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Kleiss SF, Michi M, Schuurman SN, de Vries JPP, Werker PM, de Jongh SJ. Tissue perfusion in DIEP flaps using Indocyanine Green Fluorescence Angiography, Hyperspectral imaging, and Thermal imaging. JPRAS Open 2024; 41:61-74. [PMID: 38948075 PMCID: PMC11214344 DOI: 10.1016/j.jpra.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/02/2024] Open
Abstract
Flap necrosis continues to occur in skin free flap autologous breast reconstruction. Therefore, we investigated the benefits of indocyanine green angiography (ICGA) using quantitative parameters for the objective, perioperative evaluation of flap perfusion. In addition, we investigated the feasibility of hyperspectral (HSI) and thermal imaging (TI) for postoperative flap monitoring. A single-center, prospective observational study was performed on 15 patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction (n=21). DIEP-flap perfusion was evaluated using ICGA, HSI, and TI using a standardized imaging protocol. The ICGA perfusion curves and derived parameters, HSI extracted oxyhemoglobin (oxyHb) and deoxyhemoglobin (deoxyHb) values, and flap temperatures from TI were analyzed and correlated to the clinical outcomes. Post-hoc quantitative analysis of intraoperatively collected data of ICGA application accurately distinguished between adequately and insufficiently perfused DIEP flaps. ICG perfusion curves identified the lack of arterial inflow (n=2) and occlusion of the venous outflow (n=1). In addition, a postoperatively detected partial flap epidermolysis could have been predicted based on intraoperative quantitative ICGA data. During postoperative monitoring, HSI was used to identify impaired perfusion areas within the DIEP flap based on deoxyHb levels. The results of this study showed a limited added value of TI. Quantitative, post-hoc analysis of ICGA data produced objective and reproducible parameters that enabled the intraoperative detection of arterial and venous congested DIEP flaps. HSI appeared to be a promising technique for postoperative flap perfusion assessment. A diagnostic accuracy study is needed to investigate ICGA and HSI parameters in real-time and demonstrate their clinical benefit.
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Affiliation(s)
- Simone F. Kleiss
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Marlies Michi
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Simone N. Schuurman
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean-Paul P.M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M.N. Werker
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J. de Jongh
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Zhang Y, Shi J, Zhang Z, Gupta A, Xiao M, Wang L. Mandibular reconstruction using an iliac bone flap with perforator-supported external oblique abdominal muscle island: a pilot study. Int J Oral Maxillofac Surg 2024; 53:644-649. [PMID: 38185542 DOI: 10.1016/j.ijom.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
The deep circumflex iliac artery (DCIA) flap is one of the bone flaps commonly used for mandibular reconstruction. Observation of the skin paddle and Doppler ultrasound are methods that are usually used to monitor DCIA flaps after mandibular reconstruction surgery. The aim of this study was to introduce a novel DCIA flap with a perforator-supported external oblique abdominal muscle (EOAM) island for postoperative flap monitoring. This study included five patients who underwent mandibular reconstruction using this modified technique. The DCIA flap and the EOAM island supplied by the ascending branch of the DCIA were harvested during the surgery. After mandibular reconstruction, the EOAM island was placed in the submandibular region to monitor the blood supply to the DCIA flap after surgery. The blood supply to the DCIA flap was monitored by observing the colour, texture, and bleeding condition of the EOAM island. After the monitoring period, the EOAM was removed and the ascending branch of the DCIA was ligated. The outcome was successful in all patients. The EOAM island supported by the ascending branch of the DCIA is reliable and safe, thus providing a robust option to monitor the blood supply to the DCIA flap.
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Affiliation(s)
- Y Zhang
- Department of Oral and Maxillofacial Surgery - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J Shi
- Department of Oral and Maxillofacial Surgery - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Z Zhang
- Department of Oral and Maxillofacial Surgery - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - A Gupta
- Department of Dentistry, Government Medical College and Hospital, Chandigarh, India
| | - M Xiao
- Department of Oral and Maxillofacial Surgery - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - L Wang
- Department of Oral and Maxillofacial Surgery - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Stomatology, Fengcheng Hospital, Fengxian District, Shanghai, China.
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Minkhorst K, Castanov V, Li EA, Farrokhi K, Jaszkul KM, AlGhanim K, DeLyzer T, Simpson AM. Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction. Ann Plast Surg 2024; 92:703-710. [PMID: 38768024 DOI: 10.1097/sap.0000000000003916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.
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Affiliation(s)
| | - Valera Castanov
- Division of Plastic and Reconstructive Surgery, Western University, London, Ontario, Canada
| | - Erica Ai Li
- From the Schulich School of Medicine, Western University, London
| | - Kaveh Farrokhi
- From the Schulich School of Medicine, Western University, London
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Lin YE, Chen MC. Dextran-40 Reduces Partial Flap Failure: A Systematic Review and Meta-analysis for Antithrombotics after Free Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5812. [PMID: 38752217 PMCID: PMC11095965 DOI: 10.1097/gox.0000000000005812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/22/2024] [Indexed: 05/18/2024]
Abstract
Background Antithrombotic agents are used after free-flap surgery to prevent thrombus formation and improve flap outcomes. However, the reports vary. Therefore, this meta-analysis aimed to elucidate the need for antithrombotic agents in this context. Methods We searched for studies that compared the outcomes of patients undergoing free-flap surgery with or without postoperative antithrombotic agents in the PubMed, Cochrane, and ClinicalTrials.gov databases. The primary outcome was total flap failure, with secondary outcomes including partial flap failure, pedicle thrombosis, and bleeding/hematoma. The relative risks (RRs) of outcomes with or without antithrombotic use were evaluated. Results Fifteen studies (n = 6755 cases) were included. Antithrombotic agents did not reduce flap failure or pedicle thrombosis risks but increased bleeding and hematoma risks (RR, 1.535). Subgroup analyses by antiplatelet and anticoagulant use demonstrated results similar to those of antithrombotic use. The RR of bleeding/hematoma was 1.761 and 2.740 in the antiplatelet and anticoagulant groups, respectively. Postoperative dextran-40 administration reduced the risk of partial flap failure, with an RR of 0.535. Conclusions Postoperative antithrombotic, antiplatelet, or anticoagulant use did not change the risk of total/partial flap failure or pedicle thrombosis but increased the risk of hematoma/bleeding. Postoperative use of dextran-40 reduced the risk of partial flap failure. Increased intraflap blood flow may decrease the risk of partial flap failure. However, dextran-40 may cause severe pulmonary distress. Further prospective studies are required to evaluate the effects of these agents on thrombus formation, intraflap blood flow, and partial flap failure risk.
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Affiliation(s)
- Yi-En Lin
- From Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Chun Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Tratnig-Frankl P, Andrews AR, Berkane Y, Guinier C, Goutard M, Lupon E, Lancia HH, Morrison ML, Roth MB, Randolph MA, Cetrulo CL, Lellouch AG. Exploring Iodide and Hydrogen Sulfide as ROS Scavengers to Delay Acute Rejection in MHC-Defined Vascularized Composite Allografts. Antioxidants (Basel) 2024; 13:531. [PMID: 38790636 PMCID: PMC11118872 DOI: 10.3390/antiox13050531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Vascularized composite allografts (VCA) face ischemic challenges due to their limited availability. Reperfusion following ischemia triggers oxidative stress and immune reactions, and scavenger molecules could mitigate ischemia-reperfusion injuries and, therefore, immune rejection. We compared two scavengers in a myocutaneous flap VCA model. In total, 18 myocutaneous flap transplants were performed in Major histocompatibility complex (MHC)-defined miniature swine. In the MATCH group (n = 9), donors and recipients had minor antigen mismatch, while the animals were fully mismatched in the MISMATCH group (n = 9). Grafts were pretreated with saline, sodium iodide (NaI), or hydrogen sulfide (H2S), stored at 4 °C for 3 h, and then transplanted. Flaps were monitored until clinical rejection without immunosuppression. In the MATCH group, flap survival did not significantly differ between the saline and hydrogen sulfide treatments (p = 0.483) but was reduced with the sodium iodide treatment (p = 0.007). In the MISMATCH group, survival was similar between the saline and hydrogen sulfide treatments (p = 0.483) but decreased with the sodium iodide treatment (p = 0.007). Rhabdomyolysis markers showed lower but non-significant levels in the experimental subgroups for both the MATCH and MISMATCH animals. This study provides insightful data for the field of antioxidant-based approaches in VCA and transplantation.
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Affiliation(s)
- Philipp Tratnig-Frankl
- Division of Plastic, Reconstructive and Aesthetic Surgery, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria;
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Alec R. Andrews
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Yanis Berkane
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU de Rennes, University of Rennes, 35000 Rennes, France
| | - Claire Guinier
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
- Department of Plastic Surgery, NOVO Hospital, 95300 Pontoise, France
| | - Marion Goutard
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Elise Lupon
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
- Department of Plastic and Reconstructive Surgery, Institut Universitaire Locomoteur et du Sport, Pasteur 2 Hospital, University Côte d’Azur, 06300 Nice, France
| | - Hyshem H. Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Michael L. Morrison
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.L.M.); (M.B.R.)
| | - Mark B. Roth
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.L.M.); (M.B.R.)
| | - Mark A. Randolph
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Curtis L. Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Alexandre G. Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; (A.R.A.); (C.G.); (M.G.); (E.L.); (H.H.L.); (M.A.R.); (A.G.L.)
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Children’s Boston, Boston, MA 02114, USA
- INSERM UMRS 1140 Innovation Thérapeutique en Hémostase, University of Paris, 75006 Paris, France
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Sorotos M, Firmani G, Tornambene R, Marrella D, Paolini G, Santanelli di Pompeo F. DIEP flap perfusion assessment using microdialysis versus Doppler ultrasonography: A comparative study. Microsurgery 2024; 44:e31097. [PMID: 37538001 DOI: 10.1002/micr.31097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/03/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The increasing number of buried free-tissue transfer procedures and the need for an objective method to evaluate vascular complications of free flaps has led to the development of new technologies. Microdialysis has been used to monitor free flaps using interstitial biological markers. Previous uses mainly focused on muscular flaps. Our aim is to compare external Doppler ultrasonography (EDU) evaluation versus microdialysis in the early follow-up of adipocutaneous flaps, and propose an efficient postoperative monitoring protocol. METHODS We retrospectively assessed 68 consecutive DIEP flaps (50 patients) performed between January 2019 and March 2021. All flaps received standardized post-operative monitoring using clinical signs, EDU and microdialysis. Glucose and lactate concentrations were assessed using glucose <1 mmol/L and lactate >6 mmol/L as ischemic trend thresholds. We calculated Glucose/Lactate ratio as a new parameter for the assessment of flap viability. RESULTS Among all the 68 flaps, two flaps returned to the operative theater when a combination of unsatisfactory microdialysis values and clinical/EDU signs identified vascular impairment; only one developed total flap necrosis. Reoperation rate was 2.94% with an overall flap success rate of 98.53%. External Doppler ultrasonography had 100% sensitivity and 82% specificity, while microdialysis had 100% sensitivity and 100% specificity. CONCLUSIONS Microdialysis values proved flap viability sooner than external Doppler ultrasonography, making it an excellent tool for post-operative monitoring. With the appropriate thresholds for glucose and lactate concentrations, and glucose/lactate ratio used as a new parameter, it can help potentially avoiding unnecessary re-explorations, and reducing flap ischemia times.
