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Park JKH, Myung Y. Treatment of delayed venous congestion of the nipple-areolar complex after reduction mammoplasty. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2021. [DOI: 10.14730/aaps.2020.02369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Irvine LE, Azizzadeh B, Kerulos JL, Nassif PS. Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty. Facial Plast Surg Aesthet Med 2020; 23:118-125. [PMID: 33054380 DOI: 10.1089/fpsam.2020.0181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Importance: This is the first study to review the incidence of nasal skin compromise after open rhinoplasty surgery and outcomes of treatment. Objectives: To determine whether risk of skin compromise after open rhinoplasty surgery can be predicted and whether our treatment protocol led to acceptable outcomes. Design, Setting, and Participants: This is a retrospective chart review of the senior author's private patients. In total, 384 rhinoplasty cases were reviewed and all cases with signs of vascular compromise requiring treatment were analyzed. Main Outcomes and Measures: Descriptive statistics were used to evaluate characteristics of patients who developed intra- and postoperative skin compromise, and unpaired two-tailed t-test was used to compare the characteristics of patients with and without compromised nasal skin when possible. Overall satisfaction results and complications in the skin compromise group were reported. Results: A total of 384 open rhinoplasties were performed by the senior author between October 1, 2015, and December 31, 2018. Of them, 109 were primary rhinoplasties and 275 were revision rhinoplasties. Of the 384 rhinoplasties, 27 (7%) had skin compromise leading to unplanned postoperative treatment. Two of the patients in the skin compromise group underwent primary surgeries (7.4%) and 25 underwent revision procedures (92.6%). Advanced age (p < 0.0001), prior or current history of smoking (p = 0.027), and greater number of prior rhinoplasty surgeries (p = 0.0002) were significantly correlated with risk of skin compromise. The average time to last follow-up in the skin compromise group was 392 days (range 15-1057 days). At their last follow-up, 12 patients had complete resolution of all signs of nasal skin compromise with no further treatment required (44.4%). The revision rate for patients experiencing skin compromise was 22.2%. One patient underwent revision surgery directly related to a complication of skin compromise and one is considering revision directly related to skin breakdown. Conclusions and Relevance: The rate of skin compromise after open rhinoplasty is low. Older patients and patients with more prior rhinoplasty surgeries may be at increased risk. Prompt treatment of compromised nasal blood supply after rhinoplasty surgery can salvage skin in most patients.
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Affiliation(s)
| | - Babak Azizzadeh
- Division of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA.,Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA
| | - Julia L Kerulos
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago-College of Medicine, Chicago, Illinois, USA
| | - Paul S Nassif
- Nassif MD, Inc., and Associates, Beverly Hills, California, USA.,Department of Head and Neck Surgery, Keck School of Medicine at the University of Southern California, Los angeles, California, USA
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Ritschl LM, Schmidt LH, Fichter AM, Hapfelmeier A, Wolff KD, Mücke T. Multimodal analysis using flowmeter analysis, laser-Doppler spectrophotometry, and indocyanine green videoangiography for the detection of venous compromise in flaps in rats. J Craniomaxillofac Surg 2018; 46:905-915. [PMID: 29661662 DOI: 10.1016/j.jcms.2018.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/26/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022] Open
Abstract
Venous congestion results in tissue damage and remains the most common failure of free microvascular transfer if it is not recognized early. The purpose of this experimental study was to evaluate venous congestion and describe the findings with two different monitoring tools. A standardized epigastric flap was raised, and total occlusion of the draining vein was temporarily applied for 4, 5, 6, or 7 h. Blood flow measurements, including laser-Doppler flowmetry, and tissue spectrophotometry (O2C) and indocyanine green (ICG) videoangiography using the FLOW® 800 tool, were performed systematically after each surgical step, an interval of venous occlusion, and 1 week of clinical observation. Both monitoring tools were capable of detecting acute venous occlusion. ICG videoangiography data showed a significant decrease in the first and second maximum, and the area under the curve, during venous occlusion, whereas hemoglobin levels in the O2C analysis remained stable. Changes in fluorescence values in border areas of the flap correlated significantly with the incidence of necrosis. O2C data later showed significant correlation with the area of necrosis, and more individual changes during flap monitoring. ICG videoangiography might therefore be useful in the prediction of flap necrosis in critical areas of perfusion.
