Reconstruction with latissimus dorsi flap after complicated perianal fistulisation.

Chronic fistulas are a dreaded complication to surgery. They are often persistent to treatment and involve several negative side effects and a significant reduction in quality of life. We present a case report of a 36-year-old male with a deep chronic fistula in the pelvis after pouch surgery. More than 60 procedures were performed under general anaesthesia without treatment effect. Through a multidisciplinary approach a complete rectum extirpation and reconstruction with a free latissimus dorsi flap was performed. The patient was seen at followup 18 months after the surgery; pain free and without relapse.

Severe midface necrosis after liver failure induced fungal infection: A case report on the outcome after reconstruction.

INTRODUCTION: Reconstruction of the complex anatomy of the midface is challenging and requires meticulous preparation. Immunosuppression therapy increases patient susceptibility to infection and can compromise wound healing. PRESENTATION OF CASE: A 22-year-old male presented with acute hepatic failure and underwent liver transplantation. The subsequent immunosuppressing therapy resulted in an invasive fungal infection in the midface involving the left lower eyelid, skin and soft tissue of the cheek and the underlying maxilla and zygoma. After multiple revisions, a primary surgical closure of the defect was performed with a free partial myocutaneous latissimus dorsi flap. 3 years post-transplantation the patient was referred to our hospital with no nasal airflow on the right side and completely obliterated nasal airway on the left side. He experienced trouble with the left eye tearing up and double vision when looking upward. Furthermore, he was troubled by missing 4 teeth in the left upper jaw. Lastly, he was not entirely satisfied with the general cosmetic outcome. These issues were addressed in two stages of surgery while considering that the patient was immunosuppressed. DISCUSSION: The patient did not suffer any complications or adverse side effects. Overall, the patient was satisfied with the results, and a questionnaire showed a clear improvement in patient reported outcome on both functional and cosmetic results of the problems addressed. CONCLUSION: Here we present how to plan a complex 3D midface reconstruction on an immunosuppressed patient and a questionnaire follow up on patient reported outcome. The patient reported overall satisfaction.

Improving Visualization of Intramuscular Perforator Course: Augmented Reality Headsets for DIEP Flap Breast Reconstruction.

Background: Augmented reality (AR) technology, exemplified by devices such as the Microsoft HoloLens 2, has gained interest for its potential applications in preoperative guidance. This study explores the use of AR technology for perforator identification during deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Methods: A case series of five patients where an AR device was used to identify perforators during DIEP flap breast reconstruction is presented. The device was utilized to recognize preoperative perforators and map their extra- and intramuscular routes. Sound and/or color Doppler confirmation was used to verify the findings. Results: In all five cases, the AR device successfully identified preoperative perforators and delineated their extra- and intramuscular routes. AR technology in perioperative visualization of vasculature offers the potential to enhance surgical precision and reduce operative times. By providing an augmented three-dimensional overlay of patients' vascular structures, AR can facilitate a more comprehensive understanding of individual anatomy, ultimately improving surgical outcomes. Conclusions: AR technology shows promise in enhancing perforator identification efficiency and deepening understanding of perforator trajectories during preoperative planning. Nonetheless, additional research is needed to establish whether the advantages of AR technology warrant its widespread adoption for perforator identification.

Knee-saving Amputation by Use of a Bipedicled Four-zone Deep Inferior Epigastric Artery Perforator Flap.

Degloving traumatic lower extremity injuries can lead to an above-knee amputation with decreased functional capacity compared with below-knee amputation. The unique properties of the deep inferior epigastric artery perforator flap providing a substantial amount of skin and subcutaneous tissue combined with reliability and low donor-site morbidity makes the flap ideal for coverage of below-knee amputation stumps when soft tissue is required. A bipedicled four-zone deep inferior epigastric artery perforator flap with a skin area of 13 × 33 cm was used as coverage of a degloved lower leg amputation stump, in a 27-year-old woman with a left-sided Gustillo type 3B comminute diaphyseal tibial fractur and major degloving injury. Hereby, above-knee amputation was avoided. Ten months postoperatively the patient had achieved full prosthetic function.

Effect of Remote Ischemic Conditioning on Bleeding Complications in Surgery: A Systematic Review and Meta-Analysis.

