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Buried Free Flaps for Breast Reconstruction: A New Technique Using the Cook-Swartz Implantable Doppler Probe for Postoperative Monitoring

Iain Whitaker

Cronfa at Swansea University

 Cronfa -  Swansea University Open Access Repository   _____________________________________________________________   This is an author produced version of a paper published in :Plastic and Reconstructive Surgery                                              Cronfa URL for this paper:http://cronfa.swan.ac.uk/Record/cronfa18850_____________________________________________________________ Paper:Rozen, W., Whitaker, I., Wagstaff, M., Audolfsson, T. & Acosta, R. (2010).  Buried Free Flaps for BreastReconstruction: A New Technique Using the Cook-Swartz Implantable Doppler Probe for Postoperative Monitoring.Plastic and Reconstructive Surgery, 125(4), 171e-172e.http://dx.doi.org/10.1097/PRS.0b013e3181d4703f        _____________________________________________________________  This article is brought to you by Swansea University. Any person downloading material is agreeing to abide by theterms of the repository licence. Authors are personally responsible for adhering to publisher restrictions or conditions.When uploading content they are required to comply with their publisher agreement and the SHERPA RoMEOdatabase to judge whether or not it is copyright safe to add this version of the paper to this repository. http://www.swansea.ac.uk/iss/researchsupport/cronfa-support/  We conclude that autologous dermal graft can beused as an adjunct to tissue expander breast recon-struction in the same fashion previously described withacellular dermal grafts. In addition, autologous dermalgrafts can be used to treat implant malposition. Obvi-ously, various sources of dermis are available. The ab-domen, breast, and arm skin were found to be gooddonor sites in our study. We feel this is an excitingadditional tool to consider for breast reconstructionand treatment of breast implant malposition that canproduce great patient and physician satisfaction.DOI: 10.1097/PRS.0b013e3181d45ac7Pirko Maguina, M.D.Ryan Hoffman, M.D.Stefan Szczerba, M.D.St. Alexius Medical CenterHoffman Estates, Ill.Correspondence to Dr. SzczerbaSt. Alexius Medical CenterDepartment of Surgery1786 Moon Lake Boulevard, Suite 205Hoffman Estates, Ill. 60169plasticsurgerymd@gmail.comREFERENCES1. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008;32:418–425.2. Breuing KH, Warren SM. Immediate bilateral breast recon-struction with implants and AlloDerm slings. Ann Plast Surg.2005;55:232–239.3. Colwell AS, Breuing KH. Improving shape and symmetry inmastopexy with autologous or cadaveric dermal slings. AnnPlast Surg. 2008;61:138–142.Buried Free Flaps for Breast Reconstruction:A New Technique Using the Cook-SwartzImplantable Doppler Probe forPostoperative MonitoringSir:Buried free flaps in breast reconstruction have thepotential to offer superior aesthetic outcomes,avoiding the need for a monitoring skin paddle fol-lowing skin and nipple-areola complex–sparing mas-tectomy. One of the reasons this has not been widelyused is the difficulty of monitoring buried flaps.1 Weintroduced the Cook-Swartz probe into our clinicalpractice in May of 2006. The Cook-Swartz venousDoppler system is a technique for monitoring venousflow in free tissue transfer consisting of an implant-able 20-MHz ultrasonic probe placed against the re-cipient vein and a battery-operated portable moni-tor. Although it was developed in the United Statessome time ago2 and has been available for clinical usefor several years, it has only been distributed outsideNorth America since 2006.Buried microvascular free tissue transfers without amonitoring skin paddle for breast reconstruction hasnot been widely performed, and to our knowledge, theonly technique in the literature described for moni-toring these cases is color duplex sonography.3 With theincreasing use of the implantable Cook-Swartz Dopplerprobe, this technique is becoming a safe option.4Eight women undergoing free microvascular tissuetransfer for breast reconstruction were recruited.These included five deep inferior epigastric artery per-forator (DIEP) flaps (four unilateral and one bilateral)and three superior gluteal artery perforator flaps (twounilateral and one bilateral). All eight women under-went delayed reconstruction.In all cases, venous anastomoses were performedusing a venous ring coupler (mean anastomotic time,3 minutes; range, 2.5 to 4 minutes). Implantable probeswere attached