Hand-held Doppler Research Articles

Propeller flaps in partial ear reconstruction: a case series

BackgroundEar defect reconstruction still remains a surgical challenge today. Proper reconstruction should result in correction of the deformity with minimum morbidity with the aim of achieving the most esthetically pleasing outcome possible. Herein, we present our clinical experience with propeller flap reconstruction of external ear defects with a focus on indications and surgical technique.MethodsFourteen patients underwent surgery at our Plastic Surgery Unit between January 2015 and October 2019. After identifying perforators with a handheld Doppler ultrasound, a tailor-made flap was designed for each patient. Following tumor excision, dissection of the pedicle and of the remaining flap was performed with the aid of surgical loops. Flap in-setting and donor site closure were final steps.ResultsFlaps have survived in their entirety in almost all our patients (13/14) maintaining optimal color and elasticity and showing no complications. In one case, a superficial distal necrosis was observed and, in another patient, tumor recurrence took place.ConclusionsPropeller flaps offer great advantages when used in ear reconstruction ensuring excellent esthetic results with a one-stage technique. Nevertheless, it must be kept in mind that good dissection skills are required in order to avoid complications.Level of evidence: Level IV, Therapeutic study.

A Comparison of Handheld Doppler and Indocyanine Green Angiography for Perforator Localization.

The preoperative identification of perforators is critical to the success of perforator flaps. Several technologies, including handheld Doppler (HHD) and indocyanine green angiography (ICGA), facilitate this process; however, each technology comes with unique downsides. This study directly compares the performance of HHD and ICGA in preoperative perforator identification and measures the effects of flap thickness and body mass index (BMI) on perforator localization. Data from preoperative HHD and ICGA assessments were compared with the criterion standard of intraoperative perforator localization. Sensitivity, specificity, accuracy, and positive predictive values were calculated for both and correlated with flap thickness and BMI. Thirty flaps were transferred in 30 patients across 15 different donor sites. Indocyanine green angiography had higher sensitivity, accuracy, and positive predictive value (79.2%, 74.2%, and 87.5%, respectively) than HHD (55.6%, 46.6%, and 69.4%, respectively). Perforators detected by ICGA were used as flap pedicles in 21 cases compared with 13 with HHD. There were no correlations between HHD or ICGA performance and patient BMI (both P > 0.05). Increasing flap thickness was negatively correlated with the accuracy of ICGA ( P = 0.001) but not HHD ( P > 0.05). Indocyanine green angiography was more sensitive, specific, and accurate than HHD in identifying perforators across various donor sites; however, its performance suffered in thicker flaps, whereas HHD did not. Patient BMI was not correlated with the performance of either technology. Additional research can further delineate the interrelationships of flap thickness and technologies for perforator localization.

Diagnostic Accuracy of Ankle-Brachial Pressure Index Compared with Doppler Arterial Waveforms for Detecting Peripheral Arterial Disease: A Systematic Review.

To present the results of a research study evaluating the diagnostic accuracy of the ankle-brachial pressure index (ABPI) compared with that of Doppler arterial waveforms (DAWs) to detect peripheral arterial disease (PAD).This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After completing this continuing education activity, the participant will:1. Summarize the evidence the authors considered when comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.2. Select the characteristics of the participants in the studies the authors analyzed.3. Identify the results of the authors' study comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.4. Distinguish the authors' conclusions about the advantages of using Doppler arterial waveforms to detect PAD.Although the ankle-brachial pressure index (ABPI) is a useful tool for the noninvasive assessment of peripheral arterial disease (PAD), it has several limitations necessitating alternative noninvasive diagnostic tools. This study assesses the diagnostic accuracy of ABPI compared with Doppler arterial waveforms (DAWs) to detect PAD. The authors searched Embase and MEDLINE for original studies that reported sensitivities and specificities for both the ABPI and DAW. Four studies were included representing 657 patients (58.8% men) with a mean age of 63.4 years. The authors detected overall higher sensitivities using DAW compared with ABPI but higher specificities with ABPI compared with DAW. In conclusion, because of the higher sensitivity and lower specificity of DAW compared with ABPI, the authors recommend DAW as a potential screening tool for PAD. To confirm these results, larger sample sizes and comparative trials with homogeneous reference standards and patient populations are required. In addition, DAW is not easily documented for everyday bedside practice in the community. With COVID-19 restrictions, an audible handheld Doppler signal may act as a reproducible equivalent to DAW and thus facilitate timely, safe application of compression therapy at point-of-care.

