Sutured attachment of the implantable Doppler probe cuff for large or complex pedicles in free tissue transfer

The Cook-Swartz implantable Doppler probe (Cook Medical(®), Cook Ireland Ltd., Limerick, Ireland) has evolved as a useful option for postoperative free flap monitoring. For placement, the probe either is left unattached around the venous pedicle or is secured. In our experience with over 300 applications, we typically secure the cuff with two small microclips, or use fibrin glue. These techniques require redundant silicone cuff for apposition; however, we have encountered some vessels that are of sufficiently large diameter as to not provide enough cuff to employ these methods. The first technique comprises the application of two interrupted sutures through the cuff ends to mimic the technique of microclips. The sutures can be tightened to the desired tension and can be used in cases where the cuff ends are not in direct apposition. A second technique is to excise a segment of silicone cuff and either clip or suture the excised segment to the cuff ends, effectively elongating the cuff diameter. All four techniques (nonattachment, microclip fixation, suture fixation, silicone cuff elongation) have been used effectively, and none have resulted in any complications. Of note, the technique of nonattachment was associated with an increased rate of false-positive results, as migration away from the vessel was postulated to have occurred. There are a range of techniques for attachment of the implantable Doppler probe, and each contributes to the range of options for cuff attachment in difficult cases, with each technique worthwhile in particular settings.