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Wlodarczyk J, Leng A, Abadchi SN, Shababi N, Mokhtari-Esbuie F, Gheshlaghi S, Ravari MR, Pippenger EK, Afrasiabi A, Ha J, Abraham JM, Harmon JW. Transfection of hypoxia-inducible factor-1α mRNA upregulates the expression of genes encoding angiogenic growth factors. Sci Rep 2024; 14:6738. [PMID: 38509125 PMCID: PMC10954730 DOI: 10.1038/s41598-024-54941-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Hypoxia-Inducible Factor-1α (HIF-1α) has presented a new direction for ischemic preconditioning of surgical flaps to promote their survival. In a previous study, we demonstrated the effectiveness of HIF-1a DNA plasmids in this application. In this study, to avoid complications associated with plasmid use, we sought to express HIF-1α through mRNA transfection and determine its biological activity by measuring the upregulation of downstream angiogenic genes. We transfected six different HIF-1a mRNAs-one predominant, three variant, and two novel mutant isoforms-into primary human dermal fibroblasts using Lipofectamine, and assessed mRNA levels using RT-qPCR. At all time points examined after transfection (3, 6, and 10 h), the levels of HIF-1α transcript were significantly higher in all HIF-1α transfected cells relative to the control (all p < 0.05, unpaired Student's T-test). Importantly, the expression of HIF-1α transcription response genes (VEGF, ANG-1, PGF, FLT1, and EDN1) was significantly higher in the cells transfected with all isoforms than with the control at six and/or ten hours post-transfection. All isoforms were transfected successfully into human fibroblast cells, resulting in the rapid upregulation of all five downstream angiogenic targets tested. These findings support the potential use of HIF-1α mRNA for protecting ischemic dermal flaps.
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Affiliation(s)
- Jakub Wlodarczyk
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
- Department of General and Oncological Surgery, Medical University of Lodz, Lodz, Poland
| | - Albert Leng
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Sanaz Nourmohammadi Abadchi
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Niloufar Shababi
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Farzad Mokhtari-Esbuie
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Shayan Gheshlaghi
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Mohsen Rouhani Ravari
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
- Department of Surgery, University of Chicago Medicine, Chicago, IL, 60637, USA
| | - Emma K Pippenger
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Ali Afrasiabi
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21224, USA
| | - John M Abraham
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA
| | - John W Harmon
- Department of Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, 1550 Orleans Street, Baltimore, MD, 21224, USA.
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Corbett J, Rocks M, Wu M, Nemir S, Castro J, Gonzalez G, Azad A, Hacquebord J, Diamond S. Tourniquet Use in Extremity-Based Microsurgery. J Reconstr Microsurg 2024; 40:227-231. [PMID: 37467770 DOI: 10.1055/a-2132-9804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.
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Affiliation(s)
- John Corbett
- Department of Surgery, George Washington University, Washington, Dist. of Columbia
- Department of Surgery, Texas Tech University Health Science Center El Paso, El Paso, Texas
| | - Madeline Rocks
- Division of Hand Surgery, NYU Langone Health Department of Orthopedic Surgery, New York, New York
| | - Meagan Wu
- Sidney Kimmel Medical College, Thomas Jefferson University Philadelphia, Pennsylvania
| | - Stephanie Nemir
- Department of Surgery, Texas Tech University Health Science Center El Paso, El Paso, Texas
| | - Jose Castro
- Department of Surgery, Texas Tech University Health Science Center El Paso, El Paso, Texas
| | - Gilberto Gonzalez
- Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Ali Azad
- Division of Hand Surgery, NYU Langone Health Department of Orthopedic Surgery, New York, New York
| | - Jacques Hacquebord
- Division of Hand Surgery, NYU Langone Health Department of Orthopedic Surgery, New York, New York
- NYU Langone Health Hansjörg Wyss Department of Plastic Surgery, New York, New York
| | - Shawn Diamond
- Department of Surgery, Texas Tech University Health Science Center El Paso, El Paso, Texas