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Affiliation(s)
- Michail Sorotos
- Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Guido Firmani
- Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Roberta Tornambene
- Department of Human Pathology, Division and Residency Program in Plastic, Reconstructive and Aesthetic Surgery, University of Messina, Messina, Italy
| | - Domenico Marrella
- Department of Human Pathology, Division and Residency Program in Plastic, Reconstructive and Aesthetic Surgery, University of Messina, Messina, Italy
| | - Guido Paolini
- Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
| | - Fabio Santanelli di Pompeo
- Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
- Chair of Plastic Surgery, Faculty of Medicine and Psychology, Sapienza University of Rome - Sant'Andrea Hospital, Rome, Italy
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Youkharibache A, Ramelli E, Pavon G, Atlan M, Letourneur D, Cristofari S. [Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]. ANN CHIR PLAST ESTH 2024; 69:34-41. [PMID: 36966098 DOI: 10.1016/j.anplas.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/20/2023] [Indexed: 03/27/2023]
Abstract
INTRODUCTION Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM. MATERIAL AND METHODS All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded. RESULTS Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM. CONCLUSION PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.
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Affiliation(s)
- A Youkharibache
- Department of Plastic Surgery, Sorbonne University and inserm 1148, LVTS, Bichat Hospital, Paris, France.
| | - E Ramelli
- Department of Plastic Surgery, Sorbonne University, Paris, France.
| | - G Pavon
- INSERM 1148, LVTS, Bichat Hospital, Paris City University, Paris, France.
| | - M Atlan
- Department of Plastic Surgery, Sorbonne University and inserm 1148, LVTS, Bichat Hospital, Paris, France.
| | - D Letourneur
- Inserm 1148, LVTS, Bichat Hospital, Paris City University, Paris, France.
| | - S Cristofari
- Department of Plastic Surgery, Sorbonne University and inserm 1148, LVTS, Bichat Hospital, Paris, France.
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Ooms M, Winnand P, Heitzer M, Peters F, Sophie Katz M, Bickenbach J, Hölzle F, Modabber A. Free Flap Perfusion in Microvascular Head and Neck Reconstruction: Influence of the Number of Ischemia Intervals and Ischemia Duration-A Retrospective Study. J Otolaryngol Head Neck Surg 2024; 53:19160216241265089. [PMID: 39077923 PMCID: PMC11289802 DOI: 10.1177/19160216241265089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/27/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion. METHODS Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration. RESULTS Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis. CONCLUSIONS The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
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9
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Ooms M, Winnand P, Heitzer M, Peters F, Bock A, Katz M, Hölzle F, Modabber A. Flap perfusion monitoring with an attached surface probe in microvascular reconstruction of the oral cavity. Clin Oral Investig 2023; 27:5577-5585. [PMID: 37522990 PMCID: PMC10492739 DOI: 10.1007/s00784-023-05177-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Postoperative flap monitoring is essential in oral microvascular reconstruction for timely detection of vascular compromise. This study investigated the use of attached surface probes for the oxygen-2-see (O2C) analysis system (LEA Medizintechnik, Germany) for intraoral flap perfusion monitoring. MATERIALS AND METHODS The study included 30 patients who underwent oral reconstruction with a microvascular radial-free forearm flap (RFFF) or anterolateral thigh flap (ALTF) between 2020 and 2022. Flap perfusion was measured with attached (3-mm measurement depth) and unattached surface probes (2- and 8-mm measurement depths) for the O2C analysis system at 0, 12, 24, 36, and 48 h postoperatively. Flap perfusion monitoring with attached surface probes was evaluated for cut-off values for flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation indicative of vascular compromise and for accuracy and concordance with unattached surface probes. RESULTS Three RFFFs were successfully revised, and one ALTF was unsuccessfully revised. The cut-off values indicative of vascular compromise for flap perfusion monitoring with attached surface probes were for RFFF and ALTF: blood flow < 60 arbitrary units (AU) and < 40AU, hemoglobin concentration > 100AU and > 80AU (both > 10% increase), and hemoglobin oxygen saturation < 40% and < 30%. Flap perfusion monitoring with attached surface probes yielded a 97.1% accuracy and a Cohen's kappa of 0.653 (p < 0.001). CONCLUSIONS Flap perfusion monitoring with attached surface probes for the O2C analysis system detected vascular compromise accurately and concordantly with unattached surface probes. CLINICAL RELEVANCE Attached surface probes for the O2C analysis system are a feasible option for intraoral flap perfusion monitoring.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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10
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Li J, Li Y, Wang X, Xie Y, Lou J, Yang Y, Jiang S, Ye M, Chen H, Diao W, Xu S. Pinocembrin alleviates pyroptosis and apoptosis through ROS elimination in random skin flaps via activation of SIRT3. Phytother Res 2023; 37:4059-4075. [PMID: 37150741 DOI: 10.1002/ptr.7864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 05/09/2023]
Abstract
Random skin flap grafting is the most common skin grafting technique in reconstructive surgery. Despite progress in techniques, the incidence of distal flap necrosis still exceeds 3%, which limits its use in clinical practice. Current methods for treating distal flap necrosis are still lacking. Pinocembrin (Pino) can inhibit reactive oxygen species (ROS) and cell death in a variety of diseases, such as cardiovascular diseases, but the role of Pino in random flaps has not been explored. Therefore, we explore how Pino can enhance flap survival and its specific upstream mechanisms via macroscopic examination, Doppler, immunohistochemistry, and western blot. The results suggested that Pino can enhance the viability of random flaps by inhibiting ROS, pyroptosis and apoptosis. The above effects were reversed by co-administration of Pino with adeno-associated virus-silencing information regulator 2 homolog 3 (SIRT3) shRNA, proving the beneficial effect of Pino on the flaps relied on SIRT3. In addition, we also found that Pino up-regulates SIRT3 expression by activating the AMP-activated protein kinase (AMPK) pathway. This study proved that Pino can improve random flap viability by eliminating ROS, and ROS-induced cell death through the activation of SIRT3, which are triggered by the AMPK/PGC-1α signaling pathway.
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Affiliation(s)
- Jiafeng Li
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yifan Li
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuanwei Wang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yamin Xie
- Department of Service Quality Management, Sanmen People's Hospital, Taizhou, China
| | - Junsheng Lou
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yute Yang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuai Jiang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Meihan Ye
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huaizhi Chen
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weiyi Diao
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sanzhong Xu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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11
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Kawai K, Fujiwara T, Nishimoto S, Ishise H, Saito T, Nakajima K, Kubo T, Kakibuchi M. Surgical Correction of Nipple Hypertrophy after Nipple-sparing Mastectomy with Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5134. [PMID: 37465282 PMCID: PMC10351939 DOI: 10.1097/gox.0000000000005134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/07/2023] [Indexed: 07/20/2023]
Abstract
Nipple hypertrophy is a relatively common phenomenon, particularly in the Asian patient population. The incidence and prevalence or cause of nipple hypertrophy are not well defined in the literature. As survival rates for breast cancer patients continue to improve, there is an increasing emphasis on enhancing their quality of life. Treatment options, such as lumpectomy and radiation therapy or mastectomy, now prioritize preservation of the nipple-areolar complex (NAC) through techniques like nipple-sparing mastectomy (NSM). This approach has been shown to improve patient satisfaction and quality of life. However, it is important to note that NSM is associated with certain complications, including NAC necrosis, malposition, and local recurrence of the tumor. Among those complications, nipple hypertrophy is quite rare. In this report, we present a case of nipple hypertrophy that developed after breast reconstruction, using autologous tissue. The patient, a 48-year-old woman, underwent NSM for breast cancer, and had a tissue expander placed simultaneously. Following tissue expansion, breast reconstruction with a deep inferior epigastric perforator (DIEP) flap was performed. However, during the tissue expansion phase, the patient's nipple gradually enlarged, and the protrusion became more pronounced after the DIEP flap transfer. Nipple reduction surgery was subsequently performed for both diagnostic and cosmetic purposes. We present this case along with a review of relevant literature.
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Affiliation(s)
- Kenichiro Kawai
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Toshihiro Fujiwara
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Soh Nishimoto
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hisako Ishise
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Takuya Saito
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Koyo Nakajima
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masao Kakibuchi
- From the Department of Plastic Surgery, Hyogo Medical University, Nishinomiya, Japan
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12
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Wang Y, Li X, Lv H, Sun L, Liu B, Zhang X, Xu X. Therapeutic potential of naringin in improving the survival rate of skin flap: A review. Front Pharmacol 2023; 14:1128147. [PMID: 36937856 PMCID: PMC10017745 DOI: 10.3389/fphar.2023.1128147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Naringin is the main component of Drynaria. Modern pharmacological studies have shown that naringin has a wide range of pharmacological activities, including antioxidant, anti-inflammatory, anti-apoptotic, anti-ulcer, and anti-osteoporosis effects. Its therapeutic effects have been observed in various clinical models, such as atherosclerosis, cardiovascular diseases, diabetes, neurodegenerative diseases, and rheumatic diseases. This review investigates the pharmacological effects of naringin and the associated mechanisms in improving flap survival. This review will also provide a reference for future rational application of naringin, especially in research to improve flap survival.
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Affiliation(s)
- Yincang Wang
- Heilongjiang University of Chinese Medicine, Harbin, China
| | - Xiaodong Li
- The Third Department of Orthopedics and Traumatology, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
| | - Hang Lv
- The Third Department of Orthopedics and Traumatology, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
| | - Lin Sun
- Heilongjiang University of Chinese Medicine, Harbin, China
| | - Bo Liu
- Heilongjiang University of Chinese Medicine, Harbin, China
| | - Xiaofeng Zhang
- Teaching and Research Section of Orthopedics and Traumatology, Heilongjiang University of Chinese Medicine, Harbin, China
- *Correspondence: Xiaofeng Zhang, ; Xilin Xu,
| | - Xilin Xu
- The Third Department of Orthopedics and Traumatology, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
- *Correspondence: Xiaofeng Zhang, ; Xilin Xu,
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13
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Odorico SK, Reuter Muñoz K, J Nicksic P, Gunderson KA, Wood K, H Nkana Z, Bond E, Poore SO. Surgical and demographic predictors of free flap salvage after takeback: A systematic review. Microsurgery 2023; 43:78-88. [PMID: 35611652 PMCID: PMC10084419 DOI: 10.1002/micr.30921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/21/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage. METHODS A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis. RESULTS The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure. CONCLUSIONS Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.