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Affiliation(s)
- Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technische Universität München, Germany.
| | - Leonard H Schmidt
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Andreas M Fichter
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology Munich, Technische Universität München, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Thomas Mücke
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar, Technische Universität München, Germany; Department of Oral and Maxillofacial Surgery, Malteser Kliniken Rhein-Ruhr, Krefeld-Uerdingen, Germany
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Berlim GL, Oliveira ACP, Portinho CP, Morello E, Linhares CB, Collares MVM. Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats. Rev Col Bras Cir 2018; 45:e1276. [PMID: 29451640 DOI: 10.1590/0100-6991e-20181276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/17/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to validate an experimental model for the measurement of glycemic levels in surgical flaps with the use of common glucometers, and to analyze the diagnostic criteria for hypoperfusion of such flaps. METHODS we performed vertical myocutaneous rectus abdominis flaps with upper pedicles bilaterally in 20 male Wistar rats, divided into two groups: with and without venous occlusion of the pedicle. We measured glucose levels in the flaps and in the systemic circulation with standard glucometers. We tested the accuracy of alternative diagnostic criteria for the detection of hypoperfusion. RESULTS from 15 minutes of venous occlusion on, there was a significant reduction in glucose levels measured in the congested flap (p<0.001). Using a minimum difference of 20mg/dl in the glycemic levels between the flap and systemic blood, 30 minutes after occlusion, as a diagnostic criterion, the sensitivity was 100% (95% CI 83.99-100%) and specificity of 90% (95% CI 69.90-97.21%) for the diagnosis of flap congestion. CONCLUSION It is possible to measure glucose levels in vertical myocutaneous rectus abdominis flaps of Wistar rats, perfused or congested, using a common glucometer. The diagnostic criteria that compare the glucose levels in the flaps with the systemic ones were more accurate in the evaluation of tissue perfusion.
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Affiliation(s)
- Gustavo Levacov Berlim
- Post-Graduate Program in Surgical Sciences, Medical School, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Emerson Morello
- Post-Graduate Program in Surgical Sciences, Medical School, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Vascular Occlusion in a Porcine Flap Model: Effects on Blood Cell Concentration and Oxygenation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1531. [PMID: 29263951 PMCID: PMC5732657 DOI: 10.1097/gox.0000000000001531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022]
Abstract
Background: Venous congestion in skin flaps is difficult to detect. This study evaluated the ability of tissue viability imaging (TiVi) to measure changes in the concentration of red blood cells (CRBC), oxygenation, and heterogeneity during vascular provocations in a porcine fasciocutaneous flap model. Methods: In 5 pigs, cranial gluteal artery perforator flaps were raised (8 flaps in 5 pigs). The arterial and venous blood flow was monitored with ultrasonic flow probes. CRBC, tissue oxygenation, and heterogeneity in the skin were monitored with TiVi during baseline, 50% and 100% venous occlusion, recovery, 100% arterial occlusion and final recovery, thereby simulating venous and arterial occlusion of a free fasciocutaneous flap. A laser Doppler probe was used as a reference for microvascular perfusion in the flap. Results: During partial and complete venous occlusion, increases in CRBC were seen in different regions of the flap. They were more pronounced in the distal part. During complete arterial occlusion, CRBC decreased in all but the most distal parts of the flap. There were also increases in tissue oxygenation and heterogeneity during venous occlusion. Conclusions: TiVi measures regional changes in CRBC in the skin of the flap during arterial and venous occlusion, as well as an increase in oxygenated hemoglobin during venous occlusion that may be the result of reduced metabolism and impaired delivery of oxygen to the tissue. TiVi may provide a promising method for measuring flap viability because it is hand-held, easy to-use, and provides spatial information on venous congestion.
