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Preserving skin microcirculation with “Dolphin” Bed Technology
Abstracts autograft A total of 24 procedures were performed (ten bilateral and four unilateral). Follow-up periods were 12 to 60 months. Postoperative complications rarely necessitated regrafting (one patient due to haematoma); more often showed partial dermal loss replaced by granulation tissue that was suitable as well for skin graft. Two autologus skin graft were lost needed regrafting. After a healing time of 6 to 14 weeks, scars were flat and linear. No recurrence of hidradenitis suppurativa has been observed. Range of motion or function was rated as good (minimal loss in range of motion or function) or excellent (complete range of motion or function preserved). All subjects were satisfied with the results of the procedure, and complications were minimal. Significant morbidity derives from extensive hidradenitis suppurativa caused by the disease extension and large wounds that result from surgical treatment. Wide surgical excision is the treatment of choice. Skin-grafting and healing by second intention lead to effective wound healing but with height recurrence rate for conservative surgery or with retraction and limitation in movement for aggressive surgery. Integra appears as an alternative to full-thickness skin grafting, and skin flaps in treating Hidradenitis suppurativa. The disadvantages of using Integra are the necessity of two operations. On the other hand, Integra has many advantages including its immediate availability, the availability of large quantities, the simplicity and reliability of the technique, and the minimal morbidity.
Biomechanical Properties of Fascia Lata Grafts L.H. Evers, D. Bhavsar, R. Bodor, G. Lemperle Department of Plastic Surgery, University of Luebeck, Germany Division of Plastic Surgery, University of California, San Diego, CA Fascia lata grafts are commonly employed as support structures in plastic and reconstructive surgery. Despite this widespread application, little objective testing has been published regarding the biomechanical features of this graft particularly as related to the clinical relevance of directional orientation. Cadaveric study was approved by institutional review board. 16 sheets of fascia lata (2.5 cm x 0.8 cm) were surgically and meticulously dissected, either in horizontal or vertical orientation, from fresh adult post-mortem specimens. The end of each sheet was affixed to the ZP-44 force gauge (IMADAâ Northbrook, IL) for measurement of bursting strength. Group A (n Z 8) were tested with fascia oriented horizontally, Group B (n Z 8) were tested with fascia oriented vertically. Force gauge was set for peak values and bursting strength as well as course of the biomechanical curve were recorded. Difference between the groups was analyzed with ANOVA test. The mean peak bursting strength of the fascia lata graft oriented in the horizontal direction was 11.5 N (SD 5.8) and in vertical direction 76.8 N (SD 17.1). The difference between bursting strengths for horizontal and vertical orientations is statistically significant (p < 0.01). Fascial fibre orientation is responsible for significant differences in strength and should be considered when employing these grafts for biomechanical and structural support applications. Fascial fibre orientation is likely derived from functional demands and graft harvest should reflect a balance of recipient site needs and donor site morbidity. Fascia lata in horizontal orientation does not provide adequate strength (11.5 N) when compared to native rectus fascia (peak bursting strength 59 N, Choe et al). Our data could form a base for further refinement in orienting the clinical applications of fascia lata for abdominal wall and other reconstructions.
The use of Spectrophotometric Intracutaneous Analysis (SIAscopy) in reduction mammaplasty and its clinical application in predicting ‘T-junction’ wound breakdown A. Lawa, P. Vaiudeb, A. Magdumc, H. Tehranib, M. Dalalc a Medical School, University of Manchester, United Kingdom
831 b
Plastic & Reconstructive Surgery, Mersey Deanery, United Kingdom Plastic & Reconstructive Surgery, Royal Preston Hospital, Preston, United Kingdom
c
Reduction mammaplasty or breast reduction is one of the most frequently performed breast surgeries worldwide. The commonest complication reported in up to 24 percent of breast reduction surgeries is T-junction wound breakdown. The ‘T-junction’ is the area at the base of the breast where skin flaps are approximated. It is widely accepted that the general cause of this phenomenon is reduced vascularity secondary to skin tension, smoking, diabetes and obesity. The study aims to evaluate the use of Spectrophotometric Intracutaneous Analysis (SIAscopy) to assess ‘T-junction’ skin vascularity, and therefore assess SIAscopy as a tool for predicting wound breakdown. 15 patients undergoing breast reduction were recruited and non-contact SIAscope readings were taken prior to the surgery, immediately postoperative on the operating table and at 2 weeks postoperatively. Tissue perfusion was based on image analysis of SIAscans. It was found that ‘T-junction’ breakdown occurred in 44.8 percent of the cases. The relationship between reduced vascularity and wound breakdown was found to be statistically significant (p Z 0.002). Of interest, no significant relationship was found between wound breakdown, pedicle choice and weight of breast tissue reduced. SIAscopy is a portable and non-invasive technology to investigate skin vascularity. There may be a role for its use in the assessment of skin flaps to modify a variety of surgical techniques in order to achieve an improved outcome.