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Affiliation(s)
- Scott K Odorico
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Katie Reuter Muñoz
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter J Nicksic
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kirsten A Gunderson
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kasey Wood
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Zeeda H Nkana
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Evalina Bond
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Samuel O Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
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14
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Horner VK, Schneider LA, Leibig N, Zeller J, Kiefer J, Eisenhardt SU. An Analysis of the Implantable Doppler Probe for Postoperative Free-Flap Monitoring and Risk Factor Analysis for Revision Surgery in Facial Reanimation Surgery. Facial Plast Surg Aesthet Med 2022; 24:345-351. [DOI: 10.1089/fpsam.2021.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Verena K. Horner
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Laura A. Schneider
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nico Leibig
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Zeller
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen U. Eisenhardt
- Department of Plastic and Hand Surgery, Medical Center—the University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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15
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Li Y, Liu H, Zeng Z, Lin H, Chen X, Yuan X, Qiu J, Fu F, Chen Z, Kuang J. Ginsenoside Rb3 attenuates skin flap ischemia-reperfusion damage by inhibiting STING-IRF3 signaling. J Mol Histol 2022; 53:763-772. [PMID: 35732862 DOI: 10.1007/s10735-022-10081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
We investigate the protective effect of ginsenoside Rb3 on skin flap microvasculature following ischemia-reperfusion (I/R) injury and its regulatory mechanism. We used a rat model of I/R injury with the right iliolumbar artery and oxidative stress model of human dermal microvascular endothelial cells. The effects of Rb3 on skin flap tissue and endothelial cell survival, STING-IRF3 pathway activation, and endothelial cell adhesion were measured. Following reperfusion, the survival rate of rat perforator flaps in the Rb3-treated group gradually increased with increasing Rb3 concentration. The treatment also reduced the amount of STING protein, phosphorylated IRF3, and P-selectin in skin flap tissue, with this change being most obvious in microvascular endothelial cells. In vitro, activated IRF3 binds to the P-selectin promoter and induces P-selectin expression. Our results suggest that Rb3 plays a role in reducing I/R flap damage through negatively regulating STING-IRF3 activation to limit leukocyte-endothelial cell adhesion.
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Affiliation(s)
- Yuanbin Li
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Haifen Liu
- Department of Radiology, Hunan Provincial Hospital of Traditional Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Zhaohui Zeng
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Hui Lin
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Xin Chen
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Xianglian Yuan
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Jizhe Qiu
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Fengchun Fu
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
| | - Zhuang Chen
- Department of Medicine, Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China.
| | - Jianjun Kuang
- Department of Science and Technology, Hunan Academy of Chinese Medicine, Changsha, 410000, Hunan, China.
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16
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Weinzierl A, Ampofo E, Menger MD, Laschke MW. Tissue-Protective Mechanisms of Bioactive Phytochemicals in Flap Surgery. Front Pharmacol 2022; 13:864351. [PMID: 35548348 PMCID: PMC9081973 DOI: 10.3389/fphar.2022.864351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/24/2022] [Indexed: 11/21/2022] Open
Abstract
Despite careful preoperative planning, surgical flaps are prone to ischemic tissue damage and ischemia–reperfusion injury. The resulting wound breakdown and flap necrosis increase both treatment costs and patient morbidity. Hence, there is a need for strategies to promote flap survival and prevent ischemia-induced tissue damage. Phytochemicals, defined as non-essential, bioactive, and plant-derived molecules, are attractive candidates for perioperative treatment as they have little to no side effects and are well tolerated by most patients. Furthermore, they have been shown to exert beneficial combinations of pro-angiogenic, anti-inflammatory, anti-oxidant, and anti-apoptotic effects. This review provides an overview of bioactive phytochemicals that have been used to increase flap survival in preclinical animal models and discusses the underlying molecular and cellular mechanisms.
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Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Germany
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17
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Oral H, Türkyılmaz Z, Karabulut R, Kaya C, Dayanır D, Karakaya C, Sonmez K. Protective Effects of Hydrogen-Rich Saline on Experimental Intestinal Volvulus in Rats. J INVEST SURG 2022; 35:1427-1433. [PMID: 35331073 DOI: 10.1080/08941939.2022.2056273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intestinal volvulus can cause morbidity and mortality. Surgical reduction, on the other hand, could result in ischemia-reperfusion (I/R) injury. Hydrogen rich saline solution (HRSS neutralizes free radicals in the body. This study aimed to investigate the effects of HRSS in I/R injury in experimental intestinal volvulus in rats. METHODS Thirty rats were randomly allocated into 5 groups. All procedures were done under general anesthesia and sterile conditions in each animal. Five ml/kg of saline and HRSS were administered intraperitoneally (ip) in Sham (Group 1) and HRSS (Group 2) groups, respectively. Groups 3, 4, and 5 constituted the study groups in which volvulus was created in a 5-cm- long ileal segment 2 cm proximal to the ileocecal valve. After 2 hours the volvuli were reduced and following 2 hours of reperfusion, these segments were removed. In volvulus-I/R group (Group 3) no additional procedure was done. HRSS was administered shortly before reperfusion (reduction of the volvulus) in Treatment I (Group 4) and 1 h before experimental volvulus in Treatment II (Group 5) groups. Blood and intestinal tissue samples were obtained from all rats at the 4th hour. Both tissue and blood total oxidant (TOS) and antioxidant status (TAS) levels were determined and tissue histomorphologies were studied. Oxidative stress indices (TOS ÷ TAS) (OSI) were calculated. RESULTS Tissue TOS and OSI levels and histomorphological injury scores were statistically lower in treatment groups than I/R group, whereas blood TOS and OSI levels were similar between the groups. CONCLUSIONS This study provides biochemical and histomorphological evidence that HRSS prevents intestinal damage in I/R injury caused by volvulus.
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Affiliation(s)
- Hayrunnisa Oral
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zafer Türkyılmaz
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ramazan Karabulut
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Cem Kaya
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Duygu Dayanır
- Histology and Embryology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Cengiz Karakaya
- Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kaan Sonmez
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
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18
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Dong C, Chen Z, Zhu L, Bsoul N, Wu H, Jiang J, Chen X, Lai Y, Yu G, Gu Y, Guo X, Gao W. Diallyl Trisulfide Enhances the Survival of Multiterritory Perforator Skin Flaps. Front Pharmacol 2022; 13:809034. [PMID: 35242032 PMCID: PMC8885991 DOI: 10.3389/fphar.2022.809034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/04/2022] [Indexed: 12/13/2022] Open
Abstract
The multiterritory perforator flap is one of the widest flap patterns used to repair tissue defects. However, flap necrosis of the distal part is still a challenging issue for plastic surgeons. Diallyl trisulfide (DATS) is an efficient ingredient extracted from garlic, exerting many important effects on different diseases. Our experiment aims to reveal whether DATS has a beneficial effect on the survival of perforator flaps and to explore its mechanism of action. The results showed that DATS enhanced angiogenesis and autophagy and reduced cell apoptosis and oxidative stress, thereby improving the survival rate of skin flaps. After co-administration with autophagy inhibitor 3-methyladenine (3MA), perforator flap survival was further improved. Mechanistically, we showed that PI3K/Akt and AMPK-HIF-1α signaling pathways in flap were activated under DATS treatment. All in all, DATS promoted the survival of multiterritory perforator flaps via the synergistic regulation of PI3K/Akt and AMPK-HIF-1α signaling pathways, and inhibition of DATS-induced autophagy further improves flap survival.
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Affiliation(s)
- Chengji Dong
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Zhuliu Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Linxin Zhu
- Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Najeeb Bsoul
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Hongqiang Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Jingtao Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Xuankuai Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Yingying Lai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Gaoxiang Yu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Yanlan Gu
- Department of Histology and Embryology, Wenzhou Medical University, Zhejiang, China
| | - Xiaoshan Guo
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Weiyang Gao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
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19
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Moellhoff N, Gernert C, Frank K, Giunta RE, Ehrl D. The 72-Hour Microcirculation Dynamics in Viable Free Flap Reconstructions. J Reconstr Microsurg 2022; 38:637-646. [PMID: 35158397 DOI: 10.1055/s-0042-1742733] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The risk for vascular complications is the highest within the first 24 hours after free flap transfer. Clinical signs of critical perfusion are often recognized with time delay, impeding flap salvage. To detect failing flaps as soon as possible and to prevent persisting microvascular impairments, knowledge of physiological perfusion dynamics in free flaps is needed. Aim of this study was to investigate the physiological perfusion dynamics of viable free flaps using the Oxygen to See (O2C) device for continuous monitoring. METHODS Microcirculation was continuously monitored in 85 viable free flaps over a period of up to 72 hours following microvascular anastomosis using tissue spectrophotometry and laser Doppler flowmetry (O2C, LEA Medizintechnik, Gießen, Germany). The parameters investigated included capillary-venous blood flow (flow), oxygen saturation (SO2), and relative amount of hemoglobin (rHB). RESULTS Microcirculatory blood flow increased significantly overall, especially within the first 18 hours after microsurgical anastomosis, after which peak formation was occurred. Mean values of SO2 showed a decreasing trend and the steepest decrease of SO2 (slope: 1.0) occurred during the steepest increase of flow between 3 and 6 hours (slope: 4.7) postanastomosis. The rHB values remained fairly constant throughout the study period. CONCLUSION Hyperemia after free flap transfer accounts for a significant increase of microvascular flow. Tissue oxygenation is reduced, likely due to an increase of oxygen consumption after anastomosis. A better understanding of physiological perfusion dynamics in free flaps can aid surgeons in recognizing compromised vasculature earlier and improve free flap salvage.