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Popa F, Georgescu AV. Abdominal Wall Reconstruction after Flap Surgery and the Effect on the Immune System. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2421585. [PMID: 29201900 PMCID: PMC5671673 DOI: 10.1155/2017/2421585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/24/2017] [Accepted: 09/06/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aim of our study was to investigate the impact of abdominal wall reconstruction surgery on tissue anatomy and to explore how flap surgery influences the patient's immune status. METHODS Experimental abdominal wall defects were created in 8 Sus scrofa (swine) animal models. The animals were divided into two groups: 4 swine were euthanized one month after surgery for the biopsies retrieval purpose and the other 4 swine were kept alive and the collection of blood samples has been done 6 months after surgery. In order to evaluate the relative gene expression in operated-on animal cohorts we compared them with samples from 4 healthy swine used as controls. RESULTS The inflammatory process was present in all types of repairs. Collagen I deposition was higher in the flap repairs. The expression level for the genes related to immune response after 6 months from surgery was relatively similar to the control group except minor alteration registered in the case of two swine models. CONCLUSION Our findings indicate a less pronounced proinflammatory response to surgical trauma in animal models after flap surgery. The postoperative levels of the inflammatory cytokines did not show significant differences after abdominal wall reconstruction using flap surgery.
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Affiliation(s)
- F. Popa
- Department of Plastic Surgery and Reconstructive Microsurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - A. V. Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Accurate Prediction of Tissue Viability at Postoperative Day 7 Using Only Two Intraoperative Subsecond Near-Infrared Fluorescence Images. Plast Reconstr Surg 2017; 139:354-363. [PMID: 28121867 DOI: 10.1097/prs.0000000000003009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ability to predict the future viability of tissue while still in the operating room and able to intervene would have a major impact on patient outcome. Although several objective methods to evaluate tissue perfusion have been reported, none to date has sufficient accuracy. METHODS In eight Sprague-Dawley rats, reverse McFarlane dorsal skin flaps were created. Continuous near-infrared fluorescence angiography using indocyanine green was performed immediately after surgery, for a total of 30 minutes. These dynamic measurements were used to quantify indocyanine green biodistribution and clearance, and to develop a simple metric that accurately predicted tissue viability at postoperative day 7. The new metric was compared to previously described metrics. RESULTS Reproducible patterns of indocyanine green biodistribution and clearance from the flap permitted quantitative metrics to be developed for predicting flap viability at postoperative day 7. Previously described metrics, which set the boundary between healthy and necrotic tissue as either 17 or 25 percent of peak near-infrared fluorescence at 2 minutes after indocyanine green injection, underestimated the area of necrosis by 75 and 48 percent, respectively. Our data suggest that both the shape and area of clinical necrosis occurring at postoperative day 7 can be predicted intraoperatively, with the boundary defined as near-infrared fluorescence intensities of 40 to 55 percent of peak fluorescence measured at 5 minutes. CONCLUSION Two 750-msec intraoperative near-infrared fluorescence images obtained at time 0 and at 5 minutes after injection of indocyanine green accurately predicted skin flap viability 7 days after surgery.
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Zötterman J, Bergkvist M, Iredahl F, Tesselaar E, Farnebo S. Monitoring of partial and full venous outflow obstruction in a porcine flap model using laser speckle contrast imaging. J Plast Reconstr Aesthet Surg 2016; 69:936-43. [PMID: 27026039 DOI: 10.1016/j.bjps.2016.02.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 01/28/2016] [Accepted: 02/28/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND In microsurgery, there is a demand for more reliable methods of post-operative monitoring of free flaps, especially with regard to tissue-threatening obstructions of the feeding arteries and draining veins. In this study, we evaluated laser speckle contrast imaging (LSCI) and laser Doppler flowmetry (LDF) to assess their possibilities to detect partial and full venous outflow obstruction, as well as full arterial occlusion, in a porcine flap model. METHODS Cranial gluteal artery perforator flaps (CGAPs) were raised, and arterial and venous blood flow to and from the flaps was monitored using ultrasonic flow probes. The venous flow was altered with an inflatable cuff to simulate partial and full (50% and 100%) venous obstruction, and arterial flow was completely obstructed using clamps. The flap microcirculation was monitored using LSCI and LDF. RESULTS Both LDF and the LSCI detected significant changes in flap perfusion. After partial (50%) venous occlusion, perfusion decreased from baseline, LSCI: 63.5 ± 12.9 PU (p = 0.01), LDF 31.3 ± 15.7 (p = 0.64). After 100% venous occlusion, a further decrease in perfusion was observed: LSCI 54.6 ± 14.2 PU (p < 0.001) and LDF 16.7 ± 12.8 PU (p < 0.001). After release of the venous cuff, LSCI detected a return of the perfusion to a level slightly, but not significantly, below the baseline level 70.1 ± 11.5 PU (p = 0.39), while the LDF signal returned to a level not significant from the baseline 36.1 ± 17.9 PU (p > 0.99). Perfusion during 100% arterial occlusion decreased significantly as measured with both methods, LSCI: 48.3 ± 7.7 (PU, p < 0.001) and LDF: 8.5 ± 4.0 PU (p < 0.001). During 50% and 100% venous occlusion, LSCI showed a 20% and 26% intersubject variability (CV%), respectively, compared to 50% and 77% for LDF. CONCLUSIONS LSCI offers sensitive and reproducible measurements of flap microcirculation and seems more reliable in detecting decreases in blood perfusion caused by venous obstruction. It also allows for perfusion measurements in a relatively large area of flap tissue. This may be useful in identifying areas of the flap with compromised microcirculation during and after surgery.