Preserving skin microcirculation with ‘‘Dolphin’’ Bed Technology L.H. Evers, D. Bhavsar, K. Broder, A. Breithaupt, R. Bodor Division of Plastic Surgery, University of California, San Diego, CA Department of Plastic Surgery, University of Luebeck, Germany Pressure ulcers remain a major concern for healthcare facilities, from both economical and quality-of-care points of view, but with proper patient care their occurrence can be reduced. Interestingly, studies as rare as they are on this particular subject demonstrate that even though a 7 to 29 % range of incidents for pressure sores exists in the general acute care population, the incidence increases to an alarming 12 to 66 % rate for pressure sores acquired intraoperatively. Studies examining factors most likely associated with intra-operatively acquired pressure ulcers have not resulted in the development of reliable risk reduction tools adequately intervening in the surgical patient population. Current technology in pressure sores prevention consist in air flow mattresses. Regardless of previous improvements in these beds, the deflation during the surgery is still a significant drawback. Recently, a new technology has been introduced which uses three dimensional volumetric pressure redistribution. Our study aims to investigate the impact of this naval engineered bedding material on the effect of pressure on vulnerable cutaneous microcirculation. A total number of 10 healty volunteers were tested with the Microsolo 900 T surgical table surface (Biologics, Inc., Clearwater, Flo) and compared to a regular operating gurney. Objective measurement of the perfusion at pressure points of shoulder prominence were achieved with Laser Doppler Flowmetry (Periflux System 5000, Perimed, Sweden). With this technique the dynamic changes in the microcirculation were followed closely in real time. The percentage of the perfusion changes was calculated. Statistical analysis was performed using Student’s t-Test. The mean reduction of perfusion from a warmed subject (maximum heat), which represents maximum vasodilation, to regular gurney was 90.52 %, to the Dolphin bed only 22.31 %. The mean change of perfusion from Dolphin bed to regular gurney
832 was 88.71 %. The differences are statistically significant (p < 0.01). Our results indicate a significant improvement in microcirculation using the Dolphin Bed technology in comparison to regular gurneys. This results may lead to a prevention of pressure ulcer development. Further studies especially in high risk populations are warranted to investigate this new technology.
The application of a new laser Doppler imaging system in planning and monitoring of surgical flaps S. Schlossera, R. Wirtha, J.A. Plocka, A. Serovb, I. Pavlovb, A. Banica, D. Ernia a Department of Hand and Plastic Surgery, Inselspital, University of Berne, Bern, Switzerland b Division of Immunology and Allergy, CHUV, Lausanne, Switzerland Despite the latest technical improvements in reconstructive flap surgery, the operative success may still be jeopardized by ischemia. Therefore, there is a demand of technologies enabling to assess flap microcirculation quantitatively and reliably. We tested a new high-speed laser Doppler imaging (LDI) system developed for 2D high-definition imaging of superficial blood flow in skin. We assessed the potential of the new LDI system in the use of preoperative flap design and intra- and postoperative monitoring. LD images were taken at the donor site skin of 21 consecutive patients scheduled for reconstructive flap surgery (axial and free flaps) on the day before surgery. Perforators were identified and mapped on the flap skin intraoperatively and their position was correlated to LDI mapping. We took further images of the flap directly postoperatively and for the 5 following days. Flaps from 9 different donor sites (6xTRAM, 3x ALT/free fibula, 2x subcostal, 1xVRAM/lat. Dorsi/TFL/radialis) were measured. Sixty two spots with flow increase were detected in the preoperative LDI pictures, which partly corresponded to perforators found intraoperatively in the same field of measurement. The average LDI value dropped by 46 27% (mean SD) of the preoperative value (p < 0.01)) after disconnecting the flap tissue in cases of free flaps, whereas flow increased to 143 43% postoperatively (p < 0.05). The new LDI system allows a fast and clear evaluation of skin flap microcirculation. We were able to assess superficial distribution of blood flow suggesting the presence of perforators to some extent. A threshold could be identified, below which a flap can be considered not adequately perfused, which may serve for detecting anastomosic failure requiring surgical revision. Skin flaps could be easily monitored even in regions, which are usually difficult to access e.g. intraorally. Therefore, our experience suggests that the LDI technology may be a useful tool for free flap monitoring.
