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Smit, Jeroen M. M.D.; Zeebregts, Clark J. M.D., Ph.D.; Acosta, Rafael M.D.; Werker, Paul M. N. M.D., Ph.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 679-680
doi: 10.1097/PRS.0b013e3181df7230
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We would like to thank Dr. Lin et al. for their interest in our review.1 We agree with them that if there is any sign whatsoever of vascular compromise, a flap should immediately be taken back to the operating room for exploration, even when a monitoring device gives off a good signal. We can imagine that, based on this experience, they prefer conventional over other methods.

The aim of our article was not to plead for change toward monitoring using any of the devices, but rather to create an overview of the current monitoring systems, together with their advantages and shortcomings, and their potential to become the ideal monitoring method. Although conventional monitoring methods are still most widely used today, the literature shows that methods such as the implantable Doppler system,2 near-infrared spectroscopy,3 microdialysis,4 and laser Doppler flowmetry5 are in some cases able to detect a vascular complication earlier compared with conventional monitoring methods. Earlier detection of flap compromise, at least theoretically, might increase the chances of flap salvage. As stated earlier, we do acknowledge that the newer methods have their limitations and are not failure free, of which a false-negative reading as described in the letter above is potentially the most disastrous.

Because of the complete lack of “head-to-head” comparisons of the different monitoring methods and the scarcity of reports on how salvage rates changed after the introduction of a new monitoring method, no uniform statement can at present be made about which monitoring method is best. Until multiple trials report on these subjects, personal experience remains the most important factor in choosing a specific monitoring method, and in many hands, this remains conventional monitoring.


The authors have no potential or actual, personal, political, or financial interests in the material, information, or techniques described in this communication.

Jeroen M. Smit, M.D.

Department of Plastic Surgery

Clark J. Zeebregts, M.D., Ph.D.

Department of Surgery

Division of Vascular Surgery

University Medical Center Groningen

Groningen, The Netherlands

Rafael Acosta, M.D.

Department of Plastic and Reconstructive Surgery

Uppsala University Hospital

Uppsala, Sweden

Paul M. N. Werker, M.D., Ph.D.

Department of Plastic Surgery

University Medical Center Groningen

Groningen, The Netherlands


1. Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements in free flap monitoring in the last decade: A critical review. Plast Reconstr Surg. 2010;125:177–185.
2. Guillemaud JP, Seikaly H, Cote D, Allen H, Harris JR. The implantable Cook-Swartz Doppler probe for postoperative monitoring in head and neck free flap reconstruction. Arch Otolaryngol Head Neck Surg. 2008;134:729–734.
3. Repez A, Oroszy D, Arnez ZM. Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy. J Plast Reconstr Aesthet Surg. 2008;61:71–77.
4. Setälä L, Papp A, Romppanen EL, Mustonen P, Berg L, Härmä M. Microdialysis detects postoperative perfusion failure in microvascular flaps. J Reconstr Microsurg. 2006;22:87–96.
5. Heller L, Levin LS, Klitzman B. Laser Doppler flowmeter monitoring of free-tissue transfers: Blood flow in normal and complicated cases. Plast Reconstr Surg. 2001;107:1739–1745.

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