Duration of Smoking Cessation and Its Impact on Skin Flap Survival:

REVERSE SURAL FLAP FOR LOWER LIMB RECONSTRUCTION

ABSTRACT Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.

Association of vaping with decreased vascular endothelial growth factor expression and decreased microvessel density in cutaneous wound healing tissue in rats

Vaping is suggested to be a risk factor for poor wound healing akin to smoking. However, the molecular and histologic mechanisms underlying this postulation remain unknown. Our study sought to compare molecular and histologic changes in cutaneous flap and non-flap tissue between vaping, smoking and control cohorts. Animal study of 15 male Sprague-Dawley rats was randomized to three cohorts: negative control (n = 5), e-cigarette (n = 5) and cigarette (n = 5) and exposed to their respective treatments with serum cotinine monitoring. After 30 days, random pattern flaps were raised and healed for 2 weeks after which skin punch biopsies of flap and non-flap tissues were collected for quantitative-reverse transcription-polymerase chain reaction of three selected wound healing genes (transforming growth factor β [TGF-β], vascular endothelial growth factor [VEGF], matrix metalloproteinase-1 [MMP-1]); then, immunohistochemistry for CD68 expression, α-smooth muscle actin looking at microvessel density (MVD) and in situ hybridization to localize VEGF production were undertaken. In flap tissue, vaping (mean[SEM]) (0.61[0.07]) and smoking (0.70[0.04]) were associated with decreased fold change of VEGF expression compared with controls (0.91[0.03]) (p < 0.05, p < 0.05, respectively). In non-flap tissue, only vaping was associated with decreased VEGF expression (mean[SEM]) (0.81[0.07]), compared with controls (1.17[0.10]) (p < 0.05) with expression primarily localized to basal keratinocytes and dermal capillaries. Immunohistochemistry showed decreased MVD in smoking (0.27[0.06]) and vaping (0.26[0.04]) flap tissue compared to matched controls (0.65[0.14]) (p < 0.05, p < 0.05, respectively) and decreased areas of fibrosis compared with controls on gross histology. Vaping and smoking were similarly associated with decreased VEGF expression, MVD and fibrotic changes in flap tissue. The results suggest attenuated angiogenesis via decreased VEGF expression as a mechanism for poor wound healing in vaping-exposed rats.

Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats

IMPORTANCE

Smoking is a known risk to wound healing, but whether electronic cigarettes present the same risk remains unknown.

OBJECTIVE

To evaluate the rate of flap necrosis in the e-cigarette vapor-exposed group and the unexposed control and to detect a difference in the rate of flap necrosis between the traditional cigarette smoke-exposed group and the unexposed control.

DESIGN, SETTING, AND PARTICIPANTS

From March 10, 2018, to May 4, 2018, a cohort study was conducted on 45 male Sprague-Dawley rats at Boston University School of Medicine. Each rat weighed approximately 100 g at the beginning of the study and was randomized to 1 of 3 groups: negative control (n = 15), experimental (exposed to e-cigarette vapor; n = 15), and positive control (exposed to traditional cigarette smoke; n = 15). Rats in the experimental and positive control groups were exposed to electronic cigarette vapor and traditional cigarette smoke in a smoking chamber for 30 minutes twice a day for 30 consecutive days. Levels of serum cotinine were monitored and maintained between 150 ng/mL and 200 ng/mL. After 30 days, random pattern dorsal skin flaps were raised.

MAIN OUTCOMES AND MEASURES

Percentage of flap necrosis for each group.

RESULTS

All 45 rats survived the surgical procedure and postoperative recovery, and all rats thrived and gained weight over the course of the study. The highest rate of flap necrosis was found in the positive control cohort, with a mean (SD) of 68.7% (8.6%), followed by the experimental cohort, with a mean (SD) of 65.9% (11.8%); the negative control cohort had the least amount of flap necrosis, with a mean (SD) of 50.8% (9.4%). The percentage of flap necrosis in the negative control rats (95% CI, 46.0-55.6; P < .001) was substantially lower than that for both the positive control rats (95% CI, 64.3-73.0; P < .001) and the experimental rats (95% CI, 59.9-71.8; P < .001). No statistically significant difference in flap necrosis was noted between the rats in the experimental cohort and the rats in the positive control cohort (95% CI, 59.9-71.8 vs 95% CI, 64.3-73.0; P = .46).

CONCLUSIONS AND RELEVANCE

Smoking and vaping appear to be equally detrimental to wound healing and to be associated with a statistically significant increase in flap necrosis compared with the unexposed group. The results suggest that vaping should not be seen as a better alternative to cigarette smoking in the context of wound healing.

LEVEL OF EVIDENCE

NA.

