Volume 135 Number 2 • Letters Reply: The First Smartphone Application for Microsurgery Monitoring: SilpaRamanitor Sir:
Thank you for your letter and constructive comments, which we read carefully. We feel that we ought to clarify some of the points raised. In reply to your questions,1 it is logical to assume that as the comparison field does not include the whole flap skin surface area, the smartphone application (SilpaRamanitor) could not assess the viability of every part of tissue in the flap. Even if the whole flap skin surface was observed, partial flap necrosis could occur in deeper tissues without obvious skin color changes (e.g., fat necrosis in deep inferior epigastric artery perforator flaps). Monitoring part of a flap to pick up an acute perfusion problem is far from being a new concept. In the same way, monitoring skin paddles are regularly used to observe for flap viability representing, to a degree, the health of the majority of flap tissue.2 Furthermore, an overall compromised flap, which is what the SilpaRamanitor observes for, could potentially be rectified by means of a prompt reexploration and reanastomosis. In contrast, a partial flap viability problem most often represents an inherent problem with flap vascular architecture and signifies problems in flap design and raising, which are difficult to rectify in retrospect.3 If, despite the above, it is felt that the skin area monitored is small, multiple areas could be monitored in parallel for each flap. These could include an area in the proximity of the perforator and another at greater risk of partial vascular compromise, such as at the periphery of the flap. If the application indicates that both areas are compromised, that would represent a total flap viability problem, requiring urgent reexploration. However, if the skin around the perforator is judged to be normal and the peripheral skin is compromised, this could indicate an intraflap architecture problem, which is unlikely to benefit from anastomotic revision. Expert analysis is the mainstay of flap monitoring currently in our institute, as the validation study for our application is still in progress. Our current protocol includes clinical monitoring by nurses and plastic surgery residents, combined with photography of the flap together with SilpaRamanitor detection1 and report to the responsible consultant surgeon. Eventually, it is hoped that the application technology will be able to replace expert analysis on site, thus reducing the requirement for highly experienced, trained, expensive nursing and medical staff to be continuously present. It is envisaged that SilpaRamanitor is to be used regularly by a ward nurse, and in the event that vascular compromise is diagnosed, expert staff will be called on to reevaluate the patient and make the clinical decision for return to the operating room. There are strong indications from our current clinical practice that the device is superior to experienced staff in spotting subtle changes in skin color and thus vascular compromise and can expedite return to the operating room, thus increasing salvage rates. We are currently
evaluating the system formally through a clinical trial, the results of which will be published shortly, together with a cost-effectiveness study, as kindly suggested. DOI: 10.1097/PRS.0000000000000925
Kidakorn Kiranantawat, M.D. Division of Plastic and Maxillofacial Surgery Department of Surgery Ramathibodi Hospital Mahidol University Bangkok, Thailand
Joannis Constantinides, M.D. Department of Plastic Surgery St Thomas’ Hospital London, United Kingdom
Stamatis Sapountzis, M.D. China Medical University Hospital Taichung, Taiwan
Ngamcherd Sitpahul, M.D. Division of Plastic and Maxillofacial Surgery Department of Surgery Ramathibodi Hospital Mahidol University Bangkok, Thailand Correspondence to Dr. Kiranantawat Division of Plastic and Maxillofacial Surgery Department of Surgery Faculty of Medicine Ramathibodi Hospital Mahidol University Rama 6 Road Ratchathewi, Bangkok, Thailand [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kiranantawat K, Sitpahul N, Taeprasartsit P, et al. The first Smartphone application for microsurgery monitoring: SilpaRamanitor. Plast Reconstr Surg. 2014;134:130–139. 2. Kim SC, Kim EK. Externalized monitoring of totally buried free flap in hypopharyngeal reconstruction. J Craniofac Surg. 2013;24:575–578. 3. Hallock GG. Partial failure of a perforator free flap can be salvaged by a second perforator free flap. Microsurgery 2014;34:177–182.