Remote ischemic conditioning (RIC) is administered with an inflatable tourniquet by inducing brief, alternating cycles of limb ischemia and reperfusion. RIC possibly impacts the hemostatic system, and the intervention has been tested as protective therapy against ischemia-reperfusion injury and thrombotic complications in cardiac surgery and other surgical procedures. In the present systematic review, we aimed to investigate the effect of RIC on intraoperative and postoperative bleeding complications in meta-analyses of randomized controlled trials including adult patients undergoing surgery. A systematic search was performed on November 7, 2020 in PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials comparing RIC versus no RIC in adult patients undergoing surgery that reported bleeding outcomes in English publications were included. Effect estimates with 95% confidence intervals were calculated using the random-effects model for intraoperative and postoperative bleeding outcomes. Thirty-two randomized controlled trials with 3,804 patients were eligible for inclusion. RIC did not affect intraoperative bleeding volume (nine trials; 392 RIC patients, 399 controls) with the effect estimate -0.95 [-9.90; 7.99] mL (p = 0.83). RIC significantly reduced postoperative drainage volume (seven trials; 367 RIC patients, 365 controls) with mean difference -83.6 [-134.9; -32.4] mL (p = 0.001). The risk of re-operation for bleeding was reduced in the RIC group (16 trials; 838 RIC patients, 839 controls), albeit not significantly, with the relative risk 0.65 [0.39; 1.09] (p = 0.10). In conclusion, RIC reduced postoperative bleeding measured by postoperative drainage volume in this meta-analysis of adult patients undergoing surgery.

Oncological results and morbidity following intended curative resection and free jejunal graft reconstruction of cervical esophageal cancer: a retrospective Danish consecutive cohort study.

BACKGROUND: The role of surgery in treatment of locally advanced cervical esophageal cancer (CEC) remains debated. In the European and American treatment guidelines, definitive chemoradiotherapy (dCRT) is preferred over surgery, while in the Danish guidelines, the two treatment modalities are equally recommended. Surgical treatment of CEC is centralized at our center in Denmark. We present our outcomes following neoadjuvant chemoradiotherapy (nCRT) when possible and resection as first-line therapy for CEC and compare with recent published dCRT results. METHOD: We retrospectively reviewed the medical charts of patients treated for cervical esophageal cancer at Aarhus University Hospital from 2001-2018 with nCRT when possible and pharyngolaryngectomy followed by reconstruction with a free jejunal graft. RESULTS: Forty consecutive patients were included. About, 45% received nCRT. The median survival was 21 months. The overall, disease-specific and disease-free 5-year survival was 43.6%, 53.2%, and 47.4%, respectively. The rate of microscopically radical resection was 85%. The recurrence rate was 47% and 81% of recurrences were locoregional. The in-hospital and 30-day mortality rate was 0%. Major complications occurred in 27.9%. Anastomotic leakage, graft failure, fistulas and strictures occurred in 10%, 7.5%, 30%, and 30%, respectively. CONCLUSION: Our treatment offers equal oncological results compared to the best internationally published results for dCRT for CEC. Results vary considerably between dCRT studies. Morbidity appears more pronounced following surgery. Future studies are warranted to investigate the Danish national outcomes following dCRT as first-line treatment for curable locally advanced CEC.

Bone mineral density changes in a free vascularised fibular graft in the distal femoral bone after osteosarcoma in a 10-year-old boy: a 7-year follow-up.

A 10-year-old boy presented with continuous reports of pain located to the left knee. Imaging revealed a sclerotic process in the left distal femur, and biopsies were consistent with chondroblastic osteosarcoma. As part of standard treatment the patient underwent neoadjuvant chemotherapy followed by limb sparring surgery and adjuvant chemotherapy. The entire tumour was excised and femoral bone reconstruction was performed with a double barrel free vascularised fibular graft. Bone mineral density (BMD) can be decreased in childhood survivors of cancer. The patient was followed for 7 years with dual-energy X-ray absorptiometry scans in order to assess BMD and graft adaption. Despite two accidental fractures to the graft region local and global BMD underwent an overall increase. Approximately 7 years after tumour resection the patient had a global Z-score of 0.2, which is considered within normal range.

Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series.

Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Remote ischemic preconditioning does not influence lectin pathway protein levels in head and neck cancer patients undergoing surgery.