The effect of radial artery reconstruction on the radial forearm donor site S. Suominena, S. Giordanob, F. Lorenzettia, E. Tukiainena a Department of Plastic Surgery, To¨o¨lo¨ Hospital, Helsinki University Hospital, Helsinki, Finland b Department of Surgery, Vaasa Central Hospital, Vaasa, Finland The purpose of this study was to evaluate the effect of radial artery reconstruction after radial forearm flap elevation and to study whether a vein graft can stay patent in this position. Ten consecutive oral cancer patients were included in the study. Pre-operatively Allen’s test was performed and the flow velocity of both radial and ulnar arteries was recorded using colour Doppler ultrasonography. After flap elevation the radial artery was
Abstracts reconstructed using the cephalic vein of the donor forearm as a free vein graft. The reconstructed artery was completely covered with surrounding skin while the actual donor defect was covered with a split thickness skin-graft. Colour Doppler ultrasonography was performed at 1e2 weeks, 3e5 months and at 6e12 months postoperatively to record long-term patency. Radial artery reconstruction did not prolong the operations. All donor sites healed uneventhfully. All but one of the reconstructed arteries were patent at two weeks postoperatively. No areas of stenosis were detected. The mean vein graft diameter proximally was 1.3 mm larger than the non-operated control side. The mean blood flow velocity of the vein graft at 3e5 months postoperatively was proximally 0.48 cm/s, while in the non-operated control hand the mean radial artery flow velocity was 0.53 cm/s (p Z 0.89). Similarly, the mean blood flow velocity of the vein graft at 6e12 months postoperatively was distally 0.40 cm/s, while in the non-operated control hand the mean radial artery flow velocity was 0.53 cm/s (p Z 0.33). In one patient graft flow was patent peri-operatively but was missing already on the first postoperative day. A vein graft can remain patent with a high success rate after radial artery reconstruction. A negative Allen’s test is not an absolute contraindication of a radial forearm flap as radial artery reconstruction can be performed.
Intraoperative haemodynamic evaluation of the radial and ulnar arteries during free radial forearm flap procedure S. Giordanob, F. Lorenzettia, S. Suominena, E. Tukiainena a Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland b Department of Surgery, Vaasa Central Hospital, Vaasa, Finland The purpose of this study was to assess intra-operatively the blood flow in the radial and ulnar arteries before and after radial forearm flap raising. Twenty-two consecutive patients underwent to radial forearm microvascular reconstruction for head, neck and lower leg soft tissue defects. By using transit-time and ultra-sonic flowmeter we measured intra-operatively the blood flow in the radial and ulnar artery before and after the transplantation. The recipient arteries were assessed as well. In the in situ radial artery the mean blood flow was 60.5 47.7 ml/min before, 6.7 4.1 ml/min after raising the flap and 5.8 2.0 ml/min after end-to-end anastomosing it to the recipient artery. In the ulnar artery the mean blood flow was 60.5 43.3 ml/min before harvesting the radial forearm flap and significantly increased 85.7 57.9 ml/min after radial artery sacrifice. A significant difference was also found between this value and the value of blood flow in the ulnar and radial arteries pooled together (p < 0.05). The vascular resistance in the ulnar artery decreased significantly after the radial artery flap raising (from 2.7 3.1 to 1.9 2.2 peripheral resistance units, p Z 0.010). The forearm presents a cospicous vascularization not only through the radial and ulnar arteries but also through the interosseous system. The raising of the radial forearm flap increases blood flow and decreases vascular resistance in the ulnar artery. These haemodynamic changes seem to partially compensate the removal of the radial artery. After the radial artery sacrifice the interosseous system likely plays an important compensatory role. The radial forearm flap needs little blood flow to survive and behaves as a vascular shunt. Allen’s test seems not to be predictive of donor site hand vascular complications as the vascularization of the hand is very dynamic through the radial and ulnar arteries as well as the interosseous system.