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Affiliation(s)
- Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Clara Gernert
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Riccardo E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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20
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Suyama Y, Yagi S, Fukuoka K, Morita M, Kinjo A, Fukuhara T, Fujiwara K, Kodani I, Osaki Y. Risk Factors of Free Flap Complications in Reconstruction for Head and Neck Cancer. Yonago Acta Med 2022; 65:215-225. [DOI: 10.33160/yam.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Yoshiko Suyama
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Shunjiro Yagi
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Kohei Fukuoka
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Maki Morita
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Aya Kinjo
- Department of Social Medicine, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan
| | - Takahiro Fukuhara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Isamu Kodani
- Division of Oral and Maxillofacial Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yoneatsu Osaki
- Department of Social Medicine, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan
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21
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Than PA, Davis CR, Rennert RC, Morrison SD, Findlay MW, Kay MA, Gurtner GC. Selective Microvascular Tissue Transfection Using Minicircle DNA for Systemic Delivery of Human Coagulation Factor IX in a Rat Model Using a Therapeutic Flap. Plast Reconstr Surg 2022; 149:117-129. [PMID: 34757962 DOI: 10.1097/prs.0000000000008630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gene therapy is a promising treatment for protein deficiency disorders such as hemophilia B. However, low tissue selectivity and efficacy are limitations of systemic vector delivery. The authors hypothesized that selective transfection of rat superficial inferior epigastric artery flaps could provide systemic delivery of coagulation factor IX, preventing the need for systemic vector administration. METHODS Minicircle DNA containing green fluorescent protein, firefly luciferase, and human coagulation factor IX was created. Vector constructs were validated by transfecting adipose-derived stromal cells isolated from Wistar rat superficial inferior epigastric artery flaps and evaluating transgene expression by fluorescence microscopy, bioluminescence, and enzyme-linked immunosorbent assay. Minicircle DNA luciferase (10 and 30 μg) was injected into murine (wild-type, C57/BL/6) inguinal fat pads (n = 3) and followed by in vivo bioluminescence imaging for 60 days. Wistar rat superficial inferior epigastric artery flaps were transfected with minicircle DNA human coagulation factor IX (n = 9) with plasma and tissue transgene expression measured by enzyme-linked immunosorbent assay at 2 and 4 weeks. RESULTS Transfected adipose-derived stromal cells expressed green fluorescent protein for 30 days, luciferase for 43 days, and human coagulation factor IX (21.9 ± 1.2 ng/ml) for 28 days in vitro. In vivo murine studies demonstrated dose-dependence between minicircle DNA delivery and protein expression. Ex vivo rat superficial inferior epigastric artery flap transfection with minicircle DNA human coagulation factor IX showed systemic transgene expression at 2 (266.6 ± 23.4 ng/ml) and 4 weeks (290.1 ± 17.1 ng/ml) compared to control tissue (p < 0.0001). CONCLUSIONS Rat superficial inferior epigastric artery flap transfection using minicircle DNA human coagulation factor IX resulted in systemic transgene detection, suggesting that selective flap or angiosome-based tissue transfection may be explored as a treatment for systemic protein deficiency disorders such as hemophilia B.
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Affiliation(s)
- Peter A Than
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Christopher R Davis
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Robert C Rennert
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Shane D Morrison
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Michael W Findlay
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Mark A Kay
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Geoffrey C Gurtner
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
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22
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Ouyang SY, Cai ZG, Shan XF, Li Y. Prospective Trial of Near-Infrared Spectroscopy for Continuous Noninvasive Monitoring of Free Fibular Flaps. Ann Plast Surg 2021; 87:e29-e36. [PMID: 34334668 DOI: 10.1097/sap.0000000000002915] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Some free flaps develop postoperative vessel thrombosis, which influences the flap survival rate. Early discovery and identification of vascular crisis are critical to the success rate of flap salvage. The primary aims of this study were to determine the features of postoperative blood supply changes in fibular flaps with normal and abnormal blood flow, using near-infrared spectroscopy (NIRS), to monitor oxygenation and blood flow, and to characterize the probable risk factors for vascular crisis. METHODS Sixty-three consecutive patients undergoing reconstruction of unilateral mandibular defects with free fibular flaps at the Peking University School of Stomatology were included. Patients were divided into 2 groups, A (n = 38) and B (n = 25); fibular flaps in group A underwent continuous NIRS monitoring from immediately postoperatively until 7 days postoperatively (approximately 150 hours), whereas fibular flaps and opposite mandibles in group B underwent intermittent monitoring: once every 4 hours during the first 24 hours postoperatively and once every 12 hours from 24 to 168 hours postoperatively. RESULTS Six fibular flaps developed vascular thromboses: 4 were venous thromboses and 2 were arterial thromboses; 5 were rescued after exploration. Of 6 regional oxygen saturation (rSO2) values in the continuous monitoring group, 4 showed no significant differences at any time point compared with the intermittent monitoring group (P > 0.05). The rSO2 of the fibular flap was significantly different from that in the opposite mandible in the first 36 hours postoperatively (P < 0.05). This difference decreased over time. During the initial period of venous thrombosis, rSO2, deoxyhemoglobin, and oxygenated hemoglobin all rose slightly, then showed simultaneous rapid reduction. However, the magnitude of reduction was smaller for deoxyhemoglobin than for oxygenated hemoglobin. CONCLUSIONS Near-infrared spectroscopy can be used for noninvasive and reliable assessment of oxygenation and blood flow in free flaps through continuous, real-time monitoring. It is also portable, inexpensive, and simple to operate. In addition, the detection depth of NIRS is up to 2.0 cm, so it can be used to monitor buried flaps with depths <2.0 cm.
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Affiliation(s)
- Si-Yuan Ouyang
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Zhi-Gang Cai
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Xiao Feng Shan
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Yue Li
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, P.R. China
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23
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Ergan Sahin A, Karasoy Yesilada A, Yalcin O, Guler EM, Erbek H, Karabıyık D. Hydrogen-rich saline reduces tissue injury and improves skin flap survival on a rat hindlimb degloving injury model. J Plast Reconstr Aesthet Surg 2021; 74:2095-2103. [PMID: 33451944 DOI: 10.1016/j.bjps.2020.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/01/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Degloving injuries represent a challenge in plastic surgery. The aim of this study is to acknowledge the protective effects of hydrogen-rich saline (HRS) solution on a rat hindlimb degloved skin flap. METHODS Twenty-one Sprague-Dawley rats were divided into three groups (control, saline and HRS). Degloving injury model was established, and flaps were sutured back following 5 min of ischemia. The control group did not receive any treatment. The saline group received intraperitoneal physiological saline (10 ml/kg) and the HRS group received intraperitoneal HRS solution (10 ml/kg) postoperatively and daily for 5 days after the operation. Skin samples were obtained for histological, immunohistochemical and biochemical evaluations. RESULTS Inflammation was lower in the HRS compared with saline (p = 0.02) and control (p = 0.004) groups. Edema was lower in the HRS compared with saline (p = 0.02) and control (p = 0.001) groups. Malondialdehyde (MDA) level was lower in the HRS than the control group (p = 0.01). Total antioxidant level was higher in the HRS compared with saline (p = 0.009) and control (p = 0.03) groups. Total oxidant level was lower in the HRS than the control group (p = 0.02). Oxidative stress index was lower in the HRS compared with saline (p = 0.001) and control (p = 0.0001) groups`. Vascular proliferation was higher in the HRS compared with the control group (p = 0.01). CONCLUSION Repeated HRS injections after trauma increased the viability of skin flap in rat degloving injury model by decreasing local tissue injury, due to its antioxidant, anti-inflammatory and angiogenic effects.
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Affiliation(s)
- Ayca Ergan Sahin
- Department of Plastic Surgery, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey.
| | - Aysin Karasoy Yesilada
- Department of Plastic Surgery, Medipol Healthcare Group, Camlica Medipol University Hospital, Istanbul, Turkey
| | - Ozben Yalcin
- Department of Pathology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Eray M Guler
- Health Sciences University Hamidiye Medicine Faculty Department of Medical Biochemistry, Istanbul, Turkey
| | - Harun Erbek
- Department of Plastic Surgery, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Damla Karabıyık
- Department of Pathology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
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DEMİRHAN İ, BELGE KURUTAŞ E. Kalp İskemi-Reperfüzyonunda Vitaminlerin Rolü. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2021. [DOI: 10.38079/igusabder.856218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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25
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Lindelauf AAMA, Vranken NPA, Schols RM, Bouman EAC, Weerwind PW, van der Hulst RRWJ. Exploring personalized postoperative non-invasive tissue oximetry in DIEP flap breast reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01873-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Early detection of vascular compromise after autologous breast reconstruction is crucial to enable timely re-exploration for flap salvage. Several studies proposed non-invasive tissue oximetry for early identification of ischemia of deep inferior epigastric perforator (DIEP) flaps. The present study aimed to explore the utility of non-invasive tissue oximetry following DIEP flap surgery using a personalized oxygenation threshold.
Methods
Patients undergoing immediate/delayed DIEP flap surgery were included in this prospective observational study. DIEP flap tissue oxygenation (StO2) was monitored continuously using near-infrared spectroscopy. A baseline measurement was performed by positioning one sensor at the marked position of the major inferior epigastric perforator on the abdomen. A new sensor was positioned postoperatively on the transplanted tissue. In unilateral procedures, postoperative StO2 values of the native breast were also obtained. Measurements were continued for 24 h.
Results
Thirty patients (42 flaps) were included. Fourteen patients (46.7%) had an uncomplicated postoperative course. A minor complication was observed in thirteen patients; in five patients, at least one major complication occurred, requiring re-exploration. Median StO2 readings were significantly lower in patients with major complications compared to uncomplicated cases. In fourteen unilateral DIEP flap procedures, StO2 values of the native breast were similar to the preoperative baseline measurement (92%; p = 0.452).
Conclusions
Non-invasive tissue oximetry following DIEP flap surgery could aid in early detection of vascular compromise. StO2 values of the native breast and abdominal wall preoperatively can be used interchangeably and can serve as personalized reference value.
Level of evidence: Level IV, diagnostic / prognostic study.
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26
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Seyid M, Tiftikcioglu Y, Erdem M, Akdemir O, Tatar BE, Uyanıkgil Y, Ercan G. The Effect of Ceruloplasmin Against Ischemia-Reperfusion Injury in Epigastric Island Flap in Rats. J Surg Res 2021; 267:627-635. [PMID: 34273792 DOI: 10.1016/j.jss.2021.05.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Flap surgery is frequently used in plastic surgery to close tissue defects. Ischemia-reperfusion (I/R) injury is a significant problem resulting in partial or total flap necrosis. This study aimed to investigate the effect of ceruloplasmin on I/R injury in epigastric island flaps in rats. MATERIAL AND METHOD A total of 32 male Sprague-Dawley rats were divided into four groups with eight rats in each group: The flap was not elevated in Group I; the flap was elevated without ischemia or any application in Group II, after the intraperitoneal saline and ceruloplasmin application the flaps were elevated and ischemia was created in group III-IV, respectively. Bilateral epigastric artery flap was elevated in all groups except Group I. After 6 h of ischemia, the flap was reperfused and inset. Samples were taken from the right and left side of the flap area in other groups at the postoperative 24th h for biochemical analysis (catalase and malondialdehyde-MDA) and the seventh postoperative day for histopathological analysis (Modified Verhofstad score and epidermal thicknesses), respectively. Image analysis for necrosis areas was performed on photos taken on the 7th d. RESULTS Catalase level was significantly higher in Group IV.(0.15 ± 0.04 U/mg protein) (P < 0.05) Necrosis area percentage(14.4% ± 3.3%),MDA(3.6 ± 0.9 nmol/mg protein), edema(3), necrosis(2.75), and polymorphonuclear leukocyte infiltration(2.87) scores were significantly higher in group III.(P < 0.05). Fibroblast proliferation, collagen density (0.25), vascular density (0.25) scores and epidermal thickness (15.68 µm,) was significantly lower in group III. (P < 0.05) CONCLUSIONS: Our study demonstrated that ceruloplasmin application before ischemia reduced I/R injury in epigastric island flaps in rats.