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Affiliation(s)
- Johan Zötterman
- Department of Hand and Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Max Bergkvist
- Department of Hand and Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Fredrik Iredahl
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Erik Tesselaar
- Department of Radiation Physics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Simon Farnebo
- Department of Hand and Plastic Surgery and Burns, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Coon D, Chen L, Boctor EM, Prince JL, Bojovic B. Proof-of-Concept Studies for Marker-Based Ultrasound Doppler Analysis of Microvascular Anastomoses in a Modified Large Animal Model. J Reconstr Microsurg 2015; 32:251-5. [PMID: 26645155 DOI: 10.1055/s-0035-1568158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background Despite attempts to solve the problem of flap monitoring, assessing the patency of vascular anastomoses postoperatively remains challenging. In addition, experimental data suggest that near-total vessel occlusion is necessary to produce significant changes in clinical appearance or monitoring devices. We sought to develop an ultrasound-based system that would provide definitive data on anastomotic function. Methods A system was developed consisting of a resorbable marker made from poly-lactic-co-glycolic acid (PLGA) implanted during the time of surgery coupled with ultrasound software to detect the anastomotic site and perform Doppler flow analysis. Surgical procedures consisting of microvascular free tissue transfer or femoral vessel cutdown were performed followed by marker placement, closure, and ultrasound monitoring. Transient vascular occlusion was produced via vessel-loop constriction. Permanent thrombosis was induced via an Arduino-controlled system applying current to the vessel intima. Results Four surgeries (one femoral vessel cutdown and three microvascular tissue transfer) were successfully performed in Yorkshire swine. The markers were readily visualized under ultrasound and provided a bounding area for Doppler analysis as well as orientation guidance. Transient spasm and partial occlusion were detected based on changes in Doppler data, while complete occlusion was evident as the total loss of color Doppler. Conclusion In this preliminary report, we have conceptualized and developed a novel system that enables the real-time visualization of vascular pedicle flow at the bedside using Doppler ultrasound and a surgically implanted marker. In a large animal model, use of the system allowed identification of the anastomosis, flow analysis, and real-time detection of flow loss.
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Affiliation(s)
- Devin Coon
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Lei Chen
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, Maryland
| | - Emad M Boctor
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, Maryland
| | - Jerry L Prince
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Branko Bojovic
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
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Ponticorvo A, Taydas E, Mazhar A, Ellstrom CL, Rimler J, Scholz T, Tong J, Evans GRD, Cuccia DJ, Durkin AJ. Evaluating visual perception for assessing reconstructed flap health. J Surg Res 2015; 197:210-7. [PMID: 25935469 DOI: 10.1016/j.jss.2015.03.099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 02/20/2015] [Accepted: 03/31/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Detecting failing tissue flaps before they are clinically apparent has the potential to improve postoperative flap management and salvage rates. This study demonstrates a model to quantitatively compare clinical appearance, as recorded via digital camera, with spatial frequency domain imaging (SFDI), a noninvasive imaging technique using patterned illumination to generate images of total hemoglobin and tissue oxygen saturation (stO2). METHODS Using a swine pedicle model in which blood flow was carefully controlled with occlusion cuffs and monitored with ultrasound probes, throughput was reduced by 25%, 50%, 75%, and 100% of baseline values in either the artery or the vein of each of the flaps. The color changes recorded by a digital camera were quantified to predict which occlusion levels were visible to the human eye. SFDI was also used to quantify the changes in physiological parameters including total hemoglobin and oxygen saturation associated with each occlusion. RESULTS There were no statistically significant changes in color above the noticeable perception levels associated with human vision during any of the occlusion levels. However, there were statistically significant changes in total hemoglobin and stO2 levels detected at the 50%, 75%, and 100% occlusion levels for arterial and venous occlusions. CONCLUSIONS As demonstrated by the color imaging data, visual flap changes are difficult to detect until significant occlusion has occurred. SFDI is capable of detecting changes in total hemoglobin and stO2 as a result of partial occlusions before they are perceivable, thereby potentially improving response times and salvage rates.
