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Sir: Time is a critical determinant in reconstructive microsurgical flap revision surgery.1 Revision surgery is indicated mainly on the basis of clinical measures and currently less often on visual appearance measures or the combination of both.2 However, flap inspection and recapillarization are highly dependent on and closely related to the examiner's experience. The reconstructive microsurgeon, serving as a consultant, may not necessarily inspect the microsurgical flap every hour within the first 48 hours. However, communication may not necessarily reflect the actual visual appearance of a microsurgical flap, which may have devastating adverse effects on implementation of an appropriate therapy (i.e., revision surgery) in case of signs of malperfusion or venous congestion. To overcome these issues, we decided to evaluate a prompt and easy way of transferring the clinical inspection of the flap to the reconstructive microsurgeon at any point in time in the most convenient way. We therefore hypothesized that a cell phone–based multimedia messaging service, which is incorporated into almost all currently available cell phones, might help to transfer a more comprehensive impression of a microsurgical flap at any point in time after reconstructive surgery. A 58-year-old woman underwent reconstructive microsurgery with a free transverse rectus abdominis muscle flap to her right breast, which had been ablated because of breast cancer. The reconstructive surgical procedure was hampered by the fact that venous congestion was evident after conventional anastomosis of the epigastric inferior artery and vein. Six hours postoperatively, the flap demonstrated evident signs of venous congestion in zone 4 (Fig. 1), which was photographed using the Nokia N95 5-megapixel camera. The photograph was transmitted to the consultant microsurgeon at home, who decided to use leeches in this circumstance rather than reoperation, which was referred to the resident-in-charge by means of a short message service. Conventional medicinal leeches were used, which relieved the venous congestion within 4 hours of application.3,4Fig. 1.: Nokia N95 cell phone with a 5-megapixel built-in camera for multimedia messaging service of the visual inspection of the flap for a more comprehensive impression of the consultant irrespective of current geographic location.A cell phone–based multimedia messaging service is feasible and accurate in transferring a more comprehensive impression of postoperative flap assessment to the microsurgical consultant after office hours. Multimedia messaging service in its current technology enables storage and transmission of high-resolution photographs and short videos of the clinical recapillarization testing of a microsurgical reconstructive free flap to the consultant at home. Regardless of the current geographic position of the consultant microsurgeon, the use of the cell phone–based multimedia messaging service photograph and video transmission enables immediate decision making. Currently, multimedia messaging service applications have been reported only in a neurosurgical service of computed tomographic scans1 and in the referral of musculoskeletal limb injuries to a tertiary trauma unit.5 Given the fact that earlier revision surgery is paramount for flap salvage in reconstructive microsurgery, time is of utmost importance in this regard. As in the Chinese saying, a picture is worth a thousand words, and we believe that a more comprehensive impression of the visual appearance and clinical assessment of a given free flap enables the consultant microsurgeon, irrespective of current geographic position, to make a decision about the appropriate treatment. DISCLOSURE None of the authors has a financial interest in any of the products or devices mentioned in this article. Karsten Knobloch, M.D., Ph.D. AndreasGohritz, M.D. Peter M. Vogt, M.D., Ph.D. Hannover, Germany
Knobloch et al. (Wed,) studied this question.