Free flap operations average 6 to 12 hours, a length that weighs on patients, surgeons, and the residents who learn from these cases.
Dr. Arriyan Dowlatshahi, known as ‘Dr. Sammy,’ is director of the Orthoplastic and Reconstructive Microsurgery Service and co-director of the Limb Preservation Center at Beth Israel Deaconess Medical Center in Boston, Massachusetts. He spoke in the panel ‘Seeing is believing: ultrasound in reconstruction’ at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS). The meeting was held October 15 to 18, 2026, in Houston, Texas. He explained how surgeon-performed ultrasound has shortened his free flap operations and changed how he plans them.
‘Something that we don't talk about a lot is how the ultrasound really unlocks efficiency in the OR and also lowers stress,’ Dr. Dowlatshahi said. A free flap should take about 2 hours, he noted, and long operations are ‘bad for patients.’ They burn surgeons out, and residents do not want cases that take all day. Of all the changes he made, ultrasound did the most, cutting his own free flap operations from around 6 hours to around 2.
Scanning the Recipient Site First Changes the Free Flap Plan
Dr. Dowlatshahi follows 3 rules: find and confirm vessels with the probe, scan the recipient site before the donor site, and mark the patient in the operating position, because tissue shifts as the body moves. The second rule matters most. He looks first for the target vessel, the nerves he may connect to the flap, and the veins. ‘Don't forget the veins,’ he said. ‘We are always so obsessed about the arteries.’
Scanning from the wound toward the vessel's origin, he finds the point where the vessel becomes healthy. That spot becomes the connection site, and its distance from the wound tells him how far the flap's vessels must reach. In one patient, the surgeons previously consulted had planned a muscle flap. His scan instead found a lateral calcaneal vein with good flow, which he marked as the recipient vessel, with other veins marked as backups.
Bedside Vein Measurement Sets the Baseline for Free Flap Planning
He measures the veins while the patient is awake. ‘The pre-op measurement is the only time you're going to see the vein in its physiologic state,’ he said. Once the patient is asleep, anesthesia, tourniquets, and spasm all change how the vein looks. The bedside measurement decides which vein he uses.
He also performs these scans himself. ‘A vascular tech reads for disease; I read for a target,’ he said. For revascularization in the hand, the targets are too small and the flow too slow to plan any other way.
Each of these steps moves a decision out of the operating room and into the clinic, where Dr. Dowlatshahi can make it with the patient awake and the vessels in their natural state.