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Khalaf R, Duarte Bateman D, Reyes J, Najafali D, Rampazzo A, Bassiri Gharb B. Systematic review of pathologic markers in skin ischemia with and without reperfusion injury in microsurgical reconstruction: Biomarker alterations precede histological structure changes. Microsurgery 2024; 44:e31141. [PMID: 38361264 DOI: 10.1002/micr.31141] [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: 02/21/2023] [Revised: 11/05/2023] [Accepted: 12/27/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Ischemia and ischemia-reperfusion injury contribute to partial or complete flap necrosis. Traditionally, skin histology has been used to evaluate morphological and structural changes, however histology does not detect early changes. We hypothesize that morphological and structural skin changes in response to ischemia and IRI occur late, and modification of gene and protein expression are the earliest changes in ischemia and IRI. METHODS A systematic review was performed in accordance with PRISMA guidelines. Studies reporting skin histology or gene/protein expression changes following ischemia with or without reperfusion injury published between 2002 and 2022 were included. The primary outcomes were descriptive and semi-quantitative histological structural changes, leukocyte infiltration, edema, vessel density; secondary outcomes were quantitative gene and protein expression intensity (PCR and western blot). Model type, experimental intervention, ischemia method and duration, reperfusion duration, biopsy location and time point were collected. RESULTS One hundred and one articles were included. Hematoxylin and eosin (H&E) showed inflammatory infiltration in early responses (12-24 h), with structural modifications (3-14 days) and neovascularization (5-14 days) as delayed responses. Immunohistochemistry (IHC) identified angiogenesis (CD31, CD34), apoptosis (TUNEL, caspase-3, Bax/Bcl-2), and protein localization (NF-κB). Gene (PCR) and protein expression (western blot) detected inflammation and apoptosis; endoplasmic reticulum stress/oxidative stress and hypoxia; and neovascularization. The most common markers were TNF-α, IL-6 and IL-1β (inflammation), caspase-3 (apoptosis), VEGF (neovascularization), and HIF-1α (hypoxia). CONCLUSION There is no consensus or standard for reporting skin injury during ischemia and IRI. H&E histology is most frequently performed but is primarily descriptive and lacks sensitivity for early skin injury. Immunohistochemistry and gene/protein expression reveal immediate and quantitative cellular responses to skin ischemia and IRI. Future research is needed towards a universally-accepted skin injury scoring system.
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Affiliation(s)
- Ryan Khalaf
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jose Reyes
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Najafali
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Lee JH, You HJ, Lee TY, Kang HJ. Current Status of Experimental Animal Skin Flap Models: Ischemic Preconditioning and Molecular Factors. Int J Mol Sci 2022; 23:5234. [PMID: 35563624 PMCID: PMC9103896 DOI: 10.3390/ijms23095234] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Skin flaps are necessary in plastic and reconstructive surgery for the removal of skin cancer, wounds, and ulcers. A skin flap is a portion of skin with its own blood supply that is partially separated from its original position and moved from one place to another. The use of skin flaps is often accompanied by cell necrosis or apoptosis due to ischemia-reperfusion (I/R) injury. Proinflammatory cytokines, such as nuclear factor kappa B (NF-κB), inhibitor of kappa B (IκB), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and oxygen free radicals are known causative agents of cell necrosis and apoptosis. To prevent I/R injury, many investigators have suggested the inhibition of proinflammatory cytokines, stem-cell therapies, and drug-based therapies. Ischemic preconditioning (IPC) is a strategy used to prevent I/R injury. IPC is an experimental technique that uses short-term repetition of occlusion and reperfusion to adapt the area to the loss of blood supply. IPC can prevent I/R injury by inhibiting proinflammatory cytokine activity. Various stem cell applications have been studied to facilitate flap survival and promote angiogenesis and vascularization in animal models. The possibility of constructing tissue engineered flaps has also been investigated. Although numerous animal studies have been published, clinical data with regard to IPC in flap reconstruction have never been reported. In this study, we present various experimental skin flap methods, IPC methods, and methods utilizing molecular factors associated with IPC.
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Affiliation(s)
- Ju-Hee Lee
- College of Korean Medicine, Dongguk University, Goyang 10326, Korea;
| | - Hi-Jin You
- Department of Plastic Surgery, Korea University Ansan Hospital, Ansan 15355, Korea; (H.-J.Y.); (T.-Y.L.)
| | - Tae-Yul Lee
- Department of Plastic Surgery, Korea University Ansan Hospital, Ansan 15355, Korea; (H.-J.Y.); (T.-Y.L.)