Breast reconstruction with autologous abdomen-based free flap with prior abdominal liposuction - a case-based review.

Over recent years, liposuction has become the most commonly used surgical procedure used to refine male and female body contours. In the last four decades, the incidence of breast cancer has increased. Of these patients, there are more women requiring breast reconstruction who have undergone liposuction in the past. There is little in the literature that discusses harvesting perforator flaps from previously liposuctioned donor sites. The authors report on their experience and review the current literature on the autologous abdominal-based free flap for breast reconstruction after previous liposuction of the abdominal wall. Five electronic databases were searched (Medline (PubMed), Scopus, Web of Science, Cochrane) from inception to March 2021. Also, we searched our patients records and included our experience. We included three cases who had previous liposuction prior to their breast reconstruction procedure. We report no flap loss in our cases. Moreover, the database search showed 30 patients (83.33%) underwent deep inferior epigastric perforator (DIEP) reconstruction. The age ranged from 32 to 73 years (mean of 51.7 years). The mean length of reconstruction after liposuction is 8.9 years, ranging from 1.5 years to 23 years reported in 23 patients. Seven patients (19.4%) had partial loss of the flap. Twenty patients (55.55%) had CT angiography pre-operatively for the assessment of the perforators. A careful combination of preoperative scanning, handheld Doppler and clinical examination reduce the chance of an unsuccessful outcome.

Comparing tissue oximetry to doppler monitoring in 1367 consecutive breast free flaps.

Retrospective studies evaluating tissue oximetry in a more recent cohort have shown superiority in flap outcomes. This study compares the use of tissue oximetry in a historical cohort to clinical observation and handheld doppler in a more recent cohort. We hypothesize that there is no benefit to using tissue oximetry. A retrospective review was performed on patients who underwent abdominal-based autologous breast reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Method of postoperative flap monitoring was determined then operative details and complications were analyzed. 1367 flaps were reviewed; 740 flaps in 460 patients were monitored with clinical observation and tissue oximetry, and 627 flaps in 391 patients were monitored with clinical observation and handheld doppler. There were no statistical differences in ischemic (p= .59) or congestive complications (p= .41), flap salvage rates when exploring for venous or arterial compromise (p= .52), or early flap loss (p= .56). Although not significant, acute flap-related return to the operating room was lower in the doppler group (4.6%) compared to the oximetry group (6.1%; p= .22). Flaps monitored with tissue oximetry had a statistical increase in length of stay (4.8 ± 1.4 days vs. 3.8 ± 1.6 days; p ≤ .001). The rates of late partial flap loss and fat necrosis were significantly higher in the oximetry group (2.6%, 19/740 vs. 0.3%, 2/740; p= .04) and (18.2%, 135/740 vs. 13.6%, 85/627; p= .02), respectively. There is no statistical benefit to the use of tissue oximetry compared to handheld doppler in flap monitoring with regards to flap outcomes.

Role of Ankle Brachial Pressure Index (ABI) in Screening Patients with Risk Factors For Developing Peripheral Vascular Disease

