Purpose: We evaluated the outcomes for widely used systems in terms of accuracy, salvage rates, and added cost compared to conventional monitoring. Methods: We performed a narrative review of the literature (high-impact report). Results: The overall free flap success for head and neck reconstruction is at least 95% using any type of monitoring. Salvage rates in decreasing frequency of monitoring techniques are 85% with near-infrared spectroscopy (NIRS), 81% with implantable Doppler, and 61.5% with conventional monitoring. False-positive rates in increasing frequency are 0% for NIRS, 0.4% for conventional monitoring, and <10% for implantable Doppler. Current data show implantable Doppler to be potentially cost-effective for institutions with a failure rate of at least 6%. Buried flaps may be monitored with conventional monitoring using an exteriorized paddle, or using implantable Doppler. Conclusions: The cost-effectiveness of advanced flap monitoring systems beyond conventional monitoring is related to the success rate of each institution. Cost-effectiveness studies are necessary to determine at what point NIRS becomes advantageous.

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