| | - Hyo Jin Kang
- Biomedical Research Center, Korea University Ansan Hospital, Ansan 15355, Korea
- Core Research and Development Center, Korea University Ansan Hospital, Ansan 15355, Korea
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Cao J, Lin H, Li W, Dong Z, Shi Y, Zhang X, Xiao R. Ischemia postconditioning protects dermal microvascular endothelial cells of rabbit epigastric skin flaps against apoptosis via adenosine A2a receptors. J Plast Surg Hand Surg 2019; 53:76-82. [PMID: 30688144 DOI: 10.1080/2000656x.2018.1550417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND It has been shown that endogenous adenosine-induced by ischemia postconditioning attenuates apoptosis in recent studies; however, they focus only on parenchymal cells. The detailed mechanism has not been clearly clarified in any research and the subtype of adenosine receptors involved remains unknown. In our study, dermal microvascular endothelial cells (DMECs) are used to explore the role of adenosine A2a receptor in the anti-apoptotic effects of ischemic postconditioning. MATERIAL AND METHODS The epigastric skin flaps of rabbits were elevated. After 4 h of ischemia, the flaps were either abruptly reperfused or postconditioned by six cycles of brief reperfusion (15s) and re-ischemia (15s). Adenosine A2a receptor agonist (CGS-21680) and antagonist (ZM-241385) were used separately in other groups. The apoptosis-related proteins and adenosine A2a receptors were determined by immunohistochemical staining. Then apoptosis index was calculated by TUNEL. RESULTS Ischemia/reperfusion caused severe damages in DMECs of flaps as demonstrated by an increase in apoptosis index and an increase in expressions of apoptosis-related proteins, which can be significantly attenuated by IPC treatment or exposure to a selective adenosine A2a receptor agonist (all p values <.05). Meanwhile, the anti-apoptosis effects of IPC can be blocked by a selective adenosine A2a receptor antagonist. Statistical analysis revealed that the increase of apoptosis index closely correlated inversely with the relative increase of adenosine A2a receptors (p < .0001). CONCLUSIONS Ischemia postconditioning protects DMECs of rabbit skin flap against apoptosis via activation of adenosine A2a receptors.
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Affiliation(s)
- Jiankun Cao
- a Department of Aesthetic Plastic Surgery and Laser Medicine , Beijing Anzhen Hospital, Capital Medical University-Beijing Institute of Heart Lung and Blood Vessel Diseases , Beijing , China.,b Research Center of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Huang Lin
- a Department of Aesthetic Plastic Surgery and Laser Medicine , Beijing Anzhen Hospital, Capital Medical University-Beijing Institute of Heart Lung and Blood Vessel Diseases , Beijing , China
| | - Wenzhi Li
- a Department of Aesthetic Plastic Surgery and Laser Medicine , Beijing Anzhen Hospital, Capital Medical University-Beijing Institute of Heart Lung and Blood Vessel Diseases , Beijing , China
| | - Ziying Dong
- c Cosmetic surgery , Rizhao People's Hospital , Rizhao , China
| | - Yanyu Shi
- a Department of Aesthetic Plastic Surgery and Laser Medicine , Beijing Anzhen Hospital, Capital Medical University-Beijing Institute of Heart Lung and Blood Vessel Diseases , Beijing , China
| | - Xiufang Zhang
- d Intensive Care Unit , Jining NO.1 People's Hospital , Jining , China
| | - Ran Xiao
- b Research Center of Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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Hypoxic postconditioning attenuates apoptosis via activation of adenosine A 2a receptors on dermal microvascular endothelial cells of human flaps. J Surg Res 2017; 217:144-152. [DOI: 10.1016/j.jss.2017.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/08/2017] [Accepted: 05/02/2017] [Indexed: 11/23/2022]
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Remote Ischemic Conditioning Improves Blood Flow and Oxygen Saturation in Pedicled and Free Surgical Flaps. Plast Reconstr Surg 2017; 138:1089-1097. [PMID: 27391830 DOI: 10.1097/prs.0000000000002664] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surgical flaps have become safe and reliable reconstructive tools, but total flap loss rates as high as 25 percent and partial flap loss rates as high as 36 percent have been reported due to insufficient perfusion. Therefore, a reliable, noninvasive, and effective way to improve the microcirculation of surgical flaps is desirable. The aim of this study was to assess the effect of remote ischemic conditioning on the microcirculation of pedicled and free surgical flaps. METHODS Thirty patients undergoing free (n = 20) and pedicled (n = 10) tissue transfer were included in this study. Remote ischemic conditioning was applied on the upper extremity for three cycles on postoperative days 1, 5, and 12. Blood flow, tissue oxygen saturation, and relative hemoglobin content were measured by means of a combination of laser Doppler and spectroscopy (O2C device) in the flap and the surrounding tissue. The relative increase compared with baseline measurements was assessed. RESULTS Blood flow increased significantly in controls on all 3 postoperative days (p < 0.05 for all). In free flaps, tissue oxygen saturation improved significantly on postoperative days 1 and 12 and blood flow improved significantly on postoperative days 5 and 12 (p < 0.05). In pedicled flaps, blood flow and tissue oxygen saturation increased on postoperative day12, but not significantly. CONCLUSIONS Remote ischemic conditioning is a safe, inexpensive, fast, and reliable method to improve the microcirculation of surgical flaps. Further research is warranted to see whether such an improvement translates into improved flap survival, but it is likely. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Shaked G, Czeiger D, Abu Arar A, Katz T, Harman-Boehm I, Sebbag G. Intermittent cycles of remote ischemic preconditioning augment diabetic foot ulcer healing. Wound Repair Regen 2016; 23:191-6. [PMID: 26083360 DOI: 10.1111/wrr.12269] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 02/09/2015] [Indexed: 01/13/2023]