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Affiliation(s)
- Mircafer Seyid
- Baku Medical Plaza, Department of Plastic Surgery, Baku, Azerbaijan.
| | - Yigit Tiftikcioglu
- Ege University Faculty of Medicine, Department of Plastic Surgery, Izmir, Turkey
| | - Mehmet Erdem
- University of Health Sciences, Bagcılar Training and Research Hospital, Department of Plastic Surgery, Istanbul, Turkey
| | - Ovunc Akdemir
- Esenyurt University, Department of Plastic Surgery, Istanbul, Turkey
| | - Burak Ergün Tatar
- University of Health Sciences, Bagcılar Training and Research Hospital, Department of Plastic Surgery
| | - Yigit Uyanıkgil
- Ege University Faculty of Medicine, Department of Histology and Embryology, Izmir, Turkey
| | - Gülinnaz Ercan
- Ege University Faculty of Medicine, Department of Biochemistry, Izmir Turkey
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27
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Pidlisetsky АТ, Kosiakova GV, Goridko TM, Berdyschev AG, Meged OF, Savosko SI, Dolgopolov ОV. Administration of platelet-rich plasma or concentrated bone marrow aspirate after mechanically induced ischemia improves biochemical parameters in skeletal muscle. UKRAINIAN BIOCHEMICAL JOURNAL 2021. [DOI: 10.15407/ubj93.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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28
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Sarkar A, Messerli MA. Electrokinetic Perfusion Through Three-Dimensional Culture Reduces Cell Mortality. Tissue Eng Part A 2021; 27:1470-1479. [PMID: 33820474 DOI: 10.1089/ten.tea.2021.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Cell proliferation and survival are dependent on mass transfer. In vivo, fluid flow promotes mass transfer through the vasculature and interstitial space, providing a continuous supply of nutrients and removal of cellular waste products. In the absence of sufficient flow, mass transfer is limited by diffusion and poses significant challenges to cell survival during tissue engineering, tissue transplantation, and treatment of degenerative diseases. Artificial perfusion may overcome these challenges. In this work, we compare the efficacy of pressure driven perfusion (PDP) with electrokinetic perfusion (EKP) toward reducing cell mortality in three-dimensional cultures of Matrigel extracellular matrix. We characterize electro-osmotic flow through Matrigel to identify conditions that generate similar interstitial flow rates to those induced by pressure. We also compare changes in cell mortality induced by continuous or pulsed EKP. We report that continuous EKP significantly reduced mortality throughout the perfusion channels more consistently than PDP at similar flow rates, and pulsed EKP decreased mortality just as effectively as continuous EKP. We conclude that EKP has significant advantages over PDP for promoting tissue survival before neovascularization and angiogenesis. Impact statement Interstitial flow helps promote mass transfer and cell survival in tissues and organs. This study generated interstitial flow using pressure driven perfusion (PDP) or electrokinetic perfusion (EKP) to promote cell viability in three-dimensional cultures. EKP through charged extracellular matrices possesses significant advantages over PDP and may promote cell survival during tissue engineering, transplantations, and treatment of degenerative diseases.
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Affiliation(s)
- Anyesha Sarkar
- Department of Biology and Microbiology, South Dakota State University, Brookings, South Dakota, USA
| | - Mark A Messerli
- Department of Biology and Microbiology, South Dakota State University, Brookings, South Dakota, USA
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29
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Kohler LH, Köhler H, Kohler S, Langer S, Nuwayhid R, Gockel I, Spindler N, Osterhoff G. Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study. BMC Surg 2021; 21:222. [PMID: 33931056 PMCID: PMC8086299 DOI: 10.1186/s12893-021-01232-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Free flap surgery is an essential procedure in soft tissue reconstruction. Complications due to vascular compromise often require revision surgery or flap removal. We present hyperspectral imaging (HSI) as a new tool in flap monitoring to improve sensitivity compared to established monitoring tools. METHODS We performed a prospective observational cohort study including 22 patients. Flap perfusion was assessed by standard clinical parameters, Doppler ultrasound, and HSI on t0 (0 h), t1 (16-28 h postoperatively), and t2 (39-77 h postoperatively). HSI records light spectra from 500 to 1000 nm and provides information on tissue morphology, composition, and physiology. These parameters contain tissue oxygenation (StO2), near-infrared perfusion- (NIR PI), tissue hemoglobin- (THI), and tissue water index (TWI). RESULTS Total flap loss was seen in n = 4 and partial loss in n = 2 cases. Every patient with StO2 or NIR PI below 40 at t1 had to be revised. No single patient with StO2 or NIR PI above 40 at t1 had to be revised. Significant differences between feasable (StO2 = 49; NIR PI = 45; THI = 16; TWI = 56) and flaps with revision surgery [StO2 = 28 (p < 0.001); NIR PI = 26 (p = 0.002); THI = 56 (p = 0.002); TWI = 47 (p = 0.045)] were present in all HSI parameters at t1 and even more significant at t2 (p < 0.0001). CONCLUSION HSI provides valuable data in free flap monitoring. The technique seems to be superior to the gold standard of flap monitoring. StO2 and NIR PI deliver the most valuable data and 40 could be used as a future threshold in surgical decision making. Clinical Trial Register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00020926.
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Affiliation(s)
- Lukas H Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany.
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Saxony, Germany
| | - Simon Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Stefan Langer
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Rima Nuwayhid
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Saxony, Germany
| | - Nick Spindler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Georg Osterhoff
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
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30
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Li J, Lou J, Yu G, Chen Y, Chen R, Chen Z, Wu C, Ding J, Xu Y, Jiang J, Xu H, Zhu X, Gao W, Zhou K. Targeting TFE3 Protects Against Lysosomal Malfunction-Induced Pyroptosis in Random Skin Flaps via ROS Elimination. Front Cell Dev Biol 2021; 9:643996. [PMID: 33898433 PMCID: PMC8060706 DOI: 10.3389/fcell.2021.643996] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/04/2021] [Indexed: 11/26/2022] Open
Abstract
Increasing evidence indicates that pyroptosis, a new type of programmed cell death, may participate in random flap necrosis and play an important role. ROS-induced lysosome malfunction is an important inducement of pyroptosis. Transcription factor E3 (TFE3) exerts a decisive effect in oxidative metabolism and lysosomal homeostasis. We explored the effect of pyroptosis in random flap necrosis and discussed the effect of TFE3 in modulating pyroptosis. Histological analysis via hematoxylin-eosin staining, immunohistochemistry, general evaluation of flaps, evaluation of tissue edema, and laser Doppler blood flow were employed to determine the survival of the skin flaps. Western blotting, immunofluorescence, and enzyme-linked immunosorbent assays were used to calculate the expressions of pyroptosis, oxidative stress, lysosome function, and the AMPK-MCOLN1 signaling pathway. In cell experiments, HUVEC cells were utilized to ensure the relationship between TFE3, reactive oxygen species (ROS)-induced lysosome malfunction and cell pyroptosis. Our results indicate that pyroptosis exists in the random skin flap model and oxygen and glucose deprivation/reperfusion cell model. In addition, NLRP3-mediated pyroptosis leads to necrosis of the flaps. Moreover, we also found that ischemic flaps can augment the accumulation of ROS, thereby inducing lysosomal malfunction and finally initiating pyroptosis. Meanwhile, we observed that TFE3 levels are interrelated with ROS levels, and overexpression and low expression of TFE3 levels can, respectively, inhibit and promote ROS-induced lysosomal dysfunction and pyroptosis during in vivo and in vitro experiments. In conclusion, we found the activation of TFE3 in random flaps is partially regulated by the AMPK-MCOLN1 signal pathway. Taken together, TFE3 is a key regulator of ROS-induced pyroptosis in random skin flaps, and TFE3 may be a promising therapeutic target for improving random flap survival.
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Affiliation(s)
- Jiafeng Li
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Junsheng Lou
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Gaoxiang Yu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Yijie Chen
- Department of Obstetrics and Gynecology, The Second Affliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruiheng Chen
- Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,Department of Cardiovascular and Thoracic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhuliu Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Chenyu Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Jian Ding
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Yu Xu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Jingtao Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Huazi Xu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Xuwei Zhu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Weiyang Gao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Kailiang Zhou
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
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31
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Re-exploration in the early postoperative period has a better salvage rate in free flaps. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01744-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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32
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Zhu D, Chen B, Xiang Z, Lin J, Miao Z, Wang Y, Wu Y, Zhou Y. Apigenin enhances viability of random skin flaps by activating autophagy. Phytother Res 2021; 35:3848-3860. [PMID: 33792992 DOI: 10.1002/ptr.7090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023]
Abstract
Random skin flap is widely used in plastic surgery. However, flap necrosis caused by ischemia-reperfusion injury limits its clinical applications. Apigenin, a naturally occurring flavonoid mainly derived from plants, facilitates flap survival. In this study, we explored the effects of apigenin on flap survival and the underlying mechanisms. A total of 54 mice having a dorsal random flap model were randomly divided into control, apigenin, and apigenin +3-methyladenine groups. These groups were treated with dimethyl sulfoxide solution, apigenin, and apigenin +3-methyladenine, respectively. The animals were then euthanized to assess angiogenesis, apoptosis, oxidative stress, and autophagy levels through histological and protein analyses. Apigenin promotes survival of the skin flap area and reduces tissue edema. In addition, apigenin enhanced angiogenesis, attenuated apoptosis, alleviated oxidative stress, and activated autophagy. Interestingly, 3-methyladenine reversed the effects of apigenin on flap survival, angiogenesis, apoptosis, and oxidative stress through inhibition of autophagy. The findings of this study show that apigenin promotes angiogenesis, inhibits cell apoptosis, and lowers oxidative stress by mediating autophagy, thus the improving survival rate of random skin flaps.
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Affiliation(s)
- Dingchao Zhu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Boda Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhiyang Xiang
- Department of Urology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiahao Lin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhimin Miao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yihan Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yaosen Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yifei Zhou
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
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Chen Z, Liu H, Li Y, Zhou Z, Qiu J, Tang Y, Cui T. ZNF667 attenuates leukocyte-endothelial adhesion via downregulation of P-selectin in skin flap following remote limb ischemic preconditioning. Cell Biol Int 2021; 45:1477-1486. [PMID: 33710682 DOI: 10.1002/cbin.11586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/23/2021] [Accepted: 03/07/2021] [Indexed: 12/19/2022]
Abstract
We assessed the effects and potential mechanism of romote ischemic preconditioning (RIPC) on leukocytes-endothelium cell adhesion in the flap microvessel after ischemia-reperfusion (I/R) injury. Eight hours after reperfusion, edema and intravascular leukocyte aggregation were reduced and microvessels were more obvious in the group with superficial inferior epigastric artery (SIEA) perforator flap (SIEA-flap) subjected to RIPC than in the I/R group. Zinc finger protein 667 (ZNF667) was significantly increased but P-selectin was decreased in the flaps subjected to RIPC, compared to those in the I/R group. The low expression of P-selectin was associated with ZNF667 expression and activation in human dermal microvascular endothelial cells in response to hypoxic preconditioning. ZNF667 bound to the P-selectin promoter region, suppressing its transcription through a special core sequence. The ablation of P-selectin by small interfering RNA effectively prevented the leukocytes-endothelium cell adhesion effect of ZNF667-knockdown. ZNF667 upregulation attenuates leukocyte-endothelial cell adhesion by negatively regulating the expression of P-selectin in SIEA-flap subjected to RIPC.