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Affiliation(s)
- Adrien Ponticorvo
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, California
| | - Eren Taydas
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, California
| | - Amaan Mazhar
- Modulated Imaging Inc., Beckman Laser Institute Photonic Incubator, Irvine, California
| | - Christopher L Ellstrom
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, California
| | - Jonathan Rimler
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, California
| | - Thomas Scholz
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, California
| | - June Tong
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, California
| | - Gregory R D Evans
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, California
| | - David J Cuccia
- Modulated Imaging Inc., Beckman Laser Institute Photonic Incubator, Irvine, California
| | - Anthony J Durkin
- Beckman Laser Institute and Medical Clinic, University of California Irvine, Irvine, California.
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Moosavian HR, Mirghazanfari SM, Moghaddam KG. Effect of ischemia preconditioning and leech therapy on cutaneous pedicle flaps subjected to prolonged ischemia in a mouse model. Aesthetic Plast Surg 2014; 38:1024-9. [PMID: 25189297 DOI: 10.1007/s00266-014-0399-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 08/13/2014] [Indexed: 12/20/2022]
Abstract
We sought to determine the effect of ischemic preconditioning (IPC) and hirudotherapy (leech therapy) on cutaneous pedicle flaps after they underwent prolonged ischemia (global ischemia) in a mouse model. Twenty cutaneous pedicle flaps were elevated in 20 mice, and the animals were randomized into four groups: sham, control, IPC and leech (5 flaps in each group). Except in the sham group, all flaps were subjected to global ischemia for 5 h via pedicle clamping. The control group did not receive any treatment before or after global ischemia. In the IPC group, global ischemia was preceded by three 10-min episodes of ischemia, each followed by 10 min of reperfusion. In the leech therapy group, after global ischemia, hirudotherapy was performed. Flap survival area and histopathological changes were evaluated on the 10th day after surgery. Flap survival areas were significantly higher in both the IPC and leech groups than in the control group and were significantly higher in the leech group than in the IPC group (p < 0.05). In conclusion IPC and hirudotherapy had definite effects on the survival area of cutaneous pedicle flaps that underwent prolonged ischemia in a mouse model.
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Laporta R, Longo B, Sorotos M, Pagnoni M, Santanelli Di Pompeo F. DIEP flap sentinel skin paddle positioning algorithm. Microsurgery 2014; 35:91-100. [PMID: 24771292 DOI: 10.1002/micr.22269] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 03/17/2014] [Accepted: 04/11/2014] [Indexed: 11/11/2022]
Abstract
Although clinical examination alone or in combination with other techniques is the only ubiquitous method for flap monitoring, it becomes problematic with buried free-tissue transfer. We present a DIEP flap sentinel skin paddle (SSP) positioning algorithm and its reliability is also investigated using a standardized monitoring protocol. All DIEP flaps were monitored with hand-held Doppler examination and clinical observation beginning immediately after surgery in recovery room and continued postoperatively at the ward. Skin paddle (SP) position was preoperatively drawn following mastectomy type incisions; in skin-sparing mastectomies types I-III a small SP (sSP) replaces nipple-areola complex; in skin-sparing mastectomy type IV, SSP is positioned between wise-pattern branches while in type V between medial/lateral branches. In case of nipple-sparing mastectomy SSP is positioned at inframammary fold or in lateral/medial branches of omega/inverted omega incision if used. Three hundred forty-seven DIEP flap breast reconstructions were reviewed and stratified according to SP type into group A including 216 flaps with large SP and group B including 131 flaps with SSP and sSP. Sixteen flaps (4.6%) were taken back for pedicle compromise, 13 of which were salvaged (81.25%), 11 among 13 from group A and 2 among 3 from group B. There was no statistical difference between the groups concerning microvascular complication rate (P = 0.108), and time until take-back (P = 0.521) and flap salvage rate (P = 0.473) resulted independent of SP type. Our results suggest that early detection of perfusion impairment and successful flaps salvage could be achieved using SSP for buried DIEP flap monitoring, without adjunctive expensive monitoring tests.
