Nurse-Led Microsurgical Free Flap Monitoring: A Scoping Review and Evidence-Based Framework

Background: Postoperative free flap monitoring, traditionally performed by surgical residents, has shifted toward nurse-led models due to global workforce constraints. While this practice is widespread, its implementation is fragmented, creating a "standardization gap" between successful outcomes and reproducible protocols. This scoping review aimed to comprehensively map all available evidence on nurse involvement in free flap monitoring and synthesize the findings into an evidence-based framework for implementation. Methods: A scoping review was conducted following PRISMA-ScR guidelines. A comprehensive search of PubMed, CINAHL, and the Cochrane Library was performed without date or language restrictions. Data from included studies were charted and synthesized narratively to identify key themes related to protocols, education, and clinical outcomes. Results: Twelve studies met the inclusion criteria. The evidence demonstrates that well-structured, nurse-led monitoring protocols achieve high flap success rates (≥94%), comparable to physician-intensive models. Three major themes emerged from the analysis: (1) the equivalence of clinical outcomes under nurse-led care; (2) the role of technology as an enabler for objective assessment and anxiety reduction; and (3) a persistent "standardization gap" due to significant variation in protocols and training across institutions. A critical knowledge deficit among nurses regarding venous congestion was also identified as a key target for educational interventions. Conclusions: Nurse-led free flap monitoring is a safe and effective model of care. Successful implementation hinges on a framework built upon three pillars: standardized education, clear and actionable protocols, and the standardized integration of technology. This review provides the first comprehensive roadmap to bridge the existing standardization gap and offers a foundation for developing international best-practice guidelines.