title: A chimaeric-pattern flap design for implantable Doppler surrogate monitoring: a novel placement technique.
abstract: OBJECTIVE
  Postoperative flap monitoring is a vital aspect of free tissue transfer in order to detect early vascular compromise and to enable early flap salvage. The implantable Doppler monitoring system is one of many monitoring devices used to ensure accuracy and reduce unnecessary flap explorations. However, there are a number of concerns with its use, namely tension on the anastomosis, possible vessel constriction and false-negative detection. This study aimed to alleviate these concerns, by introducing a new method of placing the implantable Doppler probe on the adjacent vessel limb of a chimaeric flap. This is illustrated by a case series of chimaeric free tissue flaps that allow this surrogate placement of the Doppler probe.
  
  
  METHODS
  The flap is raised in a chimaeric fashion, with a main perforator pedicle to the skin or muscle paddle for the main reconstructive purpose and a side branch from the main pedicle going to a smaller adipofascial or muscle flap for monitoring. This branch vascular pedicle leading to the chimaeric tissue is kept sufficiently long to enable placement of the Doppler cuff and prevent turbulence. The probe of a Cook-Swartz implantable Doppler system is placed around the branch pedicle, approximately 5 mm from the branching point, and secured with a vessel clip. This is then secured away from the major vessels of the main free flap. Removal of the probe's crystal and wire is easily done with a single gentle traction on postoperative day 7.
  
  
  RESULTS
  Five cases of chimaeric free flaps were performed with this manoeuvre: three thoracodorsal perforator chimaeric flaps for head-and-neck or extremity reconstruction, one latissimus dorsi neuromuscular chimaeric flap for facial reanimation and one digastric lymph node transfer for the treatment of lower limb lymphoedema. The Doppler system showed a low but sustained oscillating flow in all cases indicating vascular patency, with minimal flow interference from other large-calibre vessels. There was no discernible kinking on the anastomosis. There were no complications encountered during probe removal. This postoperative monitoring manoeuvre was done successfully with good results.
  
  
  CONCLUSIONS
  The monitoring equipment is very sensitive to any flow disturbance due to positional changes in the head-and-neck region or the extremities and is able to detect flow changes in buried flaps postoperatively. Chimaeric flap composition is easier now than before because of perforator-oriented pedicle dissection, and surrogate Doppler monitoring is one more application of the chimaeric flap. This novel chimaeric fashion of implantable Doppler probe placement is a good surrogate measure of flow in the main pedicle.
authors.affiliation: Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, South Korea.
authors.forename: Jeong Tae
authors.initials: JT
authors.lastname: Kim
authors.affiliation: Section of Plastic and Reconstructive Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore. Electronic address: lilming2000@gmail.com.
authors.forename: Samuel Y M
authors.initials: SY
authors.lastname: Ho
authors.affiliation: Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, South Korea.
authors.forename: Youn Hwan
authors.initials: YH
authors.lastname: Kim
mesh_terms: D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D004301:Doppler Effect; D058752:Free Tissue Flaps / Q000098:blood supply*; D006230:Hand Injuries / Q000601:surgery; D006801:Humans; D008297:Male; D008444:Maxillary Sinus Neoplasms / Q000601:surgery; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation*; D011182:Postoperative Care; D019736:Prostheses and Implants; D019919:Prosthesis Implantation / Q000379:methods*; D012039:Regional Blood Flow; D014067:Tonsillar Neoplasms / Q000601:surgery
keywords: Buried; Chimeric; Doppler; Free flap; Implantable; Monitoring; Perforator; TAP; TdAP; Thoracodorsal artery