Background: Peripheral vascular diseases (PVDs) are trigged by various risk factors. The presence of PVD is associated with higher cardiovascular morbidity and mortality. Ankle brachial index (ABI) is the sensitive and also cost-effective diagnosing tool for peripheral artery disease. ABI is important for screening of peripheral arterial disease in patients at risk and for diagnosing the disease in patients having lower-extremity symptoms. Materials and Methods: This prospective observational study was performed at J. N. Medical College, A. M. U., Aligarh, UP on 135 adult patients who are asymptomatic for PVD but have one or more risk factors. Demographic and clinical data were recorded. Systolic Blood pressure of both arms and lower limb were measured using sphygmomanometer and hand held Doppler. Ankle brachial pressure index (ABPI) is detected by dividing higher of the two ankle pressures by the higher of the two brachial artery pressure. Results: Majority of the patients were aged between 46 and 65 years, males more than females. It was observed that diabetes, hypertension, smoking, and dyslipidemia patients have significantly lower ABPI score (<0.9) compared to other patients. USG Doppler has showed 10.4% were having abnormal findings and the ABI (0.68 ± 0.17) was significantly lower than the normal ones (0.89 ± 0.09). Receiver operating curve shows that ABPI below 0.77 can be used as cut-off to predict the occurrence and risk of developing PVD for screening asymptomatic with sensitivity 88.4 and specificity 85.7 and accuracy 90.1%. Conclusion: Comorbid conditions such as smoking, diabetes, hypertension, and dyslipidemia increase the risk of PVD. ABPI is a valid method to screen PVD with high levels of sensitivity and specificity.

Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

ObjectiveIn most high-income countries, the cardiotocography and handheld Doppler device have replaced the Pinard stethoscope for intrapartum foetal monitoring. As a result, the skills required to use the Pinard are rapidly disappearing from midwifery. The aim of this study was thus to illuminate the knowledge before it is lost, by exploring the practice, skills and experience of Norwegian midwives familiar with the Pinard for intrapartum foetal monitoring. We included midwives who still regularly use the Pinard in their current practice in a variety of birth settings, and those who used the Pinard in the era prior to the introduction of the CTG. DesignThis study followed a qualitative descriptive design based on mainly focus group interviews, but also including one individual interview. The interviews explored the participants` perspective on their practice, skills and experience regarding the use of the Pinard for intrapartum foetal monitoring. Reflexive thematic analysis captured common patterns across the data, and contextualism was used as research paradigm. Setting and participantsIn total, 21 midwives with experience using the Pinard for intrapartum foetal monitoring were interviewed. The midwives were either retired and had experience using the Pinard from before the CTG became widespread; worked in an alongside midwifery unit that only oversees low-risk births; or worked in an obstetric unit in a university hospital with an active policy of using the Pinard for intrapartum foetal monitoring. FindingsThe analysis resulted in four main themes: “Practice and experience with the Pinard are related to context”, “Skills with the Pinard come with work experience”, “The Pinard reveals certain characteristics of foetal sound” and “Midwives` experience with the benefits of using the Pinard”. The midwives considered the context for using the Pinard for intrapartum foetal monitoring relevant. The e availability of technology and applicable situations for using the Pinard influenced how and when they use the Pinard. They further underpinned training and work experience as important for feeling secure when using the Pinard, and this experience made them recognize normal and abnormal foetal sounds. Defining and characterizing these sounds appeared difficult for the midwives, however, and they hesitated and imitated the sound. The midwives felt that the Pinard is beneficial for both the labouring woman and the midwife, as the Pinard's features bring them closer to the labouring woman and help calm the birth suite. They also felt that the Pinard adds further information about the birth and birth process, such as foetal lie, rotation and descent. KeyconclusionsNorwegian midwives’ practice, and experiences in using the Pinard for intrapartum foetal monitoring are connected to context as technological development and applicable situations. The midwives explained that knowledge obtained through experience gives them skills to differentiate between normal and abnormal foetal sound characteristics, though they found it difficult to define the characteristics themselves. Using the Pinard stethoscope during birth calms the birth suite and brings the midwife closer to the labouring woman.

Using Duplex Ultrasound for Recipient Vessel Selection.

Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result. Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel. Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.

Safety and efficacy of anterior intercostal artery perforator flaps in oncoplastic breast reconstruction.