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Aksamitiene E, Heffelfinger RN, Hoek JB, Pribitkin ED. Standardized Pre-clinical Surgical Animal Model Protocol to Investigate the Cellular and Molecular Mechanisms of Ischemic Flap Healing. Biol Proced Online 2024; 26:2. [PMID: 38229030 DOI: 10.1186/s12575-023-00227-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Some of the most complex surgical interventions to treat trauma and cancer include the use of locoregional pedicled and free autologous tissue transfer flaps. While the techniques used for these reconstructive surgery procedures have improved over time, flap complications and even failure remain a significant clinical challenge. Animal models are useful in studying the pathophysiology of ischemic flaps, but when repeatability is a primary focus of a study, conventional in-vivo designs, where one randomized subset of animals serves as a treatment group while a second subset serves as a control, are at a disadvantage instigated by greater subject-to-subject variability. Our goal was to provide a step-by-step methodological protocol for creating an alternative standardized, more economical, and transferable pre-clinical animal research model of excisional full-thickness wound healing following a simulated autologous tissue transfer which includes the primary ischemia, reperfusion, and secondary ischemia events with the latter mimicking flap salvage procedure. RESULTS Unlike in the most frequently used classical unilateral McFarlane's caudally based dorsal random pattern skin flap model, in the herein described bilateral epigastric fasciocutaneous advancement flap (BEFAF) model, one flap heals under normal and a contralateral flap-under perturbed conditions or both flaps heal under conditions that vary by one within-subjects factor. We discuss the advantages and limitations of the proposed experimental approach and, as a part of model validation, provide the examples of its use in laboratory rat (Rattus norvegicus) axial pattern flap healing studies. CONCLUSIONS This technically challenging but feasible reconstructive surgery model eliminates inter-subject variability, while concomitantly minimizing the number of animals needed to achieve adequate statistical power. BEFAFs may be used to investigate the spatiotemporal cellular and molecular responses to complex tissue injury, interventions simulating clinically relevant flap complications (e.g., vascular thrombosis) as well as prophylactic, therapeutic or surgical treatment (e.g., flap delay) strategies in the presence or absence of confounding risk factors (e.g., substance abuse, irradiation, diabetes) or favorable wound-healing promoting activities (e.g., exercise). Detailed visual instructions in BEFAF protocol may serve as an aid for teaching medical or academic researchers basic vascular microsurgery techniques that focus on precision, tremor management and magnification.
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Affiliation(s)
- Edita Aksamitiene
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA
- Present address: Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, 405 N. Mathews Ave | M/C 251, Room 4357, Urbana, IL, 61801, USA
| | - Ryan N Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA
| | - Jan B Hoek
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, 1020 Locust St, Room 527, Philadelphia, PA, 19107, USA
| | - Edmund deAzevedo Pribitkin
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA.
- Sidney Kimmel Medical College, 31st Floor, 1101 Market Street, Philadelphia, PA, 19107, USA.
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Ha JH, Lee SY, Choi TH, Park SO. Surgical delay increases the survival of expanded random-pattern flap in pediatric patients. Sci Rep 2023; 13:19204. [PMID: 37932369 PMCID: PMC10628270 DOI: 10.1038/s41598-023-45852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023] Open
Abstract
Despite the aid of tissue expansion, the ideal design of random pattern flap is not always available in patients with extensive skin lesions. We investigated the effectiveness of surgical delay on expanded flaps in pediatric patients. Retrospective cohort study was performed on patients who underwent tissue expansion surgery for extensive skin lesions at Seoul National University Children's Hospital. The surgical delay technique was employed for patients with unfavorable flap conditions related to location or transposition angles. The dimensions of skin lesions and flaps were measured based on medical photographs. Fifty patients underwent a total of 66 tissue expansion procedures (49 conventional procedures among 41 patients, 17 surgical delay procedures among 15 patients) from January 2016 to September 2019. Although flaps in the surgical delay group were more narrow-based (p < 0.001), the partial flap loss rate and excised area-to-inflation amount ratio was comparable between the two groups (p = 0.093 and p = 0.194, respectively). Viable flaps, excluding postoperative necrosis, in the surgical delay group were significantly more narrow-based in terms of the length-to-base width ratio and the area-to-base width ratio compared to conventional group (p < 0.01, p < 0.01). Surgical delay can result in outcomes comparable to well-designed random flaps, even in disadvantageous conditions. Patients with large skin lesions but limited areas for expansion may benefit from surgical delay.