Mastectomy skin flap necrosis: challenges and solutions

Introduction

Mastectomy skin flap necrosis (MSFN) has a reported incidence of 5%–30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions.

Methods

A MEDLINE search was performed using the search term “mastectomy skin flap necrosis”. Titles and abstracts from peer-reviewed publications were screened for relevance.

Results

MSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited.

Conclusion

MSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Stepwise surgical approach to diabetic partial foot amputations with autogenous split thickness skin grafting

In the surgical treatment of severe diabetic foot infections, substantial soft tissue loss often accompanies partial foot amputations. These sizeable soft tissue defects require extensive care with the goal of expedited closure to inhibit further infection and to provide resilient surfaces capable of withstanding long-term ambulation. Definitive wound closure management in the diabetic population is dependent on multiple factors and can have a major impact on the risk of future diabetic foot complications. In this article, the authors provide an overview of autogenous skin grafting, including anatomical considerations, clinical conditions, surgical approach, and adjunctive treatments, for diabetic partial foot amputations.

Prevention of unfavourable effects of cigarette smoke on flap viability using botulinum toxin in random pattern flaps: An experimental study

BACKGROUND

There are numerous clinical and experimental studies reporting unfavourable effects of cigarette smoke on skin flaps.

OBJECTIVE

To investigate whether unfavourable effects of cigarette smoke on flap survival could be reduced by botulinum toxin type A.

METHODS

Twenty-eight male Wistar albino rats (15 months of age, mean weight 210 g [range 180 g to 230 g]) were included. They were divided into four groups of seven animals each. The control group underwent the surgical procedure alone. Surgical procedure was performed after administration of botulinum toxin type A in the botulinum toxin (BTX) group, after exposure to cigarette smoke in the cigarette smoke (CS) group, and after BTX type A administration and exposure to CS in the CS+BTX (CS+BTX) group. Random pattern cutaneous flaps (3 cm × 9 cm) were elevated from the dorsum of all rats. Necrosis area was calculated in percentages (%) using Image J computer software. Tissue samples were examined histopathologically.

RESULTS

The mean necrotic area in the control group (26%) and in the BTX group (21%) were similar (P=0.497), whereas administration of BTX type A significantly decreased flap necrosis area in the rats exposed to CS (the mean necrosis areas were 41.5% in the CS group, and 26% in the CS+BTX group; P<0.001). Histopathological examination findings corroborated the unfavourable effects of CS and preventive effects of BTX type A.

CONCLUSION

Preoperative administration of BTX significantly enhanced flap viability in the rats exposed to CS. Further human studies are warranted to verify whether BTX type A could be used as an agent to reduce the risk of flap necrosis in patients who smoke.

Prevention of unfavourable effects of cigarette smoke on flap viability using botulinum toxin in random pattern flaps: An experimental study

Background

There are numerous clinical and experimental studies reporting unfavourable effects of cigarette smoke on skin flaps.

Objective

To investigate whether unfavourable effects of cigarette smoke on flap survival could be reduced by botulinum toxin type A.

Methods

Twenty-eight male Wistar albino rats (15 months of age, mean weight 210 g [range 180 g to 230 g]) were included. They were divided into four groups of seven animals each. The control group underwent the surgical procedure alone. Surgical procedure was performed after administration of botulinum toxin type A in the botulinum toxin (BTX) group, after exposure to cigarette smoke in the cigarette smoke (CS) group, and after BTX type A administration and exposure to CS in the CS+BTX (CS+BTX) group. Random pattern cutaneous flaps (3 cm × 9 cm) were elevated from the dorsum of all rats. Necrosis area was calculated in percentages (%) using Image J computer software. Tissue samples were examined histopathologically.

Results

The mean necrotic area in the control group (26%) and in the BTX group (21%) were similar (P=0.497), whereas administration of BTX type A significantly decreased flap necrosis area in the rats exposed to CS (the mean necrosis areas were 41.5% in the CS group, and 26% in the CS+BTX group; P<0.001). Histopathological examination findings corroborated the unfavourable effects of CS and preventive effects of BTX type A.

Conclusion

Preoperative administration of BTX significantly enhanced flap viability in the rats exposed to CS. Further human studies are warranted to verify whether BTX type A could be used as an agent to reduce the risk of flap necrosis in patients who smoke.

Impact of diabetes and comorbidities on split-thickness skin grafts for foot wounds

BACKGROUND

Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy.

METHODS

We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome.

RESULTS

Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients.

CONCLUSIONS

For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population.