Partial breast reconstruction based on the anterior intercostal artery perforators (AICAP) has been suggested to avoid the unsightly 'bird's beak' deformity for lower pole breast cancers. The aims of this study were to evaluate the initial clinical experience of AICAP flaps in terms of safety and efficacy in oncoplastic breast reconstruction. Between October 2013 and April 2020, AICAP flaps were offered to 30 patients with lower pole breast cancers. Hand-held Acoustic Doppler assessments were undertaken to confirm adequate perforators. Surgical results were evaluated in terms of safety and efficacy. Patients were invited to complete sections of the Breast-Q questionnaire at least 12 months postoperatively to assess patient satisfaction in terms of cosmetic outcome, physical and psychosocial wellbeing. Median operating theatre time for AICAP flap harvesting and positioning was 20 min (range 15-28 min). The median weight of resected breast specimens was 41 g (range 10-127 g). Total tumour size ranged from 7 to 35 mm (median 16 mm; three cases exhibited multifocal disease). Clear radial resection margins were achieved in 29 cases (96.7%). The median post-operative stay was two days (range 2-3 days). There were two postoperative complications comprising delayed wound healing/fat necrosis, which resolved with monitoring and inadine dressings. Based on the Breast-Q results, patients reported high levels of satisfaction with the physical appearance of their reconstructed breast, psychosocial and physical wellbeing. AICAP flaps appear to be safe in restoring breast contour after wide excision of lower pole breast cancers, with high levels of patient satisfaction reported postoperatively.

Comparison of Detection of Superior Gluteal Artery Perforator by Indocyanine Green Fluorescence Near-Infrared ANGIOGRAPHY and Handheld Acoustic Doppler Sonography for Reconstruction of Sacral Pressure Injury.

Aims: Pressure injury is a gradually increasing disease in the aging society. The reconstruction of a pressure ulcer requires a patient and surgical technique. The patients were exposed to the radiation risk under other ways of detection of perforators such as computed tomographic angiography and magnetic resonance angiography. Here, we compared two radiation-free methods of a superior gluteal artery perforator (SGAP), flap harvesting and anchoring. One is the traditional method of detecting only handheld acoustic Doppler sonography (ADS) (Group 1). The other involves the assistance of intraoperative indocyanine green fluorescent near-infrared angiography (ICGFA) and handheld ADS (Group 2). Materials and Methods: This is a single-center, retrospective, observational study that included patients with sacral pressure injury grades III and IV, who had undergone reconstructive surgery with an SGAP flap between January 2019 and January 2021. Two detection methods were used intraoperatively. The main outcome measures included the operative time, estimated blood loss, major perforator detection numbers, wound condition, and incidence of complications. Results: Sixteen patients underwent an SGAP flap reconstruction. All patients were diagnosed with grade III to IV sacral pressure injury after a series of examinations. Group 1 included 8 patients with a mean operative time of 91 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 4. Postoperative complications included one wound infection in one case and wound edge dehiscence in one case. No mortality was associated with this procedure. The mean total hospital stay was 16 days. Group 2 included 8 patients with a mean operative time of 107.5 min, and the mean estimated blood loss was 50 mL. The mean number of perforators was 5. Postoperative complications included one wound infection. No mortality was associated with this procedure. The mean total hospital stay was 13 days. Conclusions: The combination of detection of the SGAP by ICGFA and handheld ADS for the reconstruction of a sacral pressure injury provides a more accurate method and provides the advantage of being radiation-free.

Near-Infrared Spectroscopy (NIRS) versus Hyperspectral Imaging (HSI) to Detect Flap Failure in Reconstructive Surgery: A Systematic Review.

Rapid identification of possible vascular compromise in free flap reconstruction to minimize time to reoperation improves achieving free flap salvage. Subjective clinical assessment, often complemented with handheld Doppler, is the golden standard for flap monitoring; but this lacks consistency and may be variable. Non-invasive optical methods such as near-infrared spectroscopy (NIRS) and hyperspectral imaging (HSI) could facilitate objective flap monitoring. A systematic review was conducted to compare NIRS with HSI in detecting vascular compromise in reconstructive flap surgery as compared to standard monitoring. A literature search was performed using PubMed and Embase scientific database in August 2021. Studies were selected by two independent reviewers. Sixteen NIRS and five HSI studies were included. In total, 3662 flap procedures were carried out in 1970 patients using NIRS. Simultaneously; 90 flaps were performed in 90 patients using HSI. HSI and NIRS flap survival were 92.5% (95% CI: 83.3–96.8) and 99.2% (95% CI: 97.8–99.7). Statistically significant differences were observed in flap survival (p = 0.02); flaps returned to OR (p = 0.04); salvage rate (p < 0.01) and partial flap loss rate (p < 0.01). However, no statistically significant difference was observed concerning flaps with vascular crisis (p = 0.39). NIRS and HSI have proven to be reliable; accurate and user-friendly monitoring methods. However, based on the currently available literature, no firm conclusions can be drawn concerning non-invasive monitoring technique superiority

Strengthening Fetal Heart Rate Monitoring during Labor with a Standard Handheld Doppler - Implementation Experience from India.