BACKGROUND: Cancer patients who undergo tumor removal, and reconstructive surgery by transfer of a free tissue flap, are at high risk of surgical site infection and ischemia-reperfusion injury. Complement activation through the lectin pathway (LP) may contribute to ischemia-reperfusion injury. Remote ischemic preconditioning (RIPC) is a recent experimental treatment targeting ischemia-reperfusion injury. The study aims were to investigate LP protein plasma levels in head and neck cancer patients compared with healthy individuals, to explore whether RIPC affects LP protein levels in head and neck cancer surgery, and finally to examine the association between postoperative LP protein levels and the risk of surgical site infection. METHODS: Head and neck cancer patients (n = 60) undergoing tumor resection and reconstructive surgery were randomized 1:1 to RIPC or sham intervention administered intraoperatively. Blood samples were obtained preoperatively, 6 hours after RIPC/sham, and on the first postoperative day. LP protein plasma levels were measured utilizing time-resolved immunofluorometric assays. RESULTS: H-ficolin and M-ficolin levels were significantly increased in cancer patients compared with healthy individuals (both P ≤ 0.02). Conversely, mannan-binding lectin (MBL)-associated serine protease (MASP)-1, MASP-3, collectin liver-1 (CL-L1), and MBL-associated protein of 44 kilodalton (MAp44) levels were decreased in cancer patients compared with healthy individuals (all P ≤ 0.04). A significant reduction in all LP protein levels was observed after surgery (all P < 0.001); however, RIPC did not affect LP protein levels. No difference was demonstrated in postoperative LP protein levels between patients who developed surgical site infection and patients who did not (all P > 0.13). CONCLUSIONS: The LP was altered in head and neck cancer patients. LP protein levels were reduced after surgery, but intraoperative RIPC did not influence the LP. Postoperative LP protein levels were not associated with surgical site infection.

[Orthopaedic treatment of malignant bone tumours in children].

The treatment of malignant bone tumours in children has improved significantly over the past 50 years. Previously, the only curative treatment was amputation, but today the surgical treatment has changed towards limb salvage surgery. However, there is not consensus regarding choice of surgical procedure, and it is mainly based upon the surgeon's previous experience. This review describes four reconstructive methods: rotationplasty, free vascularised fibula graft, bone transport and expandable endoprosthesis. All four methods are suitable surgical options with satisfactory functional outcome, though they vary in complications and revision rates.

Remote Ischemic Preconditioning in Microsurgical Head and Neck Reconstruction: A Randomized Controlled Trial.

The free flap failure rate is 5% in head and neck microsurgical reconstruction, and ischemia-reperfusion injury is an important mechanism behind this failure rate. Remote ischemic preconditioning (RIPC) is a recent intervention targeting ischemia-reperfusion injury. The aim of the present study was to investigate if RIPC improved clinical outcomes in microsurgical reconstruction. METHODS: Head and neck cancer patients undergoing tumor resection and microsurgical reconstruction were included in a randomized controlled trial. Patients were randomized (1:1) to RIPC or sham intervention administered intraoperatively just before transfer of the free flap. RIPC was administered by four 5-minute periods of upper extremity occlusion and reperfusion. Clinical data were prospectively collected in the perioperative period and at follow-up on postoperative days 30 and 90. Intention-to-treat analysis was performed. RESULTS: Sixty patients were randomized to RIPC (n = 30) or sham intervention (n = 30). All patients received allocated intervention. No patients were lost to follow up. At 30-day follow-up, flap failure occurred in 7% of RIPC patients (n = 2) and 3% of sham patients (n = 1) with the relative risk and 95% confidence interval 2.0 [0.2;20.9], P = 1.0. The rate of pedicle thrombosis was 10% (n = 3) in both groups with relative risk 1.0 [0.2;4.6], P = 1.0. The flap failure rate did not change at 90-day follow-up. CONCLUSIONS: RIPC is safe and feasible but does not affect clinical outcomes in head and neck cancer patients undergoing microsurgical reconstruction.

Resect or Retain Bone Fragments in Children and Teenagers with Severe Open Fractures?: A Case Report.