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Affiliation(s)
- Zhuang Chen
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Haifen Liu
- Department of Radiology, Hunan Provincial Hospital of Traditional Chinese Medicine, Zhuzhou, Hunan, China
| | - Yuanbin Li
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Zhangfu Zhou
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Jizhe Qiu
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Yi Tang
- Department of Dermatology, Hunan Provincial Hospital of Traditional Chinese Medicine, Zhuzhou, Hunan, China
| | - Taotao Cui
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
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Jiang J, Jin J, Lou J, Li J, Wu H, Cheng S, Dong C, Chen H, Gao W. Positive Effect of Andrographolide Induced Autophagy on Random-Pattern Skin Flaps Survival. Front Pharmacol 2021; 12:653035. [PMID: 33796027 PMCID: PMC8008123 DOI: 10.3389/fphar.2021.653035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/18/2023] Open
Abstract
Random-pattern skin flap replantation is generally used in the reconstruction of surgical tissues and covering a series of skin flap defects. However, ischemia often occurs at the flap distal parts, which lead to flap necrosis. Previous studies have shown that andrographolide (Andro) protects against ischemic cardiovascular diseases, but little is known about the effect of Andro on flap viability. Thus, our study aimed to building a model of random-pattern skin flap to understand the mechanism of Andro-induced effects on flap survival. In this study, fifty-four mice were randomly categorized into the control, Andro group, and the Andro+3-methyladenine group. The skin flap samples were obtained on postoperative day 7. Subsequently, the tissue samples were underwent a series of evaluations such as changes in the appearance of flap tissue, the intensity of blood flow, and neovascularization density of skin flap. In our study, the results revealed that Andro enhanced the viability of random skin flaps by enhancing angiogenesis, inhibiting apoptosis, and reducing oxidative stress. Furthermore, our results have also demonstrated that the administration of Andro caused an elevation in the autophagy, and these remarkable impact of Andro were reversed by 3-methyladenine (3-MA), the most common autophagy inhibitor. Together, our data proves novel evidence that Andro is a potent modulator of autophagy capable of significantly increasing random-pattern skin flap survival.
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Affiliation(s)
- Jingtao Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Jie Jin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Junsheng Lou
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Jiafeng Li
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Hongqiang Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Sheng Cheng
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Chengji Dong
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Hongyu Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China.,The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Weiyang Gao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
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Knitschke M, Sonnabend S, Bäcker C, Schmermund D, Böttger S, Howaldt HP, Attia S. Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years. Cancers (Basel) 2021; 13:cancers13040865. [PMID: 33670721 PMCID: PMC7922890 DOI: 10.3390/cancers13040865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.
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36
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Kwasnicki RM, Chen CM, Noakes AJ, Hettiaratchy S, Yang GZ, Darzi A. Developing a Wearable Sensor for Continuous Tissue Oxygenation Monitoring: A Proof of Concept Study. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2021. [DOI: 10.1055/s-0041-1723995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Abstract
Objective Technologies facilitating continuous free tissue flap monitoring such as near infrared spectroscopy (NIRS) have been shown to improve flap salvage rates. However, the size and associated costs of such technology create a barrier to wider implementation. The aim of this study was to develop and validate a wearable sensor for continuous tissue oxygenation monitoring.
Materials and Methods A forearm ischemia model was designed by using a brachial pressure cuff inflation protocol. Twenty healthy subjects were recruited. The forearm tissue oxygenation of each subject was monitored throughout the pressure cuff protocol by using a new optical sensor (Imperial College London), and a gold standard tissue spectrometry system (O2C, Medizintecknik, LEA, Germany). Data were processed to allow quantitative deoxygenation episode comparisons between inflations and sensor modalities.
Results The correlation between O2C and optical sensor oxygenation measurements was moderate (average R = 0.672, p < 0.001). Incremental increases in cuff inflation duration resulted in a linear increase in deoxygenation values with both O2C and optical sensors, with significant differences recorded on consecutive inflations (wall shear rate, p < 0.005). The presence or absence of pulsatile blood flow was correctly determined throughout by both sensor modalities.
Conclusion This study demonstrates the ability of a small optical sensor to detect and quantify tissue oxygenation changes and assess the presence of pulsatile blood flow. Low power, miniaturized electronics make the device capable of deployment in a wearable form which may break down the barriers for implementation in postoperative flap monitoring.
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Affiliation(s)
- Richard M. Kwasnicki
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Ching-Mei Chen
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Alex J. Noakes
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Shehan Hettiaratchy
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Guang-Zhong Yang
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Ara Darzi
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College, London, United Kingdom
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Abstract
Advances in free flap reconstruction of complex head and neck defects have allowed for improved outcomes in the management of head and neck cancer. Technical refinements have decreased flap loss rate to less than 4%. However, the potential for flap failure exists at multiple levels, ranging from flap harvest and inset to pedicle lay and postoperative patient and positioning factors. While conventional methods of free flap monitoring (reliant on physical examination) remain the most frequently used, additional adjunctive methods have been developed. Herein we describe the various modalities of both invasive and noninvasive free flap monitoring available to date. Still, further prospective studies are needed to compare the various invasive and noninvasive technologies and to propel innovations to support the early recognition of vascular compromise with the goal of even greater rates of flap salvage.
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Affiliation(s)
- Adam Jacobson
- Department of Otolaryngology - Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
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38
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Del Rio M, Lopez-Cabrera P, Malagón-López P, Del Caño-Aldonza MC, Castello JR, Provencio M. Effect of intravenous lidocaine on ischemia-reperfusion injury in DIEP microsurgical breast reconstruction. A prospective double-blind randomized controlled clinical trial. J Plast Reconstr Aesthet Surg 2020; 74:809-818. [PMID: 33199226 DOI: 10.1016/j.bjps.2020.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 07/25/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ischemia-reperfusion injury in free flaps is associated with tissue damage and is one of the main factors causing flap failure in reconstructive microsurgery. The aim of this study is to assess whether any ischemia-reperfusion injury takes place during a microsurgical flap reconstruction as seen through the levels of malondialdehyde (MDA) and superoxide dismutase, biomarkers of oxidative stress, and to analyze the effect of lidocaine in this process. METHODS Twenty-four patients operated for immediate breast reconstruction using the Deep Inferior Epigastric Perforator free flap technique were divided into two groups: one group was treated with a lidocaine intravenous perfusion and the other group with a saline perfusion. MDA and superoxide dismutase (SOD) levels were measured at several points before, during, and after surgery. RESULTS There was an increase in MDA levels in both groups, but the lidocaine group experienced a decrease during reperfusion. On the other hand, we observed a rise in SOD levels in both groups, but a decrease during reperfusion in the placebo group. However, these differences between groups were not statistically significant. CONCLUSIONS The decreased SOD activity and increased MDA content in our research prove a redox imbalance and high reactive oxygen species levels in flaps, indicating that tissues experience ischemia-reperfusion injury during microsurgical reconstruction. Lidocaine may have a protective effect in free flap surgery, but our results were not statistically significant, so further studies will be required.
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Affiliation(s)
- M Del Rio
- Department of Plastic Surgery, University Hospital Germans Trias i Pujol, Carretera de Canyet s/n, Barcelona 08916, Spain.
| | - P Lopez-Cabrera
- Paloma Lopez-Cabrera, MD, Department of Plastic Surgery, University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - P Malagón-López
- Department of Plastic Surgery, University Hospital Germans Trias i Pujol, Carretera de Canyet s/n, Barcelona 08916, Spain
| | - M C Del Caño-Aldonza
- Department of Anesthesiology, University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - J R Castello
- Paloma Lopez-Cabrera, MD, Department of Plastic Surgery, University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - M Provencio
- Department of Oncology, Autonomous University of Madrid, University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
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Derebaşınlıoğlu H, Demİröz A, Aydin Y, Ekmekçi H, Balci Ekmekçi Ö, Aydin Ö, Cankorkmaz L. Comparison of ischemic preconditioning and BotulinumA Toxin injection for the prevention of ischemia-reperfusion injury in musculocutaneous flaps. Turk J Med Sci 2020; 50:1523-1534. [PMID: 32718122 PMCID: PMC7605091 DOI: 10.3906/sag-1904-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/21/2020] [Indexed: 11/15/2022] Open
Abstract
Background/aim The aim of the study was to evaluate the protective effect of Botulinum A toxin injection against ischemia-reperfusion injury. Materials and methods Thirty-two Sprague-Dawley rats were divided into: control, ischemia-reperfusion, ischemic preconditioning, and botulinum groups. In all groups the musculocutaneous pedicle flap was occluded for 4 h, and then reperfused to induce ischemia-reperfusion injury. Serum and tissue myeloperoxidase (MPO) and nitric oxide (NO) levels were measured at 24 h and at 10 days. Results Tissue MPO levels did not differ significantly between the ischemic preconditioning and botulinum groups at 24 h but was significantly lower in the botulinum group at 10 days. Tissue NO levels were significantly higher in the ischemic preconditioning group compared to the botulinum group at 24 h and at 10 days. Serum MPO showed no significant difference between these two groups at 24 h but was significantly lower in the ischemic preconditioning group compared to the botulinum group at 10 days. Serum NO levels were not significantly different at 24 h but significantly higher in the botulinum group at 10 days. Conclusion Findings show that botulinum has a protective effect against the ischemia-reperfusion injury via increased NO and decreased MPO levels in tissue. Based on tissue NO levels, ischemic preconditioning was significantly higher than botulinum.
