Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers.

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.

Modification in flap design of the epigastric artery flap in rats--a new experimental flap model.

The standard rat epigastric artery flap has been a very reliable model for flap research. The purpose of this study was to describe a modified design of this flap that included only the medial branch of the epigastric artery. Axial-pattern epigastric island skin flaps, measuring 8 x 8 cm, were raised in two groups of Sprague-Dawley male rats. In group A (N = 20) the vascular pedicle consisted of the main trunk of the epigastric vessel and both medial and lateral branches. In group B (N = 20) the flap was based solely on the medial branch of the epigastric artery, excluding the large lateral branch. The flaps were elevated and then sutured back to their beds. Flap survival was studied and the amount of viable skin in both groups was compared 1 week later. The rats were photographed using a digital camera and the images were analyzed using imaging software. The mean percentage surviving flap area in group A was 86.24% and in group B it was 69.72%, which is statistically significant (p < 0.001). We believe that this flap model, with its new modified design that includes a larger flap and inclusion of only the medial branch, will broaden its application to microsurgery. The main advantage of this flap over the conventional epigastric flap is that in this model it is possible to achieve predictable and consistent necrosis in the random extension of the flap.

Arteriovenous cross-flow flap in rats: a novel skin flap.

Angiosomes are blocks of tissues, composed of the integument and underlying deep structures, supplied and drained by a named artery and its accompanying vein. The purpose of the current study is to describe a new principle, which allows extension of the territory of an angiosome into the adjacent angiosome, thus enabling the creation of a large skin flap (arteriovenous cross-flow flap). Epigastric skin flaps, measuring 8 x 8 cm, were raised in 30 Sprague-Dawley male rats. In group A (single-pedicle flap), the flaps were based on the epigastric artery and vein on the ipsilateral side, and the contralateral pedicle was divided. In group B (cross-flow flap), the epigastric vein on the ipsilateral side and the epigastric artery on the contralateral side of the flap were divided. In group C (skin graft), the vascular pedicles were divided bilaterally. A definitive assessment was made on the seventh day. Digital images of the flaps were analyzed using an imaging software and the areas of skin survival and necrosis were determined. Lead oxide microangiogram was performed in another set of flaps both acutely and 1 week after flap elevation. The percent survival flap area in group A was 69.94, in group B was 89.07, and in group C was 13.00. All the groups are statistically different, with a p value < 0.001. The microangiograms showed striking differences in the vascular pattern in the cross-flow and the single-pedicle flaps. It is clearly demonstrated that the arteriovenous cross-flow flaps have increased survival of skin when compared with the conventional axial-pattern flaps.

Fibrin glue-assisted end-to-side anastomosis of rat femoral vessels: comparison with conventional suture method.

Conventional methods of microvascular anastomosis using sutures cause vessel narrowing, foreign body reactions, and intravascular thrombosis. Although fibrin glue seems to be the ideal material to perform a microvascular anastomosis, its success has been limited. Excess fibrin used in some of the earlier methods has caused vessel narrowing and intravascular thrombosis. We evaluated the quality of end-to-side anastomosis using fibrin glue applied with a new technique and minimal sutures, and compared the results to those obtained with a standard suture technique. End-to-side anastomosis of femoral vessels was performed in 32 male Sprague-Dawley rats. Fibrin glue was topically applied at the anastomotic site, after inserting only two corner sutures. The fibrinogen component obtained from single donor human cryoprecipitate, was combined with bovine thrombin (500 IU per milliliter). In the control group (N = 16), the anastomosis was performed using eight to ten interrupted 10/0 nylon sutures. Fibrin glue-assisted anastomosis took less time, caused less bleeding at the anastomotic sites, and achieved a patency rate comparable to that provided by the suture technique. We have shown that a new, atraumatic technique of microvascular anastomosis with cryoprecipitate-thrombin glue and only two sutures, can produce excellent patency rates. This technique is easy to perform, inexpensive, and does not involve new equipment.

Early, fatal disseminated intravascular coagulation in a patient with 60 per cent burns.

A 23-year-old, previously fit and healthy young man was admitted to the West Midlands Regional Burns Unit at the Birmingham Accident Hospital, with 60 per cent body surface area burns and smoke inhalation. On arrival, he was briskly tachycardiac, hypotensive and disorientated. He was admitted to the intensive care unit, intubated and started on intermittent positive pressure ventilation. Despite prompt commencement of resuscitation and the infusion of enormous volumes of colloids, the patient remained oliguric. He soon developed severe haemorrhage from his gastrointestinal, urinary and respiratory tracts. He required several units of blood, but was persistently hypotensive. His condition deteriorated rapidly despite intensive supportive measures. He developed metabolic acidosis, refractory hypotension and died anuric, 20 h later. The post-mortem examination showed the presence of disseminated intravascular coagulation and adult respiratory distress syndrome.

A new method of applying fibrin glue at the microvascular anastomotic site: the "paintbrush" technique.

Fibrin glue has been used by several researchers to seal microvascular anastomoses sites. Usually the glue is delivered at the site with a syringe and needle. However, this technique can result in excess deposition of glue, which can cause intravascular thrombosis and can harden the vessel wall. We describe a new technique that avoids both these problems. We designed a "paintbrush" by inserting a suture through the syringe needle and then using the suture tip as a brush to apply the fibrin glue. End-to-side anastomoses were performed between the femoral artery and femoral vein in ten rats. Only two sutures were used to perform the anastomosis, the rest of the anastomosis being completed by sealing the gaps with fibrin glue. All the anastomoses were patent after 2 weeks, and no thromboses occurred. This is a new method for applying fibrin glue that delivers an adequate amount of fibrin glue without causing thrombosis.