CASE: A 14-year-old pedestrian was hit by a car and encountered similar bilateral Gustilo IIIB open tibial fractures. The right tibial fracture involved a large borderline vital butterfly fragment without periosteal contact, which was retained and proceeded to sufficient healing within 12 weeks. The left tibial fracture was treated according to the principles for the treatment of severe open fractures in adults, involving resection of devitalized fragments and bone transport, and healed within 15 months. CONCLUSIONS: Teenagers do possess larger bone healing potential than adults. Therefore, a rapid bone union can be achieved even with apparently devitalized bone fragments if sufficient soft-tissue closure and stable fracture fixation is established early in the treatment of open limb fractures.

The generation of enlarged eroded pores upon existing intracortical canals is a major contributor to endocortical trabecularization.

The gradual conversion of cortical bone into trabecular bone on the endocortical surface contributes substantially to thinning of the cortical bone. The purpose of the present study was to characterize the intracortical canals (3D) and pores (2D) in human fibular bone, to identify the intracortical remodeling events leading to this endocortical trabecularization. The analysis was conducted in fibular diaphyseal bone specimens obtained from 20 patients (6 women and 14 men, age range 41-75 years). µCT revealed that endosteal bone had a higher cortical porosity (p< 0.05) and canals with a larger diameter (p< 0.05) than periosteal bone, while the canal spacing and number were similar in the endosteal and periosteal half. Histological analysis showed that the endosteal half versus the periosteal half: (i) had a higher likelihood of being non-quiescent type 2 pores (i.e. remodeling of existing pores) than other pore types (OR = 1.6, p< 0.01); (ii) that the non-quiescent type 2 pores contributed to a higher porosity (p< 0.001); and that (iii) amongst these pores especially eroded type 2 pores contributed to the elevated cortical porosity (p< 0.001). In conclusion, we propose that endocortical trabecularization results from the accumulation of eroded cavities upon existing intracortical canals, favored by delayed initiation of bone formation.

Effect of remote ischemic preconditioning on hemostasis and fibrinolysis in head and neck cancer surgery: A randomized controlled trial.

INTRODUCTION: The aim of this randomized controlled trial was to investigate if remote ischemic preconditioning (RIPC) reduced platelet aggregation and increased fibrinolysis in cancer patients undergoing surgery and thereby reduced the risk of thrombosis. MATERIALS AND METHODS: Head and neck cancer patients undergoing tumor resection and microsurgical reconstruction were randomized 1:1 to RIPC or sham intervention. RIPC was administered intraoperatively with an inflatable tourniquet by four cycles of 5-min upper extremity occlusion and 5-min reperfusion. The primary endpoint was collagen-induced platelet aggregation measured with Multiplate as area-under-the-curve on the first postoperative day. Secondary endpoints were markers of primary hemostasis, secondary hemostasis, and fibrinolysis. Clinical data on thromboembolic and bleeding complications were prospectively collected at 30-day follow-up. An intention-to-treat analysis was performed. RESULTS: Sixty patients were randomized to RIPC (n = 30) or sham intervention (n = 30). No patients were lost to follow-up. The relative mean [95% confidence interval] collagen-induced platelet aggregation was 1.26 [1.11;1.40] in the RIPC group and 1.17 [1.07;1.27] in the sham group on the first postoperative day reported as ratios compared with baseline (P = 0.30). Median (interquartile range) 50% fibrin clot lysis time was 517 (417-660) sec in the RIPC group and 614 (468-779) sec in the sham group (P = 0.25). The postoperative pulmonary embolism rate did not differ between groups (P = 1.0). CONCLUSIONS: RIPC did not influence hemostasis and fibrinolysis in head and neck cancer patients undergoing surgery. RIPC did not reduce the rate of thromboembolic complications.

Intracortical Bone Mechanics Are Related to Pore Morphology and Remodeling in Human Bone.