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Affiliation(s)
- Handan Derebaşınlıoğlu
- Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey
| | - Anil Demİröz
- Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Yağmur Aydin
- Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Hakan Ekmekçi
- Department of Biochemistry, Faculty of Medicine, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Özlem Balci Ekmekçi
- Department of Biochemistry, Faculty of Medicine, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Övgü Aydin
- Department of Pathology, Faculty of Medicine, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Levent Cankorkmaz
- Department of Pediatric Surgery, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Turkey
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Demiröz A, Derebaşınlıoğlu H, Ercan A, Arslan H, Aydın Ö, Ekmekçi H, Balcı Ekmekçi Ö, Aydın Y. Comparison of Ischemic Preconditioning and Systemic Piracetam for Prevention of Ischemia-Reperfusion Injury in Musculocutaneous Flaps. J Reconstr Microsurg 2020; 37:322-335. [PMID: 32971545 DOI: 10.1055/s-0040-1716822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ischemia-reperfusion injury plays an important role in flap failure. Ischemic preconditioning technique is the only proven method for preventing ischemia-reperfusion injury, but it is not used widely in daily practice because of difficulties such as prolonging the operation time, need for surgical experience, and increasing the risk of complications. This study has been performed with the assumption that piracetam may be a simple and inexpensive alternative to the preconditioning technique due to its antioxidant, antiaggregant, rheological, anti-inflammatory, antiapoptotic, cytoprotective, and immune modulating effects. METHODS Thirty-two rats were divided into four groups and latissimus dorsi musculocutaneous flaps were raised. No extra procedure was applied, and no treatment was given to the control group. Four hours of ischemia was created by clamping the thoracodorsal pedicle in the second group. The animals in the third group were treated with 10 minutes of ischemia and reperfusion periods as a preconditioning procedure before the 4 hours of ischemia. Animals in the fourth group received systemic piracetam 30 minutes before and 6 days after reperfusion. Nitric oxide and myeloperoxidase levels in serum and tissue, acute inflammatory cell response, and vascular proliferation in tissue were examined at the postoperative 24th hour and 10th day. RESULTS Myeloperoxidase activity in both preconditioning and piracetam groups, was significantly lower than the ischemia-reperfusion group. Acute inflammatory cell response was similarly decreased in both preconditioning and piracetam groups compared with ischemia-reperfusion group. Tissue measurements of nitric oxide were also significantly higher in both preconditioning and piracetam groups than in the ischemia-reperfusion group. However, vascular proliferation increased in the preconditioning group, while it did not show any significant change in the piracetam group. CONCLUSION This study shows that systemic piracetam treatment provides protection against ischemia-reperfusion injury in musculocutaneous flaps and can offer a simple and inexpensive alternative to the preconditioning technique.
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Affiliation(s)
- Anıl Demiröz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Handan Derebaşınlıoğlu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Sivas Cumhuriyet University, Faculty of Medicine, Sivas, Turkey
| | - Alp Ercan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Hakan Arslan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Övgü Aydın
- Department of Pathology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Hakan Ekmekçi
- Department of Biochemistry, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Özlem Balcı Ekmekçi
- Department of Biochemistry, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Yağmur Aydın
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Masa I, Casado-Sánchez C, Crespo-Lora V, Ballestín A. Effects of Ischemic Preconditioning and C1 Esterase Inhibitor Administration following Ischemia-Reperfusion Injury in a Rat Skin Flap Model. J Reconstr Microsurg 2020; 37:242-248. [PMID: 32971547 DOI: 10.1055/s-0040-1717102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ischemia-reperfusion (I/R) injury is a serious condition that can affect the success rate of microsurgical reconstructions of ischemic amputated limbs and complex tissue defects requiring free tissue transfers. The purpose of this study was to evaluate the effects of ischemic preconditioning (IPC) and C1 esterase inhibitor (C1-Inh) intravenous administration following I/R injury in a rat skin flap model. METHODS Superficial caudal epigastric skin flaps (3 cm × 7 cm) were performed on 50 Wistar rats that were randomly divided into five groups. Ischemia was not induced in the control group. All other flaps underwent 8 hours of ischemia prior to revascularization: I/R control group (8-hour ischemia), IPC group (preconditioning protocol + 8-hour ischemia), C1-Inh group (8-hour ischemia + C1-Inh), and IPC + C1-Inh group (preconditioning protocol + 8-hour ischemia + C1-Inh). Survival areas were macroscopically assessed after 1 week of surgery, and histopathological and biochemical evaluations were also measured. RESULTS There were no significant differences in flap survival between the treatment groups that were suffering 8 hours of ischemia and the control group. A significant increase in neovascularization and lower edema formation were observed in the IPC group compared with that in the I/R group. Biochemical parameters did not show any significant differences. CONCLUSION Intravenous administration of C1-Inh did not significantly modulate I/R-related damage in this experimental model, but further research is needed. On the other hand, IPC reduces tissue damage and improves neovascularization, confirming its potential protective effects in skin flaps following I/R injury.
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Affiliation(s)
- Inmaculada Masa
- Department of Plastic and Reconstructive Surgery, University Hospital Clínico San Carlos, Madrid, Spain
| | - César Casado-Sánchez
- Department of Plastic and Reconstructive Surgery, University Hospital La Paz, Madrid, Spain
| | | | - Alberto Ballestín
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
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42
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Peck CT, Strauß S, Stahl GL, Vogt PM, Busche MN. Mannose-binding lectin (MBL) and the lectin complement pathway play a role in cutaneous ischemia and reperfusion injury. Innov Surg Sci 2020; 5:43-51. [PMID: 33506093 PMCID: PMC7798300 DOI: 10.1515/iss-2020-0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives Cutaneous ischemia/reperfusion (CI/R) injury has shown to play a significant role in chronic wounds such as decubitus ulcers, diabetic foot ulcers, atherosclerotic lesions, and venous stasis wounds. CI/R also plays a role in free tissue transfer in reconstructive microsurgery and has been linked to clinical burn-depth progression after thermal injury. While the role of the complement system has been elucidated in multiple organ systems, evidence is lacking with respect to its role in the skin. Therefore, we evaluated the role of the complement system in CI/R injury. Methods Using a single pedicle skin flap mouse model of acute CI/R, we performed CI/R in wild-type (WT) mice and complement knock out (KO) mice, deficient in either C1q (C1q KO; classical pathway inhibition), mannose-binding lectin (MBL null; lectin pathway inhibition) or factor B (H2Bf KO; alternative pathway inhibition). Following 10 h ischemia and 7 days reperfusion, mice were sacrificed, flaps harvested and flap viability assessed via Image J software. The flap necrotic area was expressed as % total flap area. In another group, mice were sacrificed following CI/R with 10 h ischemia and 48 h reperfusion. Two cranial skin flap samples were taken for gene expression analysis of IL1b, IL6, TNFα, ICAM1, VCAM1, IL10, IL13 using real-time polymerase chain reaction (RT-PCR). Results Following CI/R, MBL null mice had a statistically significant smaller %necrotic flap area compared to WT mice (10.6 vs. 43.1%; p<0.05) suggesting protection from CI/R. A significantly reduced mean %necrotic flap area was not seen in either C1q KO or H2Bf KO mice relative to WT (22.9 and 31.3 vs. 43.1%; p=0.08 and p=0.244, respectively). There were no statistically significant differences between groups for markers of inflammation (TNFα, ICAM1, VCAM1, IL1b, IL6). In contrast, mRNA levels of IL10, a regulator of inflammation, were significantly increased in the MBL null group (p=0.047). Conclusions We demonstrated for the first time a significant role of MBL and the lectin complement pathway in ischemia/reperfusion injury of the skin and a potential role for IL10 in attenuating CI/R injury, as IL10 levels were significantly increased in the tissue from the CI/R-protected MBL null group.
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Affiliation(s)
- Claas-Tido Peck
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Sarah Strauß
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Gregory L Stahl
- Harvard Medical School, Center for Experimental Therapeutics and Reperfusion Injury, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter-Maria Vogt
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany
| | - Marc N Busche
- Hannover Medical School, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover, Germany.,Leverkusen Hospital gGmbH, Department of Plastic and Aesthetic Surgery, Burn Surgery, Leverkusen, Germany
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Lindelauf AAMA, Vranken NPA, Rutjens VGH, Schols RM, Heijmans JH, Weerwind PW, van der Hulst RRWJ. Economic Analysis of Noninvasive Tissue Oximetry for Postoperative Monitoring of Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Review. Surg Innov 2020; 27:534-542. [PMID: 32701027 PMCID: PMC7816549 DOI: 10.1177/1553350620942985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background. Postoperative monitoring of deep inferior epigastric perforator (DIEP) flaps for breast reconstruction using noninvasive tissue oximetry enables timely recognition of vascular compromise. This may limit ischemic tissue damage, minimizing postoperative morbidity and healthcare costs. The aim of this review was to provide an economic analysis of tissue oximetry for postoperative monitoring of DIEP flap breast reconstruction. Methods. A systematic literature search was conducted utilizing PubMed and Embase. Articles reporting costs related to tissue oximetry following DIEP flap breast reconstruction, costs directly related to DIEP flap surgical procedure, and costs associated with postoperative complications were included. Risk of bias was assessed using different tools depending on study type. Results. Six articles were included. Four studies provided an overview of total costs associated with DIEP flap breast reconstruction; two studies focused on whether tissue oximetry could facilitate a decrease in hospital costs. Average overall costs for DIEP flap procedure were estimated at $28 000, with additional costs up to $37 530 in case of total flap failure. Tissue oximetry to monitor DIEP flaps could potentially save up to $1667 per procedure. Moreover, it might eliminate the need for specialized postoperative care. Conclusion. Tissue oximetry following DIEP flap breast reconstruction can potentially facilitate a decrease in hospital costs since its readings enable physicians to intervene in an early stage of tissue malperfusion, contributing to minimizing complications. Tissue oximetry may eliminate the need for specialized postoperative care. However, based on the current literature, no firm conclusions can yet be drawn regarding cost-effectiveness of standard implementation.
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Affiliation(s)
- Anouk A M A Lindelauf
- Department of Cardiothoracic Surgery, 199236Maastricht University Medical Center, The Netherlands
| | - Nousjka P A Vranken
- Department of Cardiothoracic Surgery, 199236Maastricht University Medical Center, The Netherlands
| | - Vivian G H Rutjens
- Department of Cardiothoracic Surgery, 199236Maastricht University Medical Center, The Netherlands
| | - Rutger M Schols
- Department of Plastic, Reconstructive and Hand Surgery, 199236Maastricht University Medical Center, The Netherlands
| | - John H Heijmans
- Department of Anesthesia, 199236Maastricht University Medical Center, The Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, 199236Maastricht University Medical Center, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, 199236Maastricht University Medical Center, The Netherlands
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Uludağ Ö, Doğukan M, Duran M, Annac E. Effects of Prostaglandin Analogue Iloprost Treatment on Distant Organ Damage Following Ovarian Ischemia/Reperfusion Injury in Rats: An Experimental Study. Cureus 2020; 12:e8695. [PMID: 32699692 PMCID: PMC7370693 DOI: 10.7759/cureus.8695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Ischemia/reperfusion (I/R) injury causes oxidative stress, which, in turn, may impair the oxidant/antioxidant balance in tissues and cause damage to the tissues. The local effects of I/R injury can be typically observed in the related organ while systemic effects can be observed predominantly in the heart, brain, lung, and kidney. In this study, we aimed to evaluate the effects of iloprost on heart tissues after an ovarian I/R injury in an experimental rat model. Materials and methods A total of 32 female Sprague Dawley rats were used for the experiment. The rats were divided into four groups with eight rats each: Group I, control group; Group II, ischemia group; Group III, I/R group; Group IV, I/R + iloprost group. Surgical intervention was performed in each group and after the procedures, heart tissues were obtained and examined histopathologically. Results No significant pathological finding was found in Group I and II while degeneration of muscle fibers and interstitial edema was observed in group III and dilation of the vessels was detected in Group IV. No fibrosis or inflammation was observed in any group. Conclusion Iloprost provided protection against I/R injury and thus may be an alternative treatment for I/R injury.