Biomechanical Properties of Fascia Lata Grafts L.H. Evers, D. Bhavsar, R. Bodor, G. Lemperle Department of Plastic Surgery, University of Luebeck, Germany Division of Plastic Surgery, University of California, San Diego, CA Fascia lata grafts are commonly employed as support structures in plastic and reconstructive surgery. Despite this widespread application, little objective testing has been published regarding the biomechanical features of this graft particularly as related to the clinical relevance of directional orientation. Cadaveric study was approved by institutional review board. 16 sheets of fascia lata (2.5 cm x 0.8 cm) were surgically and meticulously dissected, either in horizontal or vertical orientation, from fresh adult post-mortem specimens. The end of each sheet was affixed to the ZP-44 force gauge (IMADAâ Northbrook, IL) for measurement of bursting strength. Group A (n Z 8) were tested with fascia oriented horizontally, Group B (n Z 8) were tested with fascia oriented vertically. Force gauge was set for peak values and bursting strength as well as course of the biomechanical curve were recorded. Difference between the groups was analyzed with ANOVA test. The mean peak bursting strength of the fascia lata graft oriented in the horizontal direction was 11.5 N (SD 5.8) and in vertical direction 76.8 N (SD 17.1). The difference between bursting strengths for horizontal and vertical orientations is statistically significant (p < 0.01). Fascial fibre orientation is responsible for significant differences in strength and should be considered when employing these grafts for biomechanical and structural support applications. Fascial fibre orientation is likely derived from functional demands and graft harvest should reflect a balance of recipient site needs and donor site morbidity. Fascia lata in horizontal orientation does not provide adequate strength (11.5 N) when compared to native rectus fascia (peak bursting strength 59 N, Choe et al). Our data could form a base for further refinement in orienting the clinical applications of fascia lata for abdominal wall and other reconstructions.
The use of Spectrophotometric Intracutaneous Analysis (SIAscopy) in reduction mammaplasty and its clinical application in predicting ‘T-junction’ wound breakdown A. Lawa, P. Vaiudeb, A. Magdumc, H. Tehranib, M. Dalalc a Medical School, University of Manchester, United Kingdom
831 b
Plastic & Reconstructive Surgery, Mersey Deanery, United Kingdom Plastic & Reconstructive Surgery, Royal Preston Hospital, Preston, United Kingdom
c
Reduction mammaplasty or breast reduction is one of the most frequently performed breast surgeries worldwide. The commonest complication reported in up to 24 percent of breast reduction surgeries is T-junction wound breakdown. The ‘T-junction’ is the area at the base of the breast where skin flaps are approximated. It is widely accepted that the general cause of this phenomenon is reduced vascularity secondary to skin tension, smoking, diabetes and obesity. The study aims to evaluate the use of Spectrophotometric Intracutaneous Analysis (SIAscopy) to assess ‘T-junction’ skin vascularity, and therefore assess SIAscopy as a tool for predicting wound breakdown. 15 patients undergoing breast reduction were recruited and non-contact SIAscope readings were taken prior to the surgery, immediately postoperative on the operating table and at 2 weeks postoperatively. Tissue perfusion was based on image analysis of SIAscans. It was found that ‘T-junction’ breakdown occurred in 44.8 percent of the cases. The relationship between reduced vascularity and wound breakdown was found to be statistically significant (p Z 0.002). Of interest, no significant relationship was found between wound breakdown, pedicle choice and weight of breast tissue reduced. SIAscopy is a portable and non-invasive technology to investigate skin vascularity. There may be a role for its use in the assessment of skin flaps to modify a variety of surgical techniques in order to achieve an improved outcome.