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Affiliation(s)
- Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea.
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Se Yeon Lee
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae Hyun Choi
- The Nevus Plastic Surgery Clinic, Seoul, Republic of Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Republic of Korea.
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5
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Hypoxia in Skin Cancer: Molecular Basis and Clinical Implications. Int J Mol Sci 2023; 24:ijms24054430. [PMID: 36901857 PMCID: PMC10003002 DOI: 10.3390/ijms24054430] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Skin cancer is one of the most prevalent cancers in the Caucasian population. In the United States, it is estimated that at least one in five people will develop skin cancer in their lifetime, leading to significant morbidity and a healthcare burden. Skin cancer mainly arises from cells in the epidermal layer of the skin, where oxygen is scarce. There are three main types of skin cancer: malignant melanoma, basal cell carcinoma, and squamous cell carcinoma. Accumulating evidence has revealed a critical role for hypoxia in the development and progression of these dermatologic malignancies. In this review, we discuss the role of hypoxia in treating and reconstructing skin cancers. We will summarize the molecular basis of hypoxia signaling pathways in relation to the major genetic variations of skin cancer.
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SOGORSKI ALEXANDER, DOSTIBEGIAN MARYNA, LEHNHARDT MARCUS, WALLNER CHRISTOPH, WAGNER JOHANNESM, DADRAS MEHRAN, GLINSKI MAXIVON, KOLBENSCHLAG JONAS, BEHR BJÖRN. Postoperative Remote Ischemic Conditioning (RIC) significantly improves entire flap microcirculation beyond 4 hours. J Plast Reconstr Aesthet Surg 2022; 75:4003-4012. [DOI: 10.1016/j.bjps.2022.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 05/28/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022]
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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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8
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Sokoya F, Poonia S, Terella A. Measuring Tissue Perfusion with Laser Speckle Contrast Imaging. Facial Plast Surg Aesthet Med 2021; 24:407-409. [PMID: 34516929 DOI: 10.1089/fpsam.2021.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fiyin Sokoya
- Facial Plastic and Reconstructive Surgery, Head and Neck Microvascular Surgery, WellStar Health Systems, Atlanta, Georgia, USA
| | - Seerat Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam Terella
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
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9
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Chang KH, Shoureshi P, Lay F, Sebastian R, Alikhassy Habibabady Z, Born LJ, Marti GP, Meltzer SJ, Abraham JM, Harmon JW. Preconditioning of surgical pedicle flaps with DNA plasmid expressing hypoxia-inducible factor-1α (HIF-1α) promotes tissue viability. Gene Ther 2021; 28:319-328. [PMID: 33024315 DOI: 10.1038/s41434-020-00199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 01/29/2023]
Abstract
Ischemic necrosis of surgical flaps after reconstruction is a major clinical problem. Hypoxia-inducible factor-1α (HIF-1α) is considered the master regulator of the adaptive response to hypoxia. Among its many properties, it regulates the expression of genes encoding angiogenic growth factors, which have a short half-life in vivo. To achieve a continuous application of the therapeutic, we utilized DNA plasmid delivery. Transcription of the DNA plasmid confirmed by qRT-PCR showed significantly increased mRNA for HIF-1α in the transfected tissue compared to saline control tissue. Rats were preconditioned by injecting with either HIF-1α DNA plasmid or saline intradermally in the designated flap region on each flank. Seven days after preconditioning, each rat had two isolated pedicle flaps raised with a sterile silicone sheet implanted between the skin flap and muscle layer. The flaps preconditioned with HIF-1α DNA plasmid had significantly less necrotic area. Angiogenesis measured by CD31 staining showed a significant increase in the number of vessels per high powered field in the HIF-1α group (p < 0.05). Our findings offer a potential therapeutic strategy for significantly promoting the viability of surgical pedicle flaps by ischemic preconditioning with HIF-1α DNA plasmid.