Analysis of Risk Factors, Morbidity, and Cost Associated with Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing risk factors of 30-day mortality following plastic and reconstructive surgery, they showed that age older than
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Thank you for your letter and constructive comments, which we read carefully. We feel that we ought to clarify some of the points raised. In reply to your questions,1 it is logical to assume that as the comparison field does not include the whole flap skin surface area, the smartphone application (SilpaRamanitor) could not assess the viability of every part of tissue in the flap. Even if the whole flap skin surface was observed, partial flap necrosis could occur in deeper tissues without obvious skin color changes (e.g., fat necrosis in deep inferior epigastric artery perforator flaps). Monitoring part of a flap to pick up an acute perfusion problem is far from being a new concept. In the same way, monitoring skin paddles are regularly used to observe for flap viability representing, to a degree, the health of the majority of flap tissue.2 Furthermore, an overall compromised flap, which is what the SilpaRamanitor observes for, could potentially be rectified by means of a prompt reexploration and reanastomosis. In contrast, a partial flap viability problem most often represents an inherent problem with flap vascular architecture and signifies problems in flap design and raising, which are difficult to rectify in retrospect.3 If, despite the above, it is felt that the skin area monitored is small, multiple areas could be monitored in parallel for each flap. These could include an area in the proximity of the perforator and another at greater risk of partial vascular compromise, such as at the periphery of the flap. If the application indicates that both areas are compromised, that would represent a total flap viability problem, requiring urgent reexploration. However, if the skin around the perforator is judged to be normal and the peripheral skin is compromised, this could indicate an intraflap architecture problem, which is unlikely to benefit from anastomotic revision. Expert analysis is the mainstay of flap monitoring currently in our institute, as the validation study for our application is still in progress. Our current protocol includes clinical monitoring by nurses and plastic surgery residents, combined with photography of the flap together with SilpaRamanitor detection1 and report to the responsible consultant surgeon. Eventually, it is hoped that the application technology will be able to replace expert analysis on site, thus reducing the requirement for highly experienced, trained, expensive nursing and medical staff to be continuously present. It is envisaged that SilpaRamanitor is to be used regularly by a ward nurse, and in the event that vascular compromise is diagnosed, expert staff will be called on to reevaluate the patient and make the clinical decision for return to the operating room. There are strong indications from our current clinical practice that the device is superior to experienced staff in spotting subtle changes in skin color and thus vascular compromise and can expedite return to the operating room, thus increasing salvage rates. We are currently
evaluating the system formally through a clinical trial, the results of which will be published shortly, together with a cost-effectiveness study, as kindly suggested. DOI: 10.1097/PRS.0000000000000925
Kidakorn Kiranantawat, M.D. Division of Plastic and Maxillofacial Surgery Department of Surgery Ramathibodi Hospital Mahidol University Bangkok, Thailand
Joannis Constantinides, M.D. Department of Plastic Surgery St Thomas’ Hospital London, United Kingdom
Stamatis Sapountzis, M.D. China Medical University Hospital Taichung, Taiwan
Ngamcherd Sitpahul, M.D. Division of Plastic and Maxillofacial Surgery Department of Surgery Ramathibodi Hospital Mahidol University Bangkok, Thailand Correspondence to Dr. Kiranantawat Division of Plastic and Maxillofacial Surgery Department of Surgery Faculty of Medicine Ramathibodi Hospital Mahidol University Rama 6 Road Ratchathewi, Bangkok, Thailand [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kiranantawat K, Sitpahul N, Taeprasartsit P, et al. The first Smartphone application for microsurgery monitoring: SilpaRamanitor. Plast Reconstr Surg. 2014;134:130–139. 2. Kim SC, Kim EK. Externalized monitoring of totally buried free flap in hypopharyngeal reconstruction. J Craniofac Surg. 2013;24:575–578. 3. Hallock GG. Partial failure of a perforator free flap can be salvaged by a second perforator free flap. Microsurgery 2014;34:177–182.
Analysis of Risk Factors, Morbidity, and Cost Associated with Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing risk factors of 30-day mortality following plastic and reconstructive surgery, they showed that age older than
I
459e