India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states. Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators. Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98-2.07, P < 0.01) and in Community Health Centers (14.7-1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6-1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings. The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring.

Assessment of peripheral artery disease risk in building construction workers by Ankle-Brachial index measurement with automated oscillometric and hand-held Doppler device.

Background:Peripheral arterial disease (PAD) remains underdiagnosed, partly because of the limitations of the Doppler ankle-brachial index (ABI) with regards to equipment, training, and time constraints.Aims:To compare the accuracy and validity of automated oscillometric ABI measurement in detecting PAD in primary care settings against a gold standard Doppler device.Settings and Design:A cross-sectional observational study was conducted at the physiology department, Dr. Ram Manohar Lohia Institute of Medical Sciences (DrRMLIMS), Lucknow.Methods and Material:A total of 200 male building construction workers of all types of age groups between 20 and 40 years were recruited. The ABI measurement was performed using the Watch BP Office and hand-held HI.dop, BT-200 Vascular Doppler device.Statistical Analysis Used:The Bland-Altman plot and receiver operator characteristics (ROC) curve were determined to analyze the agreement between the two methods. For the reliability of the test, Pearson’s correlation with linear regression was done and the intraclass correlation (ICC) coefficient was calculated.Results:The mean ABI (Osc) and ABI (Dop) were 1.13 ± 0.09 and 1.06 ± 0.08, respectively. The ABI (Dop) and ABI (Osc) methods were highly correlated Pearson’s correlation coefficient of 0.96 with 95% confidence interval (CI) ranges between 0.985 and 1.066 (P < 0.001). On linear regression analysis, the ABI (Dop) predicted ABI (Osc) 92.6% correctly. The paired mean difference between the two measuring devices was 0.07 (95% CI = −0.03 to −0.12). At 0.90 cut-off value of diagnosing PAD, the sensitivity is 50%, specificity 100%, positive predictive value 100%, and negative predictive value 97% by an oscillometric automated device.Conclusion:Our finding suggested that ABI measurement by the automated oscillometric device is reliable, free of examiner bias, and less time-consuming.

Fingerstall-type Tissue Oximetry Reduced Anxiety of Nurses in Postoperative Nursing Monitoring of Free Flaps.

Background:Postoperative free flap monitoring is essential for immediately detecting obstruction of anastomosed vessels with successive recovery surgery for salvaging flaps. We performed postoperative nursing monitoring using handheld Doppler sonography, but nurses reported feeling anxious with this approach and demanded a clear-cut evaluation method. Therefore, we implemented monitoring with the fingerstall-type tissue oximeter Toccare, a noninvasive device that enables easy flap checking by simply touching the flap with a probe.Method:Handheld Doppler was used for nursing monitoring from April to October 2020, with anxiety associated with its use reported. We collected information via an anonymous questionnaire to determine the reason for the anxiety. Toccare was subsequently applied for postoperative free flap monitoring by nurses. The protocol involved measuring tissue oxygen saturation by touching the flap with a Toccare probe every 4 hours from 24 to 100 hours postoperatively. Seven months later, a second anonymous questionnaire was conducted, and results were compared.Result:Free deep inferior epigastric artery perforator flaps and anterolateral thigh flaps (n = 5 each) were included. The average tissue oxygen saturation values in the deep inferior epigastric artery perforator and anterolateral thigh flaps were 52.0% and 52.4%, respectively. According to the second questionnaire about Toccare, 7% felt anxious, 62% felt slightly anxious, and 31% did not feel anxious. Toccare was preferred by 89% of nurses who had used both methods.Conclusions:Flap monitoring using Toccare reduced nurses’ anxiety. A numerical evaluation method with easy handling and clear doctor call criteria is essential for low-anxiety nursing monitoring.