atraumatically, distal to the venous anas-tomosis. The probe was turned on immediately, allow-ing for monitoring of flow during insetting of the flapand throughout the immediate postoperative period.All eight cases were successful, with no operativecomplications or complications as a result of the use ofthe implantable Doppler probe (Figs. 1 and 2). In allcases, there was good Doppler flow throughout themonitoring period, and the probes were removed un-eventfully on the seventh postoperative day.All patients were happy with the operative outcomeand found the sound of the venous flow postoperativelyvery reassuring. The sound output on the probe wasturned down to allow the patient to sleep, and wasturned up at regular intervals for monitoring by nursesand surgical rounds.The DIEP flap can provide a large and versatile vol-ume of tissue with good donor-site outcomes. The useof a buried flap provides the additional advantage ofavoiding the need for a monitoring skin paddle, whichmay compromise aesthetic outcome. The Cook-SwartzDoppler probe has been used successfully for moni-toring DIEP flaps4; however, this is the first descriptionof the implantable Doppler probe for the monitoringof buried flaps for breast reconstruction.The Cook-Swartz Doppler probe is highly sensitive,responding to venous obstruction immediately and ar-terial insufficiency within minutes.2,5 Although all flapsin the current series were uncompromised, we havefound the implantable probes highly reliable in over150 cases of breast reconstruction.4The implantable Doppler probe is easily applied andremoved, and if two venous anastomoses are used, mul-tiple implantable Doppler probes can be applied. Theprobe permits either frequent or continuous monitor-ing, avoiding the need to wake the patient during flapassessment.This is the first study to demonstrate the implantableDoppler probe for monitoring buried free flaps inbreast reconstruction. With buried flaps potentially of-fering superior aesthetic outcomes, the safe monitor-ing of these flaps with the implantable Doppler probemay increase their application.DOI: 10.1097/PRS.0b013e3181d4703fVolume 125, Number 4 • Viewpoints171eWarren M. Rozen, M.B.B.S., P.G.Dip.Surg.Anat.Jack Brockhoff Reconstructive Plastic Surgery Research UnitDepartment of Anatomy and Cell BiologyUniversity of MelbourneParkville, Victoria, AustraliaIain S. Whitaker, M.A.(Cantab.), M.B.B.Chir.Department of Plastic, Reconstructive, and Burns SurgeryThe Welsh National Plastic Surgery UnitThe Morriston HospitalSwansea, United KingdomMarcus J. D. Wagstaff, M.B.B.S., Ph.D.Department of Plastic SurgeryUniversity Hospitals of SheffieldSheffield, United KingdomThorir Audolfsson, M.D.Rafael Acosta, M.D.Department of Plastic SurgeryUppsala Clinic HospitalUppsala, SwedenCorrespondence to Dr. AcostaDepartment of Plastic SurgeryUppsala Clinic HospitalUppsala 75185, Swedenrafael.acosta.rojas@akademiska.seDISCLOSURESThe authors declare that there is no source of financial orother support or any financial or professional relationshipsthat might pose a competing interest.REFERENCES1. Whitaker IS, Oliver DW, Ganchi PA. Postoperative monitoring ofmicrovascular tissue transfers: Current practice in the UnitedKingdom and Ireland. Plast Reconstr Surg. 2003;111:2118–2119.2. Swartz WM, Jones NF, Cherup L, Klein A. Direct monitoringof microvascular anastomoses with the 20-MHz ultrasonicDoppler probe: An experimental and clinical study. PlastReconstr Surg. 1988;81:149–161.3. Yano K, Hosokawa K, Nakai K, Kubo T, Hattori R. Moni-toring by means of color Doppler sonography after buriedfree DIEP flap transfer. Plast Reconstr Surg. 2003;112:1177.4. Smit JM, Whitaker IS, Liss AG, Audolfsson T, Kildal M,Acosta R. Post operative monitoring of microvascular breastreconstructions using the implantable Cook-Swartz dopplersystem: A study of 145 probes & technical discussion. J PlastReconstr Aesthet Surg. 2009;62:1286–1292.5. Swartz WM, Izquierdo R, Miller MJ. Implantable venousDoppler microvascular monitoring: Laboratory investi-gation and clinical results. Plast Reconstr Surg. 1994;93:152–163.Fig. 1. Appearance at 4-month follow-up of unilateral left buried free flap for breast reconstruction(DIEP flap).Fig. 2. Appearanceat 4-month follow-upofbilateral buried freeflaps for breast reconstruction (DIEP flaps).Plastic and Reconstructive Surgery • April 2010172e

Buried Free Flaps for Breast Reconstruction: A New Technique Using the Cook-Swartz Implantable Doppler Probe for Postoperative Monitoring

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