During aging and in osteoporosis, cortical bone becomes more porous, making it more fragile and susceptible to fractures. The aim of this study was to investigate the intracortical compression- induced strain energy distribution, and determine whether intracortical pores associated with high strain energy density (SED) in the surrounding bone matrix have a different morphology and distribution, as well as different remodeling characteristics than matrix with normal SED. Fibular diaphyseal specimens from 20 patients undergoing a jaw reconstruction (age range 41 to 75 years; 14 men and 6 women) were studied. Bone specimens were µCT-scanned, plastic embedded, and sectioned for histology. Three-dimensional microfinite element models of each specimen were tested in compression, and the SED of the bone immediately surrounding the intracortical pores was calculated within a plane of interest corresponding to the histological sections. The SED of a pore, relative to the distribution of the SED of all pores in each specimen, was used to classify pores as either a high or normal SED pore. Pores with high SED were larger, less circular, and were located closer to the endosteal surface of the cortex than normal SED pores (p < 0.001). Histological analysis of the remodeling events generating the pores revealed that the high SED pores compared with normal SED pores had 13.3-fold higher odds of being an erosive (70%) or formative (7%) pore versus a quiescent pore (p < 0.001), 5.9-fold higher odds of resulting from remodeling upon existing pores (type 2 pore) versus remodeling generating new pores (type 1 pore) (p < 0.001), and 3.2-fold higher odds of being a coalescing type 2 pore versus a noncoalescing type 2 pore (p < 0.001). Overall, the study demonstrates a strong relationship between cortical bone mechanics and pore morphology, distribution, and remodeling characteristics in human fibular bone. © 2018 American Society for Bone and Mineral Research.

Local and systemic coagulation marker response to musculocutaneous flap ischemia-reperfusion injury and remote ischemic conditioning: An experimental study in a porcine model.

BACKGROUND: Remote ischemic conditioning (RIC) administered by non-lethal periods of extremity ischemia and reperfusion attenuates ischemia-reperfusion injury. We aimed to investigate the local and systemic coagulation marker response to flap ischemia-reperfusion injury, and the effects of RIC on coagulation markers following flap ischemia-reperfusion injury. METHODS: A musculocutaneous latissimus dorsi flap was subjected to 4 h of ischemia followed by 7 h of reperfusion in 16 female Danish Landrace pigs (39 kg). Systemic venous blood samples were collected 1 h before flap reperfusion. Flap and systemic venous blood samples were collected at reperfusion and hourly during reperfusion. We measured thrombin generation, fibrinogen, von Willebrand factor, antithrombin, thrombin-antithrombin complex, activated partial thromboplastin time (aPTT), and prothrombin time (PT). RIC was performed 1 h before flap reperfusion in the intervention group by three 10-min periods of hind limb ischemia and reperfusion (n = 8). RIC was not performed in the control group (n = 8). RESULTS: Local and systemic coagulation marker changes were comparable following flap ischemia-reperfusion injury. Flap ischemia-reperfusion injury reduced thrombin generation lag time from 2.0 ± 0.3 to 1.6 ± 0.3 min (P < .001), time-to-peak thrombin from 3.5 ± 0.3 to 3.0 ± 0.5 min (P = .001), peak thrombin from 79.6 ± 8.1 to 74.5 ± 7.1 nM (P = .033), endogenous thrombin potential from 211 ± 24 to 197 ± 19 nM × min (P = .01), antithrombin from 0.91 ± 0.07 to 0.79 ± 0.06 103 IU/l (P = .002), and aPTT from 37 ± 21 to 21 ± 9 s (P = .017). RIC increased peak thrombin (P < .001), endogenous thrombin potential (P < .001), and aPTT (P = .019). CONCLUSIONS: The local coagulation marker response to musculocutaneous flap ischemia-reperfusion could be measured systemically by moderate hypercoagulation. RIC did not substantially influence coagulation markers following musculocutaneous flap ischemia-reperfusion injury.

Remote ischemic perconditioning attenuates acute inflammation of experimental musculocutaneous flaps following ischemia-reperfusion injury.

