The Effects of Tumescent Solutions Containing Lidocaine and Epinephrine on Skin Flap Survival in Rats

Systematic Injection Patterned-Technique of One-Per-Mil Tumescent Solution for Perforator-Based Skin Flap: Is it Better Than the Random Patterned-Technique?

The aim of the study is to compare the systematic injection patterned-technique of 1-per-mil tumescent solution versus the random patterned-technique. Several incidences of perforator flap necrosis have been encountered with tumescent technique. Among the possible causes, the most probable cause is the injury of perforator artery due to the multi-passing needle injections. Thus, an evaluation regarding the needle injection pattern needs to be done in order to avoid necrotic flap incidence. A randomized controlled experimental study was conducted on both groins of 20 healthy Wistar stained-Rattus novergicus weighing 220 to 270 g. A comparison of a systematic injection pattern and a random injection pattern was performed. Three mL of 1-per-mil tumescent solution was injected subcutaneously before elevation of the islanded groin flap. Clarity of the operative field along with the size of the pedicle were recorded. The photos of survival area of the skin flap on postoperative day 7 were analyzed using Analyzing Digital Images. Totally bloodless operative field was observed in all subjects. Three out of 19 flaps in group A (15.78%) and 4 out of 18 flaps in group B (22.22%), were found to be necrotic, either total or partial. No significant difference (P > 0.05) was found between the injection technique groups, in terms of flap necrosis. Although the 1-per-mil tumescent technique is advantageous in a way that it provides a totally bloodless operative field, the systematic injection patterned-technique was not found to be more superior compared to the custom random patterned-multi-passing needle injection technique.

Vasopressors and reconstructive flap perfusion: a review of the literature comparing the effects of various pharmacologic agents

INTRODUCTION

Use of intraoperative vasopressors is of debate in microvascular surgery. Anesthesia is an important factor in maintaining the rate of success of flap transfer by affecting regional blood flow and global hemodynamics. We conducted a review of the literature comparing the use of different vasoactive agents on different flaps in various human and animal models.

METHODS

A systematic review of the literature was performed. Bibliographies of key articles were also reviewed for additional resources. Analysis was done to determine the overall trend of how flap perfusion is affected by the use of intraoperative vasoactive medication.

RESULTS

The literature search identified 16 relevant articles. Flaps were studied in pigs in 7 studies, rats in 5, and humans in 4. The most common flap was the rectus abdominis musculocutaneous flap. Phenylephrine and norepinephrine were the most common pressor agents used. No significant statistical changes were noted in 8 of the 16 studies; initial ischemia followed by delayed improved perfusion was observed in 4 studies, "true ischemia" and hypoperfusion of the skin flaps was noted in 3. There was no consistency in their effect on flap perfusion: initial ischemia followed by delayed improved perfusion was observed in 4 studies, whereas true ischemia and hypoperfusion of the skin flaps was noted in 3.

CONCLUSIONS

To date, there is no reliable prospective clinical evidence that supports the absolute contraindication of pressor agents during free flap surgery. This topic will continue to be a matter for debate until more definitive data can be obtained.

Local anesthetics for skin grafting and local flaps

In plastic surgery, there are many procedures that can be performed using local instead of general anesthesia. Not only can this help mitigate health care costs, but precious operating-room resources can also be directed to areas of greater need. Common procedures that can be performed under local anesthetics include skin grafts and local flaps. However, as not all patients are suitable for local anesthesia, careful patient selection is necessary to maintain the standard of care. This article describes the detailed surgical approach to using local anesthetics for skin grafts and local flaps.

Tumescent local anesthesia for excision and flap procedures in treatment of pilonidal disease

PURPOSE

We describe our experience with tumescent local anesthesia for excision and flap procedures in the treatment of pilonidal disease.

METHODS

Forty consecutive patients with symptomatic pilonidal disease were treated. Tumescent solution was prepared by mixing one volume of a lidocaine (20 mg/ml) and adrenaline (0.0125 mg/ml) combination with 9 volumes of lactated Ringer's solution. The final solution was infiltrated gradually and liberally, first subcutaneously and then into the skin. The end point was swollen and firm skin. After excision, the area was filled with an advancement flap or a rotational flap.

RESULTS

The study group consisted of 37 men (92.5%) and 3 women (7.5%); mean age, 27 (range, 18-61) years. The amount of injected solution ranged from 60 mL to 140 mL (mean, 100 mL; dose interval, 2-4 mg/kg). No additional anesthesia or sedation was needed, and no complications were observed during the procedure. Half of the patients were discharged on the day of the operation, half on the next day. Follow-up ranged from 13 to 37 months. Patients returned to daily activities after a mean of 10.5 (range, 2-30) days. Primary healing occurred uneventfully in 28 patients (70%); wound healing complications occurred in 12 (30%). No flap necrosis was observed. Thirty-seven (92.5%) patients reported satisfaction with the procedure. Recurrence was observed in 3 patients (7.5%).

CONCLUSIONS

Excision and flap procedures for sacrococcygeal pilonidal disease can be performed under tumescent local infiltration anesthesia with acceptable results, without requiring regional or general anesthesia.