Preserving skin microcirculation with ‘‘Dolphin’’ Bed Technology L.H. Evers, D. Bhavsar, K. Broder, A. Breithaupt, R. Bodor Division of Plastic Surgery, University of California, San Diego, CA Department of Plastic Surgery, University of Luebeck, Germany Pressure ulcers remain a major concern for healthcare facilities, from both economical and quality-of-care points of view, but with proper patient care their occurrence can be reduced. Interestingly, studies as rare as they are on this particular subject demonstrate that even though a 7 to 29 % range of incidents for pressure sores exists in the general acute care population, the incidence increases to an alarming 12 to 66 % rate for pressure sores acquired intraoperatively. Studies examining factors most likely associated with intra-operatively acquired pressure ulcers have not resulted in the development of reliable risk reduction tools adequately intervening in the surgical patient population. Current technology in pressure sores prevention consist in air flow mattresses. Regardless of previous improvements in these beds, the deflation during the surgery is still a significant drawback. Recently, a new technology has been introduced which uses three dimensional volumetric pressure redistribution. Our study aims to investigate the impact of this naval engineered bedding material on the effect of pressure on vulnerable cutaneous microcirculation. A total number of 10 healty volunteers were tested with the Microsolo 900 T surgical table surface (Biologics, Inc., Clearwater, Flo) and compared to a regular operating gurney. Objective measurement of the perfusion at pressure points of shoulder prominence were achieved with Laser Doppler Flowmetry (Periflux System 5000, Perimed, Sweden). With this technique the dynamic changes in the microcirculation were followed closely in real time. The percentage of the perfusion changes was calculated. Statistical analysis was performed using Student’s t-Test. The mean reduction of perfusion from a warmed subject (maximum heat), which represents maximum vasodilation, to regular gurney was 90.52 %, to the Dolphin bed only 22.31 %. The mean change of perfusion from Dolphin bed to regular gurney
832 was 88.71 %. The differences are statistically significant (p < 0.01). Our results indicate a significant improvement in microcirculation using the Dolphin Bed technology in comparison to regular gurneys. This results may lead to a prevention of pressure ulcer development. Further studies especially in high risk populations are warranted to investigate this new technology.
The application of a new laser Doppler imaging system in planning and monitoring of surgical flaps S. Schlossera, R. Wirtha, J.A. Plocka, A. Serovb, I. Pavlovb, A. Banica, D. Ernia a Department of Hand and Plastic Surgery, Inselspital, University of Berne, Bern, Switzerland b Division of Immunology and Allergy, CHUV, Lausanne, Switzerland Despite the latest technical improvements in reconstructive flap surgery, the operative success may still be jeopardized by ischemia. Therefore, there is a demand of technologies enabling to assess flap microcirculation quantitatively and reliably. We tested a new high-speed laser Doppler imaging (LDI) system developed for 2D high-definition imaging of superficial blood flow in skin. We assessed the potential of the new LDI system in the use of preoperative flap design and intra- and postoperative monitoring. LD images were taken at the donor site skin of 21 consecutive patients scheduled for reconstructive flap surgery (axial and free flaps) on the day before surgery. Perforators were identified and mapped on the flap skin intraoperatively and their position was correlated to LDI mapping. We took further images of the flap directly postoperatively and for the 5 following days. Flaps from 9 different donor sites (6xTRAM, 3x ALT/free fibula, 2x subcostal, 1xVRAM/lat. Dorsi/TFL/radialis) were measured. Sixty two spots with flow increase were detected in the preoperative LDI pictures, which partly corresponded to perforators found intraoperatively in the same field of measurement. The average LDI value dropped by 46 27% (mean SD) of the preoperative value (p < 0.01)) after disconnecting the flap tissue in cases of free flaps, whereas flow increased to 143 43% postoperatively (p < 0.05). The new LDI system allows a fast and clear evaluation of skin flap microcirculation. We were able to assess superficial distribution of blood flow suggesting the presence of perforators to some extent. A threshold could be identified, below which a flap can be considered not adequately perfused, which may serve for detecting anastomosic failure requiring surgical revision. Skin flaps could be easily monitored even in regions, which are usually difficult to access e.g. intraorally. Therefore, our experience suggests that the LDI technology may be a useful tool for free flap monitoring.