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Affiliation(s)
- Rosaria Laporta
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Italy
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Choi HN, Park JH, Han YS, Kim SR, Kim HK. Application of Digital Infrared Thermographic Imaging (DITI) in the Monitoring of Change of Skin Temperature about Vascular Supply of Lower Abdominal Axial Flap in the Rabbit. KOSIN MEDICAL JOURNAL 2013. [DOI: 10.7180/kmj.2013.28.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
MethodsEight male New Zealand white rabbits with average weight of 3kg were used. A 10 x 10 cm unipedicled fasciocutaneous island flap was elevated based on the left superficial inferior epigastric vessel. The surface temperatures on designed flap were checked with DITI for 24 hours after the operation. On 14th day after the operation, the surviving area was measured and compared with DITI image which was taken on 24 hours after the operation using digital analysis software ImageJ. Statistical analysis was evaluated by paired T-test ResultsOn DITI image 24 hours after the flap elevation, distal portion of the flap showed remarkable color change. The average percentage and the standard deviation of the survival area of the flap which is predicted by DITI and the average percentage and the standard deviation of the survival area of the flap which was actually measured 2 weeks after flap elevation were 55.3 (16.6), 56.2 (18.0), respectively. This shows no significant difference between the two. ObjectivesMonitoring viability of flap is important. The flap survival depends on the vascularity of the flap, on which the skin temperature depends. The authors applied digital infrared thermographic imaging (DITI) for monitoring the vascular supply of the flap and for the prediction of the prognosis of the flap survival. MethodsEight male New Zealand white rabbits with average weight of 3kg were used. A 10 x 10 cm unipedicled fasciocutaneous island flap was elevated based on the left superficial inferior epigastric vessel. The surface temperatures on designed flap were checked with DITI for 24 hours after the operation. On 14th day after the operation, the surviving area was measured and compared with DITI image which was taken on 24 hours after the operation using digital analysis software ImageJ. Statistical analysis was evaluated by paired T-test ResultsOn DITI image 24 hours after the flap elevation, distal portion of the flap showed remarkable color change. The average percentage and the standard deviation of the survival area of the flap which is predicted by DITI and the average percentage and the standard deviation of the survival area of the flap which was actually measured 2 weeks after flap elevation were 55.3 (16.6), 56.2 (18.0), respectively. This shows no significant difference between the two. ConclusionsThis study shows that DITI system could be used in evaluation of flap vascularity with ease, quickness and safety for patient and flap. Thus, it could be used clinically for the prediction of flap survival.
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14
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Ponticorvo A, Taydas E, Mazhar A, Scholz T, Kim HS, Rimler J, Evans GRD, Cuccia DJ, Durkin AJ. Quantitative assessment of partial vascular occlusions in a swine pedicle flap model using spatial frequency domain imaging. BIOMEDICAL OPTICS EXPRESS 2013; 4:298-306. [PMID: 23412357 PMCID: PMC3567716 DOI: 10.1364/boe.4.000298] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 12/21/2012] [Accepted: 01/04/2013] [Indexed: 05/03/2023]
Abstract
The use of tissue transfer flaps has become a common and effective technique for reconstructing or replacing damaged tissue. While the overall failure rate associated with these procedures is relatively low (5-10%), the failure rate of tissue flaps that require additional surgery is significantly higher (40-60%). The reason for this is largely due to the absence of a technique for objectively assessing tissue health after surgery. Here we have investigated spatial frequency domain imaging (SFDI) as a potential tool to do this. By projecting wide-field patterned illumination at multiple wavelengths onto a tissue surface, SFDI is able to quantify absolute concentrations of oxygenated and deoxygenated hemoglobin over a large field of view. We have assessed the sensitivity of SFDI in a swine pedicle flap model by using a controlled vascular occlusion system that reduced blood flow by 25%, 50%, 75%, or 100% of the baseline values in either the vein or artery. SFDI was able to detect significant changes for oxygenated hemoglobin, deoxygenated hemoglobin, or tissue oxygen saturation in partial arterial occlusions of at least 50% and partial venous occlusions of at least 25%. This shows SFDI is sensitive enough to quantify changes in the tissue hemoglobin state during partial occlusions and thus has the potential to be a powerful tool for the early prediction of tissue flap failure.
