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

Sir: Buried free flaps in breast reconstruction have the potential to offer superior aesthetic outcomes, avoiding the need for a monitoring skin paddle following skin and nipple-areola complex–sparing mastectomy. One of the reasons this has not been widely used is the difficulty of monitoring buried flaps.1 We introduced the Cook-Swartz probe into our clinical practice in May of 2006. The Cook-Swartz venous Doppler system is a technique for monitoring venous flow in free tissue transfer consisting of an implantable 20-MHz ultrasonic probe placed against the recipient vein and a battery-operated portable monitor. Although it was developed in the United States some time ago2 and has been available for clinical use for several years, it has only been distributed outside North America since 2006. Buried microvascular free tissue transfers without a monitoring skin paddle for breast reconstruction has not been widely performed, and to our knowledge, the only technique in the literature described for monitoring these cases is color duplex sonography.3 With the increasing use of the implantable Cook-Swartz Doppler probe, this technique is becoming a safe option.4 Eight women undergoing free microvascular tissue transfer for breast reconstruction were recruited. These included five deep inferior epigastric artery perforator (DIEP) flaps (four unilateral and one bilateral) and three superior gluteal artery perforator flaps (two unilateral and one bilateral). All eight women underwent delayed reconstruction. In all cases, venous anastomoses were performed using a venous ring coupler (mean anastomotic time, 3 minutes; range, 2.5 to 4 minutes). Implantable probes were attached atraumatically, distal to the venous anastomosis. The probe was turned on immediately, allowing for monitoring of flow during insetting of the flap and throughout the immediate postoperative period. All eight cases were successful, with no operative complications or complications as a result of the use of the implantable Doppler probe (Figs. 1 and 2). In all cases, there was good Doppler flow throughout the monitoring period, and the probes were removed uneventfully on the seventh postoperative day.Fig. 1.: Appearance at 4-month follow-up of unilateral left buried free flap for breast reconstruction (DIEP flap).Fig. 2.: Appearance at 4-month follow-up of bilateral buried free flaps for breast reconstruction (DIEP flaps).All patients were happy with the operative outcome and found the sound of the venous flow postoperatively very reassuring. The sound output on the probe was turned down to allow the patient to sleep, and was turned up at regular intervals for monitoring by nurses and surgical rounds. The DIEP flap can provide a large and versatile volume of tissue with good donor-site outcomes. The use of a buried flap provides the additional advantage of avoiding the need for a monitoring skin paddle, which may compromise aesthetic outcome. The Cook-Swartz Doppler probe has been used successfully for monitoring DIEP flaps4; however, this is the first description of the implantable Doppler probe for the monitoring of buried flaps for breast reconstruction. The Cook-Swartz Doppler probe is highly sensitive, responding to venous obstruction immediately and arterial insufficiency within minutes.2,5 Although all flaps in the current series were uncompromised, we have found the implantable probes highly reliable in over 150 cases of breast reconstruction.4 The implantable Doppler probe is easily applied and removed, and if two venous anastomoses are used, multiple implantable Doppler probes can be applied. The probe permits either frequent or continuous monitoring, avoiding the need to wake the patient during flap assessment. This is the first study to demonstrate the implantable Doppler probe for monitoring buried free flaps in breast reconstruction. With buried flaps potentially offering superior aesthetic outcomes, the safe monitoring of these flaps with the implantable Doppler probe may increase their application. Warren M. Rozen, M.B.B.S., P.G.Dip.Surg.Anat. Jack Brockhoff Reconstructive Plastic Surgery Research Unit Department of Anatomy and Cell Biology University of Melbourne Parkville, Victoria, Australia Iain S. Whitaker, M.A.(Cantab.), M.B.B.Chir. Department of Plastic, Reconstructive, and Burns Surgery The Welsh National Plastic Surgery Unit The Morriston Hospital Swansea, United Kingdom Marcus J. D. Wagstaff, M.B.B.S., Ph.D. Department of Plastic Surgery University Hospitals of Sheffield Sheffield, United Kingdom Thorir Audolfsson, M.D. Rafael Acosta, M.D. Department of Plastic Surgery Uppsala Clinic Hospital Uppsala, Sweden DISCLOSURES The authors declare that there is no source of financial or other support or any financial or professional relationships that might pose a competing interest.