The effect of radial artery reconstruction on the radial forearm donor site S. Suominena, S. Giordanob, F. Lorenzettia, E. Tukiainena a Department of Plastic Surgery, To¨o¨lo¨ Hospital, Helsinki University Hospital, Helsinki, Finland b Department of Surgery, Vaasa Central Hospital, Vaasa, Finland The purpose of this study was to evaluate the effect of radial artery reconstruction after radial forearm flap elevation and to study whether a vein graft can stay patent in this position. Ten consecutive oral cancer patients were included in the study. Pre-operatively Allen’s test was performed and the flow velocity of both radial and ulnar arteries was recorded using colour Doppler ultrasonography. After flap elevation the radial artery was
Abstracts reconstructed using the cephalic vein of the donor forearm as a free vein graft. The reconstructed artery was completely covered with surrounding skin while the actual donor defect was covered with a split thickness skin-graft. Colour Doppler ultrasonography was performed at 1e2 weeks, 3e5 months and at 6e12 months postoperatively to record long-term patency. Radial artery reconstruction did not prolong the operations. All donor sites healed uneventhfully. All but one of the reconstructed arteries were patent at two weeks postoperatively. No areas of stenosis were detected. The mean vein graft diameter proximally was 1.3 mm larger than the non-operated control side. The mean blood flow velocity of the vein graft at 3e5 months postoperatively was proximally 0.48 cm/s, while in the non-operated control hand the mean radial artery flow velocity was 0.53 cm/s (p Z 0.89). Similarly, the mean blood flow velocity of the vein graft at 6e12 months postoperatively was distally 0.40 cm/s, while in the non-operated control hand the mean radial artery flow velocity was 0.53 cm/s (p Z 0.33). In one patient graft flow was patent peri-operatively but was missing already on the first postoperative day. A vein graft can remain patent with a high success rate after radial artery reconstruction. A negative Allen’s test is not an absolute contraindication of a radial forearm flap as radial artery reconstruction can be performed.
Intraoperative haemodynamic evaluation of the radial and ulnar arteries during free radial forearm flap procedure S. Giordanob, F. Lorenzettia, S. Suominena, E. Tukiainena a Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland b Department of Surgery, Vaasa Central Hospital, Vaasa, Finland The purpose of this study was to assess intra-operatively the blood flow in the radial and ulnar arteries before and after radial forearm flap raising. Twenty-two consecutive patients underwent to radial forearm microvascular reconstruction for head, neck and lower leg soft tissue defects. By using transit-time and ultra-sonic flowmeter we measured intra-operatively the blood flow in the radial and ulnar artery before and after the transplantation. The recipient arteries were assessed as well. In the in situ radial artery the mean blood flow was 60.5 47.7 ml/min before, 6.7 4.1 ml/min after raising the flap and 5.8 2.0 ml/min after end-to-end anastomosing it to the recipient artery. In the ulnar artery the mean blood flow was 60.5 43.3 ml/min before harvesting the radial forearm flap and significantly increased 85.7 57.9 ml/min after radial artery sacrifice. A significant difference was also found between this value and the value of blood flow in the ulnar and radial arteries pooled together (p < 0.05). The vascular resistance in the ulnar artery decreased significantly after the radial artery flap raising (from 2.7 3.1 to 1.9 2.2 peripheral resistance units, p Z 0.010). The forearm presents a cospicous vascularization not only through the radial and ulnar arteries but also through the interosseous system. The raising of the radial forearm flap increases blood flow and decreases vascular resistance in the ulnar artery. These haemodynamic changes seem to partially compensate the removal of the radial artery. After the radial artery sacrifice the interosseous system likely plays an important compensatory role. The radial forearm flap needs little blood flow to survive and behaves as a vascular shunt. Allen’s test seems not to be predictive of donor site hand vascular complications as the vascularization of the hand is very dynamic through the radial and ulnar arteries as well as the interosseous system.