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Affiliation(s)
- Adrien Ponticorvo
- Beckman Laser Institute and Medical Clinic, University of California
Irvine, 1002 Health Sciences Road East, Irvine, CA 92617, USA
| | - Eren Taydas
- Beckman Laser Institute and Medical Clinic, University of California
Irvine, 1002 Health Sciences Road East, Irvine, CA 92617, USA
| | - Amaan Mazhar
- Modulated Imaging Inc., Beckman Laser Institute Photonic Incubator,
1002 Health Sciences Rd. East, Irvine, CA 92617, USA
| | - Thomas Scholz
- Department of Plastic Surgery, University of California Irvine
Medical Center, 200 S. Manchester Ave., Suite 650, Orange, CA 92868, USA
| | - Hak-Su Kim
- Department of Plastic Surgery, University of California Irvine
Medical Center, 200 S. Manchester Ave., Suite 650, Orange, CA 92868, USA
| | - Jonathan Rimler
- Department of Plastic Surgery, University of California Irvine
Medical Center, 200 S. Manchester Ave., Suite 650, Orange, CA 92868, USA
| | - Gregory R. D. Evans
- Department of Plastic Surgery, University of California Irvine
Medical Center, 200 S. Manchester Ave., Suite 650, Orange, CA 92868, USA
| | - David J. Cuccia
- Modulated Imaging Inc., Beckman Laser Institute Photonic Incubator,
1002 Health Sciences Rd. East, Irvine, CA 92617, USA
| | - Anthony J. Durkin
- Beckman Laser Institute and Medical Clinic, University of California
Irvine, 1002 Health Sciences Road East, Irvine, CA 92617, USA
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Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Decreases Flap Loss and Improves Rate of Flap Salvage. Plast Reconstr Surg 2011; 127:1080-1085. [DOI: 10.1097/prs.0b013e31820436cb] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Detection of Flap Venous and Arterial Occlusion Using Interstitial Glucose Monitoring in a Rodent Model. Plast Reconstr Surg 2010; 126:71-79. [DOI: 10.1097/prs.0b013e3181da87c8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Quantitative assessment of perfusion and vascular compromise in perforator flaps using a near-infrared fluorescence-guided imaging system. Plast Reconstr Surg 2009; 124:451-460. [PMID: 19644259 DOI: 10.1097/prs.0b013e3181adcf7d] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Techniques currently used to determine flap perfusion are mainly subjective, with the majority of reconstructive surgeons still relying on clinical examination. In this study, the authors demonstrate the use of near-infrared fluorescence angiography to directly quantify normal and abnormal perfusion in perforator flaps. METHODS Indocyanine green was injected intravenously into anesthetized adult pigs (n = 38). A custom near-infrared fluorescence imaging system was used for image acquisition and quantitation. Thirty-nine flaps were designed based on identified perforators, and postoperative imaging was performed for comparison. In select flaps, isolated occlusion of the arterial and venous pedicle was performed. In select flaps, vascular spasm was induced by local irrigation of the vessels with epinephrine. The fluorescence intensities of select regions of interest were quantified. From these data, the authors defined two indices for abnormal perfusion: the Tmax ratio and the drainage ratio. RESULTS The authors identified a normal pattern of perfusion before flap elevation, composed of a distinct fluorescence intensity peak at maximal arterial inflow followed by a smooth drop representing venous drainage. Delay of this peak after flap elevation, as indicated by the Tmax ratio, identified vascular spasm and arterial occlusion (p < 0.0001). Abnormal fall of fluorescence intensities after this peak, as indicated by the drainage ratio, identified venous occlusion (p < 0.0001). CONCLUSIONS Quantitation of fluorescence intensities by near-infrared angiography accurately characterizes arterial and venous compromise. The authors' technique can assess perfusion characteristics during the intraoperative and postoperative periods and therefore complements clinically based subjective criteria now used for flap assessment.
