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Fig. 8.11. Omentum flap. Postoperative Care

Postoperative care of free tissue transfer patients requires that patients be adequately hydrated. Maintenance of proper body temperature and hematocrit is also important Routine heparinization and anticoagulation is not utilized.

Flaps are usually monitored for a minimum of 5 days with a laser Doppler in addition to clinical observation. While the immediate postoperative period of 24-48 hours is critical, there have been late occasional failures; thus, laser Doppler monitoring should be continued for 4 or 5 days.

Extremities should be elevated at all times to augment venous return. Lower extremity patients are not allowed to ambulate postoperatively for a minimum of three weeks. The inosculation and the healing of the flap to the wound bed, the selection of muscle or skin, and the "take" of the skin graft, are factors that go into the timing to determine dependency of the lower extremity. Those patients that have reconstruction around the foot and ankle are most prone to increased venous pressure and resultant edema of the flaps. This edema can result in the dehiscence of the free flap from the surrounding tissue bed. For this reason, extremity patients are required to keep their limbs elevated and undergo bed to chair transfer for a minimum of three weeks. Some experimental data suggests that this timing can be shortened. However, it is the author's experience that this is the amount of time it takes for the flap to mature and develop a sufficient venous return to withstand hydrostatic pressure associated with standing.

Prior to proceeding with any other reconstruction such as bone grafting (such as in a case of open tibia fracture), or tendon transfers, all wound surfaces must be epithelialized. There must be no edema, cellulitis, granulation tissue, or sinus tracts that could compromise the next stage of reconstruction. For example, in cases of a free muscle flap in the distal third of an open tibia fracture that ultimately requires bone grafting, it is essential that all skin grafts be totally epithelialized to decrease skin colonization of bacteria. It is the author's preference to remove the external fixator, clean the pin sites, and place patients in a cast until the pin tracts heal. The flap can be then elevated and an autogenous bone graft can then safely be performed.

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