missed as it is a subtle
finding at its onset. Compound this with the varying levels
of expertise available, early detection of inflow problem is
a proverbial lottery.
Conventionally, arterial inflow problems in skincomponent free flaps manifest as cold, pale skin with no
bleeding on scratching. However during the early phases of
arterial thrombosis, these findings may be easily missed. In
order to achieve a more objective assessment, a digital
thermometer; commonly used for tympanic temperature
monitoring of patients on the ward (Figure 1), is used
instead to monitor the surface temperature of free flaps.
This is performed hourly alongside conventional clinical
assessment. A drop in temperature of more than 2  C
between the centre of the flap and surrounding skin is
taken as significant but this should be taken in conjunction
with other flap parameters such as capillary refill, etc.
Using this instrument, earlier detection of arterial inflow
problems is possible. A recent article has shown a positive
correlation between flap microcirculation and flap surface
temperature. In this study, a drop in temperature between
the flap and surrounding skin of more than 3 was shown to
be significant for arterial thrombosis although it is not as
good an indicator for venous thrombosis.1
Clinical drawbacks include the difficulty in assessing
a significant temperature difference, particularly when
patient warming devices are used and the variation in

Figure 1 The tympanic thermometer used to regularly

monitor tympanic temperature.

surface temperature in relation to the ambient temperature. To this end, clinical judgement is still paramount and
this remains an adjunctive test.

Conflict of interest/funding
This article has no conflict of interest or funding herein.

References
1. Kraemer R, Lorenzen J, Knobloch J, et al. Free flap microcirculatory monitoring correlates to free flap temperature
assessment. JPRAS 2011;64:1353e8.

R.Y. Kannan
Dept. of Plastic Surgery, St. Andrews Plastics Centre,
Broomfield Road, Chelmsford CM1 7ET, UK
E-mail address: ykruben@yahoo.com

21 November 2011

1748-6815/$ - see front matter 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2011.11.055