A Comparison of Accuracy between Dynamic Infrared Thermography (DIRT) and Handheld Doppler Ultrasonography in Free Flap Reconstruction Perforator Mapping: A Prospective Study

Background: Preoperative perforator mapping is one of fundamental steps for successful surgery in microsurgical perforator free flap. Currently, there is still no gold standard for preoperative perforator mapping. Objective: The present study aims to compare accuracy in perforator mapping between dynamic infrared thermography (DIRT) and handheld doppler which is the main method we used in our hospital. Materials and Methods: Twenty patients scheduled for microsurgical free flap reconstruction between October 2018 to December 2020 was enrolled. Preoperative perforator mapping was performed by both handheld doppler and smartphone dynamic infrared thermography (DIRT). During rewarming period, &ldquo;Hot spots&rdquo; were marked. Then flaps were raised intraoperatively, numbers, diameter and location of each perforators were recorded. Location of perforators at its piercing fascia were reflected to skin. Distance from actual perforators to the nearest preoperative perforator marking point by each method were measured. Results: There were 9 male and 11 female patients enrolled in the present study with mean age of 54.30 years. The average body mass index was 23.85 kg/m2. Hand-held doppler and DIRT images were obtained for 20 flaps, including 15 anterolateral thigh flaps (75%), 1 anteromedial thigh flap (5%) and 4 fibular free flaps (20%). The mean caliber of selected perforators was 2.62 mm at point of their emergence through fascia. All the flap survived without postoperative major complication. The mean distance from actual perforator to the nearest perforator from handheld doppler was 11.88+7.51 mm, and to the nearest perforator from thermal images was 12.68+8.96 mm. The mean distance difference of both methods was 0.80 mm. Perforators were usually within a 20 mm radius of preoperative marking both handheld doppler and DIRT. Conclusion: Dynamic infrared thermography is low cost, non-invasive and reliable methods for preoperative perforator mapping. Keywords: Dynamic infrared thermography; Handheld doppler ultrasonography; Perforator mapping; DIRT; Perforator free flap

Exploration of chest wall perforator vascular anatomy on standard breast MRI: A potential aid to chest wall perforator flap planning

Local chest wall perforator flaps (CWPFs) are a volume replacement technique permitting breast-conserving surgery in patients who otherwise may require a mastectomy. These flaps are based on one or more perforating arteries arising from the lateral chest wall that travel through the soft tissue and into the sub-dermal plexus to perfuse the flap. Examples include the lateral intercostal and lateral thoracic artery perforators (LICAP and LTAP, respectively). Cross-sectional imaging of perforating vessels is not routinely performed, and vessels are mapped pre- and peri-operatively using a hand-held acoustic doppler device. As many breast cancer patients undergo pre-operative MRI scanning for oncological purposes, we investigated the role of MRI in mapping the vascular anatomy to aid with the surgical planning of CWPFs. We collated data retrospectively on a cohort of breast cancer patients who underwent breast MRI as part of routine pre-operative imaging. Axial 3D high-resolution dynamic contrast-enhanced MRI sequences with multiplanar reconstructions were analysed by a consultant radiologist. The presence and calibre of lateral chest wall perforator vessels were assessed. Fifty patients were suitable for inclusion. A consistent pattern of lateral chest wall vasculature was observed. Forty-eight patients (96%) demonstrated a bilateral lateral thoracic artery (LTA) descending inferiorly along the chest wall with two-thirds of these communicating with perforating intercostal vessels. True independent LICAP vessels were identified in six patients. From our observations, lateral CWPFs are dependent on an intricate intercommunication between intercostal vessels and the LTA which in turn supply perforators to the lateral chest wall donor site.

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points.

With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery. Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups. The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74). To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. . Diagnostic, IV.