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Affiliation(s)
- Öznur Uludağ
- Anesthesiology and Reanimation, Adıyaman University Faculty of Medicine, Adıyaman, TUR
| | - Mevlüt Doğukan
- Anesthesiology and Reanimation, Adıyaman University Faculty of Medicine, Adiyaman, TUR
| | - Mehmet Duran
- Anesthesiology and Reanimation, Adiyaman University Education and Research Hospital, Adiyaman, TUR
| | - Ebru Annac
- Histology and Embryology, Adıyaman University Faculty of Medicine, Adiyaman, TUR
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Dal F, Küçük C, Talih T, Sözüer E, Topal U, Deniz K, Akyıldız H. Effects of bradykinin preconditioning in an experimental intestinal ischemia reperfusion model on rats. Acta Cir Bras 2020; 35:e202000402. [PMID: 32578722 PMCID: PMC7307719 DOI: 10.1590/s0102-865020200040000002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To investigate the effects of bradykinin on reperfusion injury in an experimental intestinal ischemia reperfusion model. METHODS We used 32 Wistar-Albino rats. We composed 4 groups each containing 8 rats. Rats in sham group were sacrified at 100 minutes observation after laparotomy. Thirty minutes reperfusion was performed following 50 minutes ischaemia in control group after observing 20 minutes. Ischaemic preconditioning was performed in one group of the study. We performed the other study group pharmacologic preconditioning by infusional administration of 10 μg/kg/minute bradykinin intravenously. We sacrified all of the rats by taking blood samples to evaluate the lactate and lactate dehydrogenase (LDH) after resection of jejunum for detecting tissue myeloperoxidase (MPO) activity. RESULTS Lactate and LDH levels were significantly higher in control and study groups than the sham group (P<0.001). There is no difference between the study groups statistically. (P>0.05). The results were the same for MPO levels. Although definitive cell damage was determinated in the control group by hystopatological evaluation, the damage in the study groups observed was lower in different levels. However, there was no significant difference between the study groups statistically (P>0.05). CONCLUSION Either ischeamic preconditioning or pharmacologic preconditioning made by bradykinin reduced the ischemia reperfusion injury at jejunum.
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Post-operative monitoring of free flaps using a low-cost thermal camera: a pilot study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01642-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Careful post-operative monitoring of free flaps is important in flap survival; immediate action increases flap salvage rate. Although various methods are available, room for improvement remains. Thermal cameras have proven their value in medicine and are nowadays readily available at low costs. The objective of this study was to evaluate the potential of an affordable infrared thermal camera and software in the detection of failing free flaps during post-operative monitoring.
Methods
Free myocutaneous rectus abdominis flaps were harvested in 16 female landrace pigs and replanted after several hours of storage. All flaps were assessed with indocyanine green fluorescence angiography as well as hourly clinical assessment of skin colour, turgor and capillary refill. Furthermore, thermal photographs were taken simultaneously with the FLIR One thermal camera smartphone module. These photographs were processed in MATLAB and evaluated on their additional value as an indicator for flap failure.
Results
Out of 16 flaps, three flaps failed due to arterial failure and one flap developed venous congestion. The mean flap temperature compared to adjacent control skin proved to be most indicative for flap failure. All unsuccessful flaps showed lower temperatures after failure compared to the uncompromised free flaps.
Conclusions
An affordable thermal camera module can potentially contribute to post-operative free flap monitoring. Vascular compromise in free flaps can be distinguished by investigating relative temperature differences between the flap and reference skin. Until the FLIR One camera has been extensively investigated in a human population, it should be used in conjunction with conventional monitoring techniques.
Level of evidence: Level IV, diagnostic study
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Hillberg NS, Beugels J, van Kuijk SMJ, van der Hulst RRJW, Tuinder SMH. Increase of major complications with a longer ischemia time in breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Abstract
Background
The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for postmastectomy breast reconstruction. Prolonged ischemia can result in (partial) flap loss. The aim of this study was to evaluate the association between ischemia time and postoperative complications of DIEP flap breast reconstruction.
Methods
A retrospective study of all patients who received a breast reconstructionwith aDIEP flap atMaastricht University Medical Center in theNetherlands, between January 2010 and June 2017 (n = 677). The flaps were divided into two groups: flaps with an ischemia time less than 60 min and those with 60 min or more. Recipient site complications, in particular major complications equal to re-exploration, and partial or total flap loss were the primary outcome measures.
Results
In 23.9% of the 677 included DIEP flaps, the ischemia time was 60 min or longer. Within this group, a complication of the recipient site occurred in 30.9% of the flaps. A major complication occurred in 17.3% of the flaps with 60 min or more ischemia time.With regard to the flaps with less than 60-min ischemia time, a complication occurred in 22.1% of the cases of which 8.9%would be considered amajor complication. A significant association was found between ischemia time and major complications on univariate (p value = 0.003) and multivariate analyses (p value = 0.016).
Conclusions
This study demonstrates that an ischemia time less than 60 min is associated with a significantly lower risk of major recipient site complications compared to an ischemia time of 60 min or more.
Level of evidence: Level III, therapeutic, risk/prognostic study.
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Callewaert G, Monteiro Carvalho Mori Da Cunha MG, Dewulf K, Albersen M, Deprest J. Simulated vaginal delivery causes transients vaginal smooth muscle hypersensitivity and urethral sphincter dysfunction. Neurourol Urodyn 2020; 39:898-906. [PMID: 32050054 DOI: 10.1002/nau.24295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 01/13/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although pelvic floor dysfunction (PFD) has a multifactorial etiology, pregnancy and childbirth are considered crucial events predisposing to urinary incontinence as well as pelvic organ prolapse, which are highly prevalent. Rats are the most frequently used animal model and pudendal nerve crush (PNC) and vaginal distension (VD) are often used to mimic vaginal delivery. OBJECTIVE To document the time course of events after simulated vaginal delivery (SVD) on the urethral sphincter and the vaginal smooth muscle layer. MATERIALS AND METHODS Virgin female Sprague-Dawley rats were subjected to SVD (PNC + VD) or sham surgery and evaluated at 7, 14, 21, and 42 days after the injury. Urethral function was determined in vivo by microultrasound during cystometry and vaginal smooth muscle layer was harvested for in vitro pharmacologic investigation by isometric tension recording. Furthermore, vaginal and urethral samples were investigated by immunohistochemistry and real-time quantitative polymerase chain reaction. RESULTS Microultrasound showed no bursting of the urethral sphincter in the SVD group at 7 days with a functional recovery starting at 14 days, and normal bursting at 21 and 42 days. Vaginal smooth muscle showed higher sensitivity to carbachol at 14 and 21 days after injury; however, at 42 days, its sensitivity decreased when compared with sham. CONCLUSION SVD induces urethral dysfunction and a shift in vaginal smooth muscle contractile responses to carbachol.
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Affiliation(s)
- Geertje Callewaert
- Academic Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | | | - Karel Dewulf
- Academic Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Albersen
- Academic Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
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Molnar A, Magyar Z, Nachmias DB, Mann D, Szabo B, Toth L, Nemeth N. Effect of short-term ischemia on microcirculation and wound healing of adipocutaneous flaps in the rat. Acta Cir Bras 2020; 34:e201901203. [PMID: 32049184 PMCID: PMC7011208 DOI: 10.1590/s0102-865020190120000003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/18/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Composite flaps used in reconstructive surgery may intra- and postoperatively suffer from hypoperfusion and/or ischemia-reperfusion influencing wound healing. We aimed to follow-up the effect of ischemia on adipocutaneous flaps' wound healing and microcirculation. METHODS In anesthetized rats groin flaps were formed bilaterally. In Control group the flaps were repositioned and sutured back. In Ischemia-Reperfusion (I/R) group before repositioning and suturing the flap pedicles were clamped for 60 minutes. Laser Doppler (LD) fluxmetry and temperature probes were applied on the cranial, central and caudal flap regions before/after preparation and ischemia, re-suturing, and on the 1st-3rd-5th-7th-14th postoperative days, before the final examinations and biopsies for histology. RESULTS Flaps' skin temperature quickly recovered after repositioning. LD values were lower in the I/R group, reaching a significant level by the 3rd postoperative day, and remained lowered till the 14th day. The magnitude of alterations differed in the flap regions. Histologically normal wound healing process was seen, except for some I/R flaps, where hypertrophized mammary glands were found. CONCLUSIONS Short-term ischemia could influence flap microcirculation and wound healing, and may result in hypertrophized mammary glands. Laser Doppler could be used to evaluate intra- and postoperative microcirculatory changes and may have significance in predicting complications.
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50
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Perrault DP, Lee GK, Bouz A, Sung C, Yu R, Pourmoussa AJ, Park SY, Kim GH, Jiao W, Patel KM, Hong YK, Wong AK. Ischemia and reperfusion injury in superficial inferior epigastric artery-based vascularized lymph node flaps. PLoS One 2020; 15:e0227599. [PMID: 31923917 PMCID: PMC6954070 DOI: 10.1371/journal.pone.0227599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 12/23/2019] [Indexed: 01/17/2023] Open
Abstract
Vascularized lymph node transfer (VLNT) is a promising treatment modality for lymphedema; however, how lymphatic tissue responds to ischemia has not been well defined. This study investigates the cellular changes that occur in lymph nodes in response to ischemia and reperfusion. Lymph node containing superficial epigastric artery-based groin flaps were isolated in Prox-1 EGFP rats which permits real time identification of lymphatic tissue by green fluorescence during flap dissection. Flaps were subjected to ischemia for either 1, 2, 4, or 8 hours, by temporarily occluding the vascular pedicle. Flaps were harvested after 0 hours, 24 hours, or 5 days of reperfusion. Using EGFP signal guidance, lymph nodes were isolated from the flaps and tissue morphology, cell apoptosis, and inflammatory cytokines were quantified and analyzed via histology, immunostaining, and rtPCR. There was a significant increase in collagen deposition and tissue fibrosis in lymph nodes after 4 and 8 hours of ischemia compared to 1 and 2 hours, as assessed by picrosirius red staining. Cell apoptosis significantly increased after 4 hours of ischemia in all harvest times. In tissue subject to 4 hours of ischemia, longer reperfusion periods were associated with increased rates of CD3+ and CD45+ cell apoptosis. rtPCR analysis demonstrated significantly increased expression of CXCL1/GRO-α with 2 hours of ischemia and increased PECAM-1 and TNF-α expression with 1 hour of ischemia. Significant cell death and changes in tissue morphology do not occur until after 4 hours of ischemia; however, analysis of inflammatory biomarkers suggests that ischemia reperfusion injury can occur with as little as 2 hours of ischemia.
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Affiliation(s)
- David P. Perrault
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Gene K. Lee
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Antoun Bouz
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Cynthia Sung
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Roy Yu
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Austin J. Pourmoussa
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Sun Young Park
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Gene H. Kim
- Departments of Pathology and Dermatology, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Wan Jiao
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Young-Kwon Hong
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
| | - Alex K. Wong
- Division of Plastic and Reconstructive Surgery and Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, United States of America
- * E-mail:
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