The Color Duplex Ultrasound: The Reconstructive Surgeon's Stethoscope

Over the years of reconstruction, the tools for diagnosis were limited for reconstructive microsurgeons. For decades, the main tools were the knowledge of anatomy, anecdotal experience, and good judgement. In the modern era, the angiogram and computed tomography (CT) angiograms played a key role in proving critical information of the vascular status.[1] With the introduction of handheld Doppler, it further brought understanding of small vessels like perforators, and the simplicity allowed it to be used not only preoperatively but help intraoperative decision-making and postoperative monitoring.[2] The handheld Doppler opened the doors to freestyle flaps where the flap can be designed around any perforator.[3] [4] Now the success rate for free flaps can be from 90 to 99%.[4] [5] Despite the high success rate, microsurgeons continues the endeavor to make flap reconstruction easier, replicable, reliable, and efficient. Thus new diagnostic evaluation tools are constantly being introduced to this field. The thermography and indocyanine green angiography are newly introduced tools that allow us to have better understanding for flap surgery. However, all tools have their pros and cons. When considering the cost, imaging speed, learning curve, perforator imaging, flow physiology, and depth of tissue information, one must determine which imaging modalities are able to provide the best information.[6] In my opinion, color duplex ultrasound (CDU) is a tool that is able to provide the most information with the highest efficiency. Early reports of using CDU have shown its efficacy and precision in identifying various anatomical structures including perforators.[7] [8] [9] Unfortunately, despite early reports, the CDU did not gain wide usage among reconstructive surgeons due to the lack of accessibility.

Now with improved technology and affordability, more surgeons are using CDU for their preoperative, intraoperative, and postoperative procedures. The learning curve for CDU does exit but can be easily learned. Knowing the surgical anatomy, the surgeon can have a detailed understanding of the anatomy under the skin prior to the first incision and also understand the physiology of flow. Now we are evolving from anatomy-based surgery into anatomy + physiology–based surgery. This allows the surgery to be efficient and to minimize complications. I truly believe that CDU is the main tool for reconstructive surgeons as the stethoscope is the symbolic tool for many health care workers. The CDU will be part of the evolution of reconstructive microsurgery until the next breakthrough device is introduced.

Publication History

Received: 02 August 2021

Accepted: 27 August 2021

Article published online:
19 October 2021

• References

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