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Affiliation(s)
- Kai-Hua Chang
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Pouria Shoureshi
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frank Lay
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raul Sebastian
- Department of Surgery, George Washington University School of Medicine and Health Science, Washington, DC, USA
| | | | - Louis J Born
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA
| | - Guy P Marti
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Clinique Saint Jean l'Ermitage, Melun, France
| | - Stephen J Meltzer
- Division of Gastroenterology, Department of Medicine and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John M Abraham
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Gastroenterology, Department of Medicine and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John W Harmon
- Hendrix burn and Wound Healing Laboratory, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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10
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Chen Z, Liu H, Li Y, Zhou Z, Qiu J, Tang Y, Cui T. ZNF667 attenuates leukocyte-endothelial adhesion via downregulation of P-selectin in skin flap following remote limb ischemic preconditioning. Cell Biol Int 2021; 45:1477-1486. [PMID: 33710682 DOI: 10.1002/cbin.11586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/23/2021] [Accepted: 03/07/2021] [Indexed: 12/19/2022]
Abstract
We assessed the effects and potential mechanism of romote ischemic preconditioning (RIPC) on leukocytes-endothelium cell adhesion in the flap microvessel after ischemia-reperfusion (I/R) injury. Eight hours after reperfusion, edema and intravascular leukocyte aggregation were reduced and microvessels were more obvious in the group with superficial inferior epigastric artery (SIEA) perforator flap (SIEA-flap) subjected to RIPC than in the I/R group. Zinc finger protein 667 (ZNF667) was significantly increased but P-selectin was decreased in the flaps subjected to RIPC, compared to those in the I/R group. The low expression of P-selectin was associated with ZNF667 expression and activation in human dermal microvascular endothelial cells in response to hypoxic preconditioning. ZNF667 bound to the P-selectin promoter region, suppressing its transcription through a special core sequence. The ablation of P-selectin by small interfering RNA effectively prevented the leukocytes-endothelium cell adhesion effect of ZNF667-knockdown. ZNF667 upregulation attenuates leukocyte-endothelial cell adhesion by negatively regulating the expression of P-selectin in SIEA-flap subjected to RIPC.
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Affiliation(s)
- Zhuang Chen
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Haifen Liu
- Department of Radiology, Hunan Provincial Hospital of Traditional Chinese Medicine, Zhuzhou, Hunan, China
| | - Yuanbin Li
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Zhangfu Zhou
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Jizhe Qiu
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
| | - Yi Tang
- Department of Dermatology, Hunan Provincial Hospital of Traditional Chinese Medicine, Zhuzhou, Hunan, China
| | - Taotao Cui
- Department of Basic Medical, Hunan Traditional Chinese Medical College, Zhuzhou, Hunan, China
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11
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Sogorski A, Spindler S, Wallner C, Dadras M, Wagner JM, Behr B, Lehnhardt M, Kolbenschlag J. Optimizing remote ischemic conditioning (RIC) of cutaneous microcirculation in humans: Number of cycles and duration of acute effects. J Plast Reconstr Aesthet Surg 2020; 74:819-827. [PMID: 33172821 DOI: 10.1016/j.bjps.2020.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/12/2020] [Accepted: 10/11/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Non-invasive Remote Ischemic Conditioning (RIC) offers an approach to reduce tissue damage in various organs/tissues. Besides attenuation of Ischemia-Reperfusion injury (I/R), beneficial effects on cutaneous microcirculation of free microsurgical flaps have been reported. Given the recency of this technique, there are considerable gaps in the current understanding of its mechanism of action. As a result, clinical transfer of RIC is prolongated in several fields. We aimed to optimize the RIC protocol by examination of different RIC-cycle numbers and its effect on changes of cutaneous microcirculation and duration. METHODS 80 subjects were divided into groups (1, 3, 5, 7 RIC cycles). RIC was applied via an inflatable tourniquet. Cutaneous microcirculation was continuously assessed at the contralateral anterior lateral thigh utilizing a ©O2C-device continuously. RESULTS RIC caused significant and sustained changes in microcirculation. Four hours after completion of RIC, a maximum increase of +80.8% (CI 1.395-2.221) in blood flow and +23.5% (CI 1.098-1.372) in tissue oxygen saturation was measured (three-cycle group). A higher number of applied cycles was accompanied with significant higher mean pain. CONCLUSION Acute improvement of cutaneous microcirculation due to RIC lasted for at least 4 h after completion of the RIC-protocol. Dose-dependent effects of RIC are likely. With regard to the increase in pain, we recommend a RIC protocol of 3 cycles for future clinical application.
