Iain Whitaker

Cronfa at Swansea University

Figure 1 The silicone cuff as it is being bi-manually wrappedaround the vein with fine non toothed forceps.Correspondence and communications 1251with perfusion through all veins being maintained in ananterograde direction.When two internal mammary veins of good calibre arepresent, each can be divided and anastomosed in ananterograde flowing direction to the two DIEVs of a bilat-eral DIEP flap. The possibility of valves and the haemody-namics within the venous system would suggest this morephysiological method of anterograde anastomosis to beadvantageous. However, the greatest benefit is of a prac-tical nature. Both veins can be cut at their most caudalextent of exposure which enables a greater length of veinto be delivered for anastomosis with the DIEVs than if oneIMV is used alone (see Figures 2 and 3).The method of anastomosis we describe is another toolin the microsurgeons repertoire, as it increases the ease ofvenous anastomosis of two pedicles at a single internalmammary recipient site.References1. Hamdi M, Khuthaila DK, Van Landuyt K, et al. Double-pedicleabdominal perforator free flaps for unilateral breast recon-struction: new horizons in microsurgical tissue transfer to thebreast. J Plast Reconstr Aesthet Surg 2007;60:904e12.2. Beahm EK, Walton RL. The efficacy of bilateral lower abdominalfree flaps for unilateral breast reconstruction. Plast ReconstrSurg 2007;120:41e54.A.G. Baraba´sM. ShafighiE.M. SassoonR.M. HaywoodDepartment of Plastic Surgery,Norfolk and Norwich University Hospital Trust,Norfolk, UKE-mail address: tonybarabas@doctors.org.ukª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2008.01.018A simple method of implantable Doppler cuffattachment: Experience in 150 DIEP breastreconstructionsFigure 2 The fixation of the silicone cuff with micro-clips(Vitalitec SLS-clip).Accurate post operative assessment of free tissue transfers ischallenging despite all the subjective and objective tech-niques available today.1,2 In our continual search to optimisepatient outcomes, we introduced the CookeSwartz probe(Cook Medical, Cook Ireland Ltd, Limerick, Ireland) into ourclinical practice in May 2006. Although this implantableprobe has been available in the USA for several years,3e5 itonly gained the CE mark, allowing European distribution, in2006. There have only been a handful of small preliminaryresults published in the European and Australasian6,7 liter-ature to date. We have used the implantable probe over 150times betweenMay 2006 and January 2008, andwould like todescribe our chosen method of Doppler cuff attachment tothe vessel adventitia. We have not seen this simple tech-nique described elsewhere, andwould like to disseminate itsuse. During attachment of the probe, we manipulate thesilicone cuff bi-manually with fine non toothed forceps. Oneside of the cuff is gently wrapped around the vein (distal tothe anastomosis) and then the other side. Both ends of thecuff are gently gripped by the forceps, and soft loadingmicro-clips (Vitalitec SLS-clip) are used to secure the cuff insitu (see Figures 1e3). It is important to get the tensioncorrect as the Doppler probe in the cuff must be securely incontact with the vein. If the cuff is too tightly secured, thepotential for venous outflow obstruction exists. If the probeis not well approximated, then either no signal is produced,or it may rotate and induce vasospasm in the arterial wall ifadjacent. Other possible methods to secure the cuff includefibrin glue8 and sutures.7 We prefer using microclips as webelieve it offers clear advantages:1) Accurate placement may be achieved2) Adjustment is easy due to the nature of application andremovalFigure 3 The with micro-clips (Vitalitec SLS-clip) securedsilicone cuff around the vein.1252 Correspondence and communications3) The atraumatic nature of application and removalensures there is no damage to the silicone cufffollowing clip removal and adjustmentWe have had no complications using this technique in ourseries, and we advocate