Ep.We.1001Name That Tune - Acccuracy of Interpreting Hand-Held Doppler Audio Signals in the Assessment of Peripheral Arterial Circulation

Abstract Aims Interpretation of Doppler audio signals among non-podiatrist has not been thoroughly investigated. This study analyses the accuracy of interpretation of Doppler audio signals among clinicians. Methods A single-centre prospective single blind study was used. Clinicians in the vascular department and with prior vascular experience in a district general hospital participated in interpreting 15 12-second Doppler audio signals (5 monophasic, 5 biphasic and 5 triphasic) into either ‘monophasic’, ‘biphasic’ and ‘triphasic’ using a Huntleigh’s Dopplex DMXTM digital hand-held Doppler ultrasound with visual waveform display covered. After all the audio signals were graded, the waveforms of each doppler signals are shown on the hand-held doppler display to reveal the correct responds. Results 8 clinicians were involved; 5 had less than 6 months of vascular experience. Out of 15 audio signals, the mean number correct grading of signals was 10.1. There is no difference in number of correct grading of the 3 waveforms (monophasic 3.5 out of 5, biphasic 3.25 out of 5, triphasic 3.5 out of 5). There is also no difference in responses between clinicians with less than 6 months and more than 6 months of vascular experience (p = 0.82). Conclusions There is a need for further ongoing education among clinicians in the use of hand held Doppler and interpretation of its audio signals. Reliability of Doppler examination in vascular assessment is also in contention, and further studies are required. The use of digital hand-held Doppler with visual wave form display will significantly improve accuracy of interpretation

Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery.

The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature. An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages. The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure. This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.

Postoperative Detection of Free Flap Congestion in a Fitzpatrick Skin Type VI Patient using the Flir Thermal Imaging Camera: A Case Report and Literature Review

BACKGROUND: Free flaps are routinely used in complex tissue reconstruction due to their functionality and reliability. Postoperative monitoring remains a challenge despite the current available modalities. Clinical examination remains the gold standard, with color being the most sensitive marker of flap compromise. Assessment of flap color is more challenging in Fitzpatrick V-VI skin types, masking visual signs of ischemia or congestion. A Forward-Looking Infrared (FLIR) ONE smartphone based thermal imaging camera can be used to detect differences in flap temperature from the surrounding native tissue and could be used to identify early flap compromise. This simple technology used with a smartphone may be a useful method to assess postoperative flap perfusion. METHODS: Institutional review board approval was obtained for postoperative flap monitoring using FLIR technology for patients undergoing complex reconstruction with a free anterolateral thigh (ALT) flap. The FLIR camera is a simple attachment that plugs into iPhone models 7–12 and takes thermal pictures with temperature readings by a spot pyrometer using their App. Preoperatively the FLIR camera spot pyrometer measured baseline temperature by ALT flap location. Temperature recordings of the flap and the surrounding native tissue were taken immediately postoperatively and then at regular intervals in addition to our standard free flap monitoring protocol. This protocol was utilized for one patient in this report who underwent a free ALT flap to scalp after sarcoma resection and Fitzpatrick skin type VI. RESULTS: FLIR thermography measured the preoperative central flap temperature at 32.6°C. Immediately postoperatively the flap temperature was 33.9°C, and the surrounding native skin was 35.8°C. Sixteen hours postoperatively the central portion of the flap was found to be 28.0°C, 8.4°C cooler than the surrounding native skin, suggesting flap ischemia. Clinical examination of the flap showed edema and return of dark blood on scratch test but no frank discoloration. Handheld Doppler signal showed arterial signal but no venous signal. The patient was taken immediately for operative exploration, which showed a 30 cm3 hematoma compressing the vascular pedicle. Following evacuation, the central flap’s temperature was 35.6°C. The patient was discharged on POD 7 and still has a complete reconstruction. CONCLUSIONS: FLIR ONE was helpful in detecting flap congestion and ultimately flap salvage. Prompt operative evacuation of the hematoma prevented flap loss and associated morbidity to the patient. This patient case highlights the inherent challenges in evaluating skin paddles of Fitzpatrick V–VI skin types and depicts the utility of a low-cost thermography camera that can aid in identifying a threatened flap. The user-friendly, non-contact nature of FLIR ONE adds a useful and objective datapoint in postoperative free flap monitoring that can improve patient outcomes when combined with conventional monitoring techniques in all patients, particularly those with difficult flaps to monitor. Our team hopes to continue studying thermal camera temperature differences in postoperative free flap monitoring to service our patients and provide insight into this technology’s utility for reconstructive plastic surgery.