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Altintas MA, Altintas AA, Guggenheim M, Knobloch K, Niederbichler AD, Vogt PM. Monitoring of microcirculation in free transferred musculocutaneous latissimus dorsi flaps by confocal laser scanning microscopy--a promising non-invasive methodical approach. J Plast Reconstr Aesthet Surg 2008; 63:111-7. [PMID: 19027386 DOI: 10.1016/j.bjps.2008.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Revised: 07/26/2008] [Accepted: 08/08/2008] [Indexed: 11/30/2022]
Abstract
INTRODUCTION For the survival of a microvascular tissue transfer, early detection of vascular complications is crucial. In vivo confocal laser scanning microscopy allows real-time, non-invasive evaluation of tissue microcirculation with a high cellular resolution. The aim of this study was to evaluate confocal laser scanning microscopy for early recognition of flap failure. METHODS Fourteen patients (ages: 40.2+/-12.4 years) were monitored postoperatively for a period of 24h following free microvascular M. latissimus dorsi transfer to the lower extremity using confocal laser scanning microscopy (Vivascope1500; Rochester; New York; USA). The following parameters were evaluated: quantitative blood-cell flow, diameter of capillary loops and minimal thickness of the epidermis. RESULTS Venous congestion was characterised by a decrease in blood-cell flow of up to 41%, accompanied by an increase of the diameter of capillary loops of up to 22% and the minimal thickness of the epidermis up to 32%. By contrast, arterial occlusion was clearly verified by a decrease in blood flow of up to 90%, accompanied by an insignificant change of both capillary loop size and epidermal thickness. CONCLUSION Confocal laser scanning microscopy appears to be a useful non-invasive tool for early recognition of flap failure during the monitoring of microsurgical tissue transfer prior to its clinical manifestation.
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Affiliation(s)
- M A Altintas
- Department of Plastic, Hand and Reconstructive Surgery, Medical School Hannover, 30625 Hannover, Germany.
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Gene silencing of CD47 and antibody ligation of thrombospondin-1 enhance ischemic tissue survival in a porcine model: implications for human disease. Ann Surg 2008; 247:860-8. [PMID: 18438125 DOI: 10.1097/sla.0b013e31816c4006] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Insufficient tissue perfusion underlies many acute and chronic diseases. Tissue perfusion in turn requires adequate blood flow, determined in large part by the relative state of relaxation or constriction of arterial vessels. Nitric oxide (NO) produced by vascular cells modulates blood flow and tissue perfusion by relaxing and dilating arteries. Recently, we reported that the secreted protein thrombospondin-1 (TSP1), through its cell surface receptor CD47, limits the ability of NO to relax and dilate blood vessels and thus decreases tissue perfusion. In the present study, we tested the hypothesis that blocking TSP1-CD47 signaling increases ischemic tissue survival in random cutaneous porcine flaps. METHODS Random cutaneous flaps 2 x 10 cm2 were raised in white hairless Yucatan miniature pigs and were treated with a monoclonal antibody to TSP1, an antisense morpholino oligonucleotide to CD47 or control agents and tissue survival assessed. Primary vascular smooth muscle cell cultured from Yucatan pigs were also treated with the same agents +/- and an NO donor (DEA/NO) and cGMP quantified. RESULTS Antibody blockade of TSP1 or morpholino suppression of CD47 dramatically enhanced survival of random tissue flaps. These responses correlated with increased blood vessel patency and tissue blood flow on vessel injection studies. NO-stimulated cGMP flux in Yucatan vascular smooth muscle cell was abrogated after antibody or morpholino treatment. CONCLUSION Antibody ligation of TSP1 or antisense morpholino knock down of CD47 greatly increased tissue survival to ischemia. Given the similarity between porcine and human soft tissues these results suggest significant therapeutic potential for people.
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