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Affiliation(s)
- A Sogorski
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
| | - S Spindler
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - C Wallner
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - M Dadras
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - J M Wagner
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - B Behr
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - M Lehnhardt
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - J Kolbenschlag
- Department of Hand, Plastic and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany
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12
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Preventive effect of trimetazidine against ischemia-reperfusion injury in rat epigastric island flaps: an experimental study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Pak CS, Moon SY, Lee YE, Kang HJ. Therapeutic Effects against Tissue Necrosis of Remote Ischemic Preconditioning Combined with Human Adipose-Derived Stem Cells in Random-Pattern Skin Flap Rat Models. J INVEST SURG 2020; 34:1304-1311. [PMID: 32691637 DOI: 10.1080/08941939.2020.1795750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Remote ischemic preconditioning (rIPC) is a preventive strategy against ischemia-reperfusion injury. To reduce ischemia-reperfusion injury of random-pattern skin flaps, we investigated the therapeutic effects of rIPC combined with human adipose-derived stem cells (hADSCs) in a rat model. MATERIAL AND METHODS In total, 24 female Sprague Dawley rats were divided into four groups (n = 6 each): control (skin flap only), rIPC, hADSCs, and rIPC + hADSCs. rIPC was performed in the hind limb of the rats over three cycles of 5 min of occlusion and 5 min of reperfusion, using a tourniquet. A rectangular (3 × 9 cm) dorsal skin flap was used. hADSCs (5 × 105 cells/100 µL) labeled with fluorescent dye were transplanted into the normal subcutaneous tissue at the skin flap boundary. After 14 days, the therapeutic effects of rIPC and hADSCs were evaluated via analysis of the necrotic flap area, histopathologic assessment, and immunohistochemistry (von Willebrand Factor (vWF) and CD31). RESULTS The necrotic area of the skin flap significantly decreased in the rIPC + hADSCs group (32.75 ± 1.43%) compared with the control (40.60 ± 3.27%, P < 0.01) and rIPC groups (38.84 ± 0.77%, P < 0.05). Dye-labeled hADSCs migrated to the skin flap from the injection site. In the rIPC + hADSCs group, the epithelial tissue and skin appendage had regenerated, and the smooth muscle and subcutaneous fat layers were preserved. Many more vWF- and CD31-positive vessels were observed in the rIPC + hADSCs group compared with the other groups. CONCLUSIONS The rIPC + hADSCs treatment appeared to reduce skin flap necrosis and activated neovascularization in rats. Therefore, it may be a good strategy for clinical treatment of ischemia-reperfusion injury.
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Affiliation(s)
- Chang Sik Pak
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, Korea.,Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Young Moon
- Biomedical Research Center, Korea University Ansan Hospital, Ansan, Gyeonggi-do, Korea
| | - Young Eun Lee
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Jin Kang
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi-do, Korea.,Biomedical Research Center, Korea University Ansan Hospital, Ansan, Gyeonggi-do, Korea
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Tourniquet use and factors associated with hematoma formation in free tissue transfer. Am J Otolaryngol 2020; 41:102404. [PMID: 32001026 DOI: 10.1016/j.amjoto.2020.102404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/17/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE Our objective was to understand which variables are associated with hematoma formation at both the donor and recipient sites in head and neck free tissue transfer and if hematoma rates are affected by tourniquet use. METHODS Patients were identified who underwent free tissue transfer at three institutions, specifically either a radial forearm free flap (RFFF) or a fibula free flap (FFF), between 2007 and 2017. Variables including use of tourniquet, anticoagulation, treatment factors, demographics, and post-operative factors were examined to see if they influenced hematoma formