Cook–Swartz Doppler Probe Surveillance for Free Flaps—Defining Pros and Cons

Abstract

Introduction The main postoperative complication of free flaps is perfusion compromise. Urgent intervention is critical to increase the chances of flap survival. Invasive flap perfusion monitoring with direct blood flow feedback through the Cook–Swartz Doppler probe could enable earlier detection of perfusion complications. Materials and Methods Between 2012 and 2016, 35 patients underwent breast reconstruction or defect coverage after trauma with a deep inferior epigastric perforator, anterolateral thigh, transverse musculocutaneous gracilis, gracilis, or latissimus dorsi flap in our department. All flaps were monitored with a Cook–Swartz probe for 10 days postoperatively. The 20 MHz probe was placed around the arterial–venous anastomosis. A flap monitoring protocol was established for standardized surveillance of postoperative perfusion. In the event of probe signal loss, immediate surgical revision was initiated. Results Signal loss was detected in 8 of the 35 cases. On return to the operating room, six were found to be true positives (relevant disruption of flap perfusion) and two were false positives (due to Doppler probe displacement). There were also two false negatives, resulting in a slowly progressive partial flap loss. Flap perfusion was restored in three of the six cases (50%) identified by the probe. Following surgical intervention, three of the six cases had persistent problems with perfusion, resulting in two total flap losses and one partial flap necrosis leading to an overall 5.7% total flap loss. Conclusion Postoperative flap perfusion surveillance is a complex matter. Surgical experience is often helpful but not always reliable. The costs, false-positive, and false-negative rates associated with invasive perfusion monitoring with Cook–Swartz probe make it most appropriate for buried flaps. Level of Evidence This is an original work.

Comparison of Hyperspectral Imaging and Microvascular Doppler for Perfusion Monitoring of Free Flaps in an In Vivo Rodent Model

“…In addition, however, some device-based monitoring methods and the measured values also depend on expert interpretation [ 48 ]. Indeed, HSI implementation is associated with high prices, but after a one-time purchase, there are no further follow-up costs, e.g., for disposable probes, and could pay off if the length of hospital stay is shortened through earlier detection of arterial perfusion disorders and more timely salvage surgeries, thereby reducing the overall MFF failure rate [ 49 , 50 ].…”

Nipple‐sparing mastectomy with immediate breast reconstruction with a deep inferior epigastric perforator flap without skin paddle using delayed primary retention suture

“…The implantable Doppler system has been reported as a simple, safe, and valid option for continuous real‐time surveillance. However, multiple reports have highlighted high false‐positive rates, fixation of the device, and cost as significant issues 32 . While extensive cohort studies and a meta‐analysis advocating the benefits and potential superiority of the implantable Doppler over clinical monitoring, none have convincingly changed clinical practice internationally 29,33,34 …”

“…However, multiple reports have highlighted high false-positive rates, fixation of the device, and cost as significant issues. 32 While extensive cohort studies and a meta-analysis advocating the benefits and potential superiority of the implantable Doppler over clinical monitoring, none have convincingly changed clinical practice internationally. 29,33,34 Our results with clinical monitoring using the DPRS technique, supplemented with hand-held transcutaneous Doppler probe, promptly identified and salvaged a flap with vascular compromise in each Group.…”

Macrophage Migration Inhibitory Factor—An Innovative Indicator for Free Flap Ischemia after Microsurgical Reconstruction

“…If a problem of the microanastomosis occurs, immediate surgical intervention is essential for flap salvage [ 14 ]. Different techniques have been described to monitor postoperative flap perfusion such as the handheld Doppler ultrasound probe, laser Doppler flowmetry, nuclear medicine, near-infrared spectrometry, perfusion photoplethysmography, surface temperature measurement, confocal microscopy, white light spectroscopy, subcutaneous pH measurement, multispectral spatial frequency domain imaging, orthogonal polarized light, sidestream dark field imaging, CO2 monitoring, pulse oximetry, fluorometry, injectable biosensors and Cook–Swartz Doppler [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. However, clinical evaluation of the flap seems to remain the gold standard [ 1 ].…”