Abstract
The morbidity and mortality caused by diabetic foot ulcer (DFU) are still significant. Conservative treatment of DFU is often ineffective. Treatment modalities using stem cells directly into the DFU or systematically have been introduced recently. Ischemic preconditioning (IPC) has been proved to be a cheap, simple, and safe method which can augment stem cells number in the peripheral blood circulation. This study's purpose was to test whether IPC can improve DFU healing. Forty diabetic patients were enrolled and divided into study and control groups. All patients received their regular treatment. The study group patients received in addition brief, transient cycles of IPC while the control group patients received a sham procedure only. The procedure was repeated every 2 weeks to complete a follow-up period of 6 weeks. The ulcers were photographed to measure wound area, and the degree of granulation tissue was assessed. No serious adverse events were noted. Twenty-two patients from the study group and 12 from the control group completed the entire follow-up. The ratio of patients who reached complete healing of their ulcer was 9/22 (41%) in the study group compared with 0/12 (0%) in the control group, p = 0.01. Furthermore, the mean remaining ulcer area at the end of the follow-up was significantly smaller in the study group, 25 ± 6% of the initial area vs. 61 ± 10% in the control group, p = 0.007. The degree of granulation increased after one cycle of treatment in 8/24 (33%) study patients compared to 3/16 (19%) in the control group, p = 0.47. Remote, repeated IPC significantly improves the healing of DFU. This simple, safe, inexpensive treatment method should be considered to be routinely applied to diabetic patients with DFU in addition to other regular treatment modalities.
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Affiliation(s)
| | | | | | | | - Ilana Harman-Boehm
- Department of Internal Medicine C and the Diabetes Unit, Soroka University Medical Center and Ben-Gurion University, Beer Sheva, Israel
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Correction: What happened if various kinds of postconditioning working on the preconditioned ischemic skin flaps. PLoS One 2015; 10:e0122425. [PMID: 25822336 PMCID: PMC4379133 DOI: 10.1371/journal.pone.0122425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kolbenschlag J, Sogorski A, Harati K, Daigeler A, Wiebalck A, Lehnhardt M, Kapalschinski N, Goertz O. Upper extremity ischemia is superior to lower extremity ischemia for remote ischemic conditioning of antero-lateral thigh cutaneous blood flow. Microsurgery 2014; 35:211-7. [PMID: 25278482 DOI: 10.1002/micr.22336] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/17/2014] [Accepted: 09/22/2014] [Indexed: 01/15/2023]
Abstract
Remote ischemic conditioning (RIC) is known to improve microcirculation in various settings, but little is known about the impact of the amount of ischemic tissue mass or the limb itself. Since ischemia and subsequent necrosis of flaps is one of the most dreaded complications in reconstructive surgery, adjuvant methods to improve microcirculation are desirable. We therefore performed a randomized trial to compare the effect of arm versus leg ischemia for RIC of the cutaneous microcirculation of the antero-lateral thigh. Forty healthy volunteers were randomized to undergo 5 min of ischemia of either the upper or lower extremity, followed by 10 min of reperfusion.Ischemia was induced by a surgical tourniquet applied to the proximal limb, which was inflated to 250 mmHg for the upper and 300 mgHg for the lower extremity. This cycle was repeated a total of three times. Cutaneous microcirculation was assessed by combined laser doppler spectrophotometry on the antero-lateral aspect of the thigh to measure cutaneous blood flow (BF), relative hemoglobin content (rHb), and oxygen saturation (StO2). Baseline measurements were performed for 10 min, after which the ischemia/reperfusion cycles were begun. Measurements were performed continuously and were afterwards pooled to obtain a mean value per minute. Both groups showed significant increases in all three measured parameters of cutaneous microcirculation after three cycles of ischemia/reperfusion when compared to baseline (BF: 95.1% (P < 0.001) and 27.9% (P = 0.002); rHb: 9.4% (P < 0.001) and 5.9% (P < 0.001), StO2: 8.4% (P = 0.045) and 9.4% (P < 0.001). When comparing both groups, BF was significantly higher in the arm group (P = 0.019 after 11 min., P = 0.009 after 45 min). In conclusions, both ischemic conditioning of the upper and lower extremity is able to improve cutaneous BF on the ALT donor site. However, RIC of the upper extremity seems to be a superior trigger for improvement of cutaneous BF.
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Affiliation(s)
- J Kolbenschlag
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Hand Surgery, Burn Center, Ruhr University, Bochum, Germany
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