Quantification of axonal ingrowth and functional recovery in a myocutaneous flap model in rats with strong clinical implications.

The process of reinnervation, an important component of functional restoration after flap transfer, is understudied, making it necessary to carry out a further investigation for delineation of the exact timeline. Seventy-six Sprague-Dawley rats were used as the experimental animals. An anatomic study was first conducted to clarify the pattern of nerve distribution in the dorsal skin of 16 rats. Afterward, a myocutaneous flap was harvested on the right flanks of 40 rats, which were then assigned into seven time points. At each time point, skin samples were harvested and immunofluorescent staining was performed using α-Bungarotoxin, and antibodies against NF-200, p75, α-SMA, and TH. One-way analysis of variance was adopted for comparison of nerve density after surgery. For evaluation of functional return, cutaneous trunci muscle reflex (CTMr) test was performed on 10 additional rats, and the Chi-square test was used for comparison of reflex intensity among six time points after surgery. The outcomes revealed that the cutaneous branches from the intercostal nerves and the dorsothoracic nerve from the brachial plexus could be found entering the dorsal skin, distributed in the skin proper and the panniculus carnosus, respectively. After flap surgery, full spontaneous reinnervation of the skin proper and vessels within the flaps could be achieved at day 180. However, if the stumps of cutaneous branches of the intercostal nerves were damaged, the nerve density in the skin proper underwent a 2/3 decline. The panniculus carnosus in the cranial part had a much better reinnervation than that in the caudal part. The CTMr test showed that the flap could regain most of its sensate and motor activity. Our study shows that strong spontaneous reinnervation could be expected after flap surgery. The pattern of the original nerve distribution in both the recipient and donor sites may have a big impact on the reinnervation of the flap.

Comparison of ischemic preconditioning and BotulinumA Toxin injection for the prevention of ischemia-reperfusion injury in musculocutaneous flaps

Background/aim: The aim of the study was to evaluate the protective effect of Botulinum A toxin injection against ischemia-reperfusion injury. Materials and methods: Thirty-two Sprague-Dawley rats were divided into: control, ischemia-reperfusion, ischemic preconditioning, and botulinum groups. In all groups the musculocutaneous pedicle flap was occluded for 4 h, and then reperfused to induce ischemia-reperfusion injury. Serum and tissue myeloperoxidase (MPO) and nitric oxide (NO) levels were measured at 24 h and at 10 days. Results: Tissue MPO levels did not differ significantly between the ischemic preconditioning and botulinum groups at 24 h but was significantly lower in the botulinum group at 10 days. Tissue NO levels were significantly higher in the ischemic preconditioning group compared to the botulinum group at 24 h and at 10 days. Serum MPO showed no significant difference between these two groups at 24 h but was significantly lower in the ischemic preconditioning group compared to the botulinum group at 10 days. Serum NO levels were not significantly different at 24 h but significantly higher in the botulinum group at 10 days. Conclusion: Findings show that botulinum has a protective effect against the ischemia-reperfusion injury via increased NO and decreased MPO levels in tissue. Based on tissue NO levels, ischemic preconditioning was significantly higher than botulinum.

The Use of Immersion Therapy Mattress With Low Air Loss in Patients With Myocutaneous Flaps.

BACKGROUND: In our hospital, air-fluidized therapy beds were used for all patients undergoing surgery for the creation of myocutaneous flaps. These beds were associated with staff injuries and patients reported dissatisfaction. The WOC nurses were asked to find an alternative support surface for postmyocutaneous flap patients. CASES: We report findings from 5 patients placed on a low air loss immersion mattress after myocutaneous flap surgery. On week 2, per our hospital's clinical pathway, all were transferred to our critical access hospitals with the immersion therapy mattress. Upon discharge, all flap incisions were approximated and closed. CONCLUSION: Our experiences with these 5 cases suggest that a support surface combining immersion and low air loss feature is a viable alternative to an air-fluidized bed for postoperative management of patient undergoing myocutaneous flap surgery for the management of full-thickness pressure injuries.

Extracorporal Shock Wave Therapy as a Delay Procedure to Improve Viability of Zone 4: An Experimental Study in a Rat TRAM Flap Model.