the use of a CookeSwartz probewhich has been well received by surgeons, nursing staff andpatients, as an adjunct to traditional clinical monitoringtechniques.Financial disclosureCook awarded Mr Iain S. Whitaker a grant to support hismicrosurgical fellowship to Uppsala University Hospital;however, the authors have no direct financial or commer-cial interest in the equipment described in this article.References1. Khouri RK. Avoiding free flap failure. Clin Plast Surg 1992;19:773e81.2. Whitaker IS, Karoo ROS, Oliver DW, et al. Master class in plasticsurgery : current techniques for the post operative monitoringof free tissue transfers. Eur J Plast Surg 2005;27:315e21.3. Kind GM, Buntic RF, Buncke GM, et al. The effect of animplantable Doppler probe on the salvage of microvasculartissue transplants. Plast Reconstr Surg 1998;101:1268e73.4. Swartz WM, Jones NF, Cherup L, et al. Direct monitoring ofmicrovascular anastomoses with the 20-MHz ultrasonic Dopplerprobe: an experimental and clinical study. Plast Reconstr Surg1988;81:149e61.5. Swartz WM, Izquierdo R, Miller MJ. Implantable venous Dopplermicrovascular monitoring: laboratory investigation and clinicalresults. Plast Reconstr Surg 1994;93:152e63.6. Mistry Y, James DW, Sinclair S. Pr44p monitoring buried freeflaps - new zealand’s first four clinical cases of free flap moni-toring with implantable 20 mhz ultrasonic Doppler probe. ANZ JSurg 2007;77:A70.7. Oliver DW, Whitaker IS, Giele H, et al. The Cook-Swartz venousDoppler probe for the post-operative monitoring of free tissuetransfers in the United Kingdom: a preliminary report. Br J PlastSurg 2005;58:366e70.8. Bill TJ, Foresman PA, Rodeheaver GT, et al. Fibrin sealant:a novel method of fixation for an implantable ultrasonicmicroDoppler probe. J Reconstr Microsurg 2001;17:257e62.Iain S. WhitakerWelsh Centre for Burns and Plastic Surgery,Morriston Hospital,Swansea, UKJeroen M. SmitCatharina Hospital, Eindhoven,The NetherlandsRafael AcostaUppsala University Hospital(Akademskia Sjukhuset),Uppsala, SwedenE-mail address: rafael.acosta.rojas@akademiska.seª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2008.01.020Bilateral mandibular reconstruction with a singlevascularised fibula flap: A case reportThe treatment of oromandibular defects following onco-logical resections is an important task for reconstructivesurgeons. The mandible is one of the most importantstructures of the head and neck, both functionally andcosmetically, contributing to the facial contour, chewing,speech and swallowing.Currently, the fibula free flap is the first choice for themajority of oromandibular reconstructions.1,2 It providessufficient bone length for reconstruction, even after widejaw resections.2e4 The quality of the fibular bone trans-ferred and its rich periosteal blood supply makes it verysafe and useful.2 Pedicle length and vessel diameter facil-itate the microsurgical transfer, with low incidence ofcomplete flap failure.3,6 The long-term donor site morbidityis acceptable in most patients after harvesting a fibulaflap.5,6 In addition, the fibula provides adequate bonewidth and height to support osseointegrated implants thatserve for functional reconstruction and to support over-dentures that enable the patient to function properly.3,5e8In this paper, we report a case of non-contiguous bilateralmandibular segment reconstruction following oncologicalresection with a single free fibula transplant.Case reportThree years after radiotherapy (66 Gy) to the site ofa primary squamous cell carcinoma (G3) of the right ret-romolar trigone, a 64-year-old man came to our depart-ment with mandibular relapse of the tumour and a secondprimary on the opposite side. At diagnosis, we observed anosteolytic lesion in the right retromolar area, withinvolvement of the lingual cortex for 30 mm, and a secondlesion in the contralateral trigone, eroding the cortical

A simple method of implantable Doppler cuff attachment: Experience in 150 DIEP breast reconstructions

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