Postmastectomy breast reconstruction using autologous free tissue transfer is a common procedure in the United Kingdom. In recent times, the trend has been toward technically challenging perforator-based reconstructions such as the deep inferior epigastric perforator flap (DIEP). These flaps provide the aesthetic advantage of autologous tissue while minimizing donor site morbidity. Increasing experience with these procedures and advances in preoperative planning have resulted in some specialized centers publishing flap loss rates of lower than 2% 1-3 however in some series, failure rates are as high as 5 to 20%. 4,5 Flap failures are usually due to pedicle compromise and require urgent re-exploration and re-establishment of inflow and outflow for salvage to occur. It is well established that early detection of compromise leads to a higher salvage rate. To date, the gold standard for detection of a compromised flap remains clinical examination by an experienced practitioner 6 with the use of common bedside tests such as the handheld Keywords ► free flap ► perforator flap ► reconstructive surgery ► monitoring Abstract Free flap monitoring is essential to the early detection of compromise thereby increasing the chance of successful salvage surgery. Many alternatives to classical clinical monitoring have been proposed. This study seeks to investigate a relatively new monitoring technology: near infrared spectroscopy (NIRS). Patients were recruited prospectively to the study from a single center. During the research period, 10 patients underwent reconstruction with a free deep inferior epigastric perforator flap (DIEP). Measurements of flap perfusion were taken using NIRS in the preoperative and intraoperative phases and postoperatively for 72 hours. NIRS showed characteristic changes in all cases which returned to theater for pedicle compromise. In these cases, NIRS identified pedicle compromise prior to clinical identification. There were no falsepositives. NIRS accurately identified all compromised flaps in our study. In most cases, there was an evidence of changes in oxygen saturation on NIRS prior to clinical observation. Further research, ideally double blind randomized control trials with large sample groups would be required to definitively establish NIRS as an ideal flap monitoring modality.
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