BACKGROUND: The purpose of this study was to test our hypothesis that preoperative application of radial extracorporeal shock wave therapy (rESWT) as a delay procedure would improve the survival of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap and reduce the resulting necrotic area. METHODS: Twenty-four Wistar rats were randomized and divided into 3 experimental groups (n = 8 each). Caudally based TRAM flap model, with the right rectus abdominis muscle as the carrier and right inferior epigastric vessels as the vascular pedicle, was used in this study. In group 1 (control), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2, the TRAM flap was raised, and rESWT was administered immediately after the flap was sutured back to its bed. In group 3, rESWT was applied 7 days before the elevation of the flap, as a delay procedure. Seven days after the administration of rESWT, TRAM flap was raised and then sutured back to its bed. RESULTS: At postoperative day 5, the mean percentage of skin flap survival was 61.82 ± 12.22 for group 1, 77.65 ± 4.62 for group 2, and 79.89 ± 5.86 for group 3. Groups 2 and 3 revealed higher survival areas when compared with control group (P = 0.02). In rESWT applied groups 2 and 3, the increase in capillary density and dilatation of microvessels in the skin flap survival areas were obvious. Histologic analysis revealed significantly higher neovascularization and less inflammation in zone 4 of rESWT applied groups (P < 0.001 and P = 0.042, respectively). CONCLUSIONS: ESWT appears to be a cheap, practical, and promising option for improving the viability of zone 4 of TRAM flap and may also be used as a delay procedure in the clinical setting.

Dynamic reconstruction of complex abdominal wall defects with the pedicled innervated vastus lateralis and anterolateral thigh PIVA flap.

BACKGROUND AND AIM: Reconstruction of large and chronically infected recurrent abdominal wall defects with exposed bowel in a scarred wound environment, when component release has been previously performed but failed, is a veritable challenge. We use a pedicled innervated vastus lateralis muscle with a fasciocutaneous anterolateral thigh flap (PIVA flap) to restore the continuity of the abdominal wall with vascularised tissues and create a dynamic component that improves the functional outcome. MATERIALS AND METHODS: A one-stage PIVA flap was used in 15 patients with grade 4 transmural chronically infected defects. They had a mean of 4.53 previous laparotomies and important co-morbidities. We determined post-operative reconstructive abdominal wall strength using a validated quality-of-life (QoL) hernia-related questionnaire and modified it to quantify donor-site morbidity at the thigh. We measured the maximal force generated at 60°/s and the force velocity at 120°/s by isokinetic dynamometric analysis at 3 and 12 months. Electromyography (EMG) was performed 12 months after the reconstruction to analyse the contractile integrity of the vastus lateralis segment. A two-sided sign test was used to analyse data. RESULTS: All transmural chronic wounds healed without recurrence. Dynamometric strength increased significantly in the abdominal wall musculature (p < 0.016) and in the donor thigh (p < 0.023) between 3 months and 12 months after the intervention, which reflected in the EMG outcome and the high scores in the QoL measurements after 12 months. CONCLUSIONS: The PIVA flap revascularises the scarred milieu, adds a dynamic component to improve function and may reach up to the xiphoid process. Donor-site morbidity is limited.

Terapia de presión negativa y podología / Negative pressure therapy and podiatry

La terapia por Presión Negativa es un sistema de cicatrización no invasivo y activo que utiliza una presión inferior al valor de la presión atmosférica normal, localizada y controlada, para estimular la curación de heridas. Esto se realiza a través de un sistema de bomba de vacío con una serie de componentes y con un protocolo de aplicación determinado. La Terapia por Presión Negativa está indicada en todos aquellos casos en los que convenga eliminar exudado y reducir edema, aumentar la microcirculación de la herida, estimular el tejido de granulación, mejorar el lecho de la herida y reducir la complejidad y tamaño de la misma. Numerosos estudios realizados demuestran las ventajas de esta terapia tanto a nivel socio-económico. Por el contrario, tras la realización de este trabajo, es evidente la falta de estudios centrados en la aplicación de la Terapia de Presión Negativa en podología (sobre todo en el pie diabético), por tanto, los resultados son insuficientes para establecer con claridad los beneficios terapéuticos y económicos de esta terapia en nuestra disciplina. El objetivo principal de este trabajo es hacer una presentación actualizada de la Terapia por Presión Negativa, de sus fundamentos biológicos y las aplicaciones clínicas actuales más frecuentes y, en consecuencia, la posibilidad de aplicación en el campo podológico (AU)

The Negative-Pressure Therapy is a non-invasive system of cicatrization that uses pressure below the normal atmospheric pressure. It is localized and controlled and also used to cure wounds. This is carried out through a vacuum system with a series of components and with a determined protocol of application. The Negative-Pressure Therapy is used in all those cases where we need to eliminate exude and reduce edema, to increase the microcirculation of the wound, to simulate the granulate tissue, to improve the wound, to stimulate the granulate tissue, to improve the wound and reduce the complexity and size of it. Numerous studies demonstrate the benefits of this therapy both at a clinical and socio-economics level. However, after the completion of this research, it is obvious that there is a lack of study focusing on the application of Negative-Pressure Therapy in podiatry (especially in the diabetic foot), therefore the results is insufficient to stablish therapeutic benefits and economic impact of this therapy in our discipline. The main goal of this article is to present an up-to-date perspective of the Negative-Pressure Therapy, its biological foundations and the most frequent clinical applications today, and as a result, the possibility of this application in the podiatry field (AU)