Preoperative risk reduction: strategies to optimize outcomes

The success of hernia repair is measured by absence of recurrence, appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound ischemia, and dehiscence, increases the risk of recurrent hernia by at least 3-fold. The surgeon should optimize all measures that promote healing, reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate perioperative period is surgical site infection. This article reviews several preoperative measures that have been reported to decrease SSOs and shorten length of hospital stay.

Smoking and the skin

Cigarette smoking has been associated with significant morbidity affecting all systems of the body, including the integumentary system. We review the many dermatologic hazards of tobacco use. It is important to distinguish between the effects of tobacco smoke from effects of pure nicotine on the skin. All skin cells express several subtypes of the nicotinic class of acetylcholine receptors, including the α7 receptor. Many chronic dermatoses are affected by smoking either negatively or positively. Elucidation of positive associations with a particular disease can lead to improvement from smoking cessation, whereas inverse correlation may lead to development of a disease-specific treatment with nicotinergic agonists.

Effects of natural and recombinant hirudin on superoxide dismutase, malondialdehyde and endothelin levels in a random pattern skin flap model

We have assessed the anti-inflammatory, anti-oxidative and anti-coagulant effects of locally applied natural and recombinant hirudin in a random skin flap rat model. Thirty Wistar rats with venous congested skin flaps were randomly divided into two treatment groups and a control group to receive subcutaneous injections of natural hirudin (6 U), recombinant hirudin (6 U) or physiological saline, respectively. Superoxide dismutase, malondialdehyde and endothelin levels as well as flap survival rates of the skin flaps were measured after surgery. Compared to the control group, the treatment groups had significant higher superoxide dismutase levels and lower malondialdehyde and endothelin levels in the skin flaps. The surviving areas of the flaps were larger in the treatment groups than the control group. Our results demonstrated that hirudin could improve skin flap survival through its anti-inflammatory, anti-oxidative and anti-coagulant activities.

Morbidity of microsurgical breast reconstruction in patients with comorbid conditions

BACKGROUND

Although free tissue-transfer with the deep inferior epigastric perforator (DIEP) flap is one of the best forms of autologous breast reconstruction, surgeons have remained guarded over selecting patients for the procedure in the presence of comorbid conditions. This study has investigated the relevance of these conditions.

METHODS

A prospective review of all free flap breast reconstructions (n = 624) was performed over a 2-year period at the Department of Plastic Surgery at the Sana Kliniken Düsseldorf. Patients were placed into three groups based on comorbid conditions such as age 65 years or older, active smoking, and body mass index greater than or equal to 30. Flap and donor-site complications were analyzed.

RESULTS

Six hundred twenty-four breast reconstructions with DIEP or muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps were performed in 558 patients (66 bilateral reconstructions). There were 36 patients older than 65 years at the time of surgery, 94 active smokers, and 79 patients with a body mass index of greater than or equal to 30. Flap complications such as venous congestion (n = 5), partial flap loss (n = 10), marginal necrosis (n = 15), and total flap loss (n = 5) occurred in 35 cases (5.6 percent). Donor-site complications such as delayed abdominal wound healing (n = 9), seroma (n = 8), abdominal hernia (n = 3), and bulging (n = 11) occurred in 31 cases (5 percent).

CONCLUSIONS

Despite having significantly higher complications in the form of delayed donor-site wound healing in active smokers and higher total flap loss in obese patients, the overall complication rates compared with other reconstructive procedures are low. Microsurgical reconstruction with DIEP and muscle-sparing TRAM flaps is associated with low complication rates, excellent aesthetic outcome, and high patient satisfaction, even in patients with known risk factors.

Split-thickness skin grafts for closure of diabetic foot and ankle wounds: a retrospective review of 83 patients

The aim of this study was to determine if split-thickness skin grafts could be successfully used for closure of foot and ankle wounds in diabetic patients. The authors retrospectively reviewed the charts of 100 consecutive patients who underwent a soft tissue surgical reconstruction with split-thickness skin grafts to their foot and/or ankle in our institution from 2005 to 2008. After application of inclusion criteria, 83 eligible charts remained. Of the 83 patients, 54 (65%) healed uneventfully, 23 (28%) required regrafting, and 6 (7%) had a complication resolved with conservative management. All patients had a successful surgical outcome, defined as having achieved complete wound closure at the final follow-up. Surgical outcome was not significantly associated with age, gender, race, hemoglobin A1C, wound size, wound location, illicit drug use, amputation history, Charcot history, or preoperative infection. However, postoperative graft complications were significantly associated with current or previous smoking history (P = .016) and the level of previous pedal amputation to which the split-thickness skin graft was applied (P = .009). This study demonstrates that application of split-thickness skin grafts with an appropriate postoperative regimen is a beneficial procedure to achieve foot and ankle wound closure in diabetic patients.