BACKGROUND: In free flap reconstruction and replantation surgery, prolonged ischemia time may lead to flap or replantation failure. The aim of the study was to investigate the effects of hypothermic flap ischemia or remote ischemic perconditioning (RIPER) during normothermic ischemia on acute inflammation of musculocutaneous flaps subjected to ischemia-reperfusion injury. MATERIALS AND METHODS: In 24 pigs, a musculocutaneous latissimus dorsi flap was dissected and subjected to 4 hours of arterial ischemia and 7 hours of reperfusion. The animals were allocated into two experimental groups: hypothermic flap ischemia at 4°C (n = 8) or normothermic flap ischemia with RIPER (n = 8), and one control group with normothermic flap ischemia (n = 8). The hypothermic ischemic flaps were cooled in a basin with fresh water and ice. RIPER was initiated 1 hour before reperfusion, by inducing three 10 min cycles of hind limb ischemia with a tourniquet, each separated by 10 min of reperfusion. Acute inflammation was described by inflammatory cytokine secretion (IL-1ß, IL-6, IL-10, IL-12p40, and TNF-α) from the flap during reperfusion, and by quantitative determination of macrophages in flap biopsies of dermis, subcutaneous tissue, and skeletal muscle following reperfusion. RESULTS: No significant differences were found between normothermic and hypothermic flap ischemia in inflammatory cytokine secretion. However, the IL-6 secretion was significantly reduced in the RIPER group compared with the control group at 5 hours of reperfusion (P = 0.036), and in the RIPER group compared with the hypothermic ischemia group at 3 (P = 0 0.0063), 5 (P = 0.0026), and 7 hours of reperfusion (P = 0.028). The IL-12p40 secretion was significantly reduced in the RIPER group compared with the control group (P = 0.0054) as well as the hypothermic ischemia group (P = 0.028) at 5 hours of reperfusion. No significant difference was found among groups in macrophage infiltration. CONCLUSION: RIPER reduced IL-6 and IL-12p40 secretion during reperfusion of porcine musculocutaneous flaps, when compared with hypothermic ischemic flaps and normothermic ischemic flaps without RIPER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:148-155, 2017.

[Microsurgery in plastic surgery].

The most common indication for free flap surgery is breast reconstruction. Deep inferior epigastric perforator flaps are safe, quick and provide excellent cosmetic results. The reconstruction in head and neck cancer patients is more complex. The aims are preservation of function and appearance. Free flaps are important in traumatology and the timing of intervention can make the difference between amputation and extremity conserving treatment. Due to the improvement in surgical technique failure rates as low as 2% can be seen. Post-operative monitoring is well-established in all microsurgical centres.

[Microsurgery in reanimation, lymphoedema and hand surgery].

Microsurgery is defined as surgery performed with the aid of ocular magnification. In Denmark, this is undertaken by four units. This review describes the history of microsurgery which evolved during the 1960s. Microsurgery in hand surgery is primarily replantation and revascularisation but also peripheral nerve surgery as well as brachial plexus surgery. Lymphoedema is being treated with super microsurgery on an experimental basis. Dynamic reconstruction of facial palsy is performed in a two-stage operation with cross-over nerve graft and a free microvascular muscle flap, typically gracilis.

Direct comparison of postoperative monitoring of free flaps with microdialysis, implantable cook-swartz Doppler probe, and clinical monitoring in 20 consecutive patients.

BACKGROUND: There is an increasing demand for successful free tissue transfer, with postoperative monitoring of flaps a key to early salvage. Monitoring methods have ranged from clinical techniques to invasive options, of which two are particularly applicable to buried flaps (Cook-Swartz Doppler probe and microdialysis). The evidence for these options has been represented largely in separate cohort studies, with no single study comparing these three techniques. We aim to perform this comparison in a single cohort of patients. METHODS: A prospective, consecutive cohort study comparing clinical monitoring, microdialysis and the implantable Doppler probe was undertaken. In 20 patients receiving 22 flaps, 21 flaps were monitored with microdialysis, 18 flaps with clinical observation, and 21 flaps with the Cook-Swartz Implantable Doppler probe. Exclusion was based on applicability and availability intra-operatively. Efficacy was assessed through sensitivity, specificity, positive, and negative predictive values. RESULTS: Nineteen of 22 flaps had no suspected anastomotic problems; 3 of 22 flaps were explored for anastomotic problems, with two salvaged and one lost. The implantable Doppler and microdialysis were found to detect flap statistically earlier than clinical assessment, with microdialysis better at detecting flap compromise: 100% specificity (confidence interval 31-100%) when compared to the implantable probe and clinical assessment (67%: 13-98% and 33%: 2-87%, respectively). CONCLUSIONS: Each of the Cook-Swartz Doppler probe, microdialysis and clinical assessment was found suitable for monitoring in free tissue transfer. The implantable Doppler and microdialysis offer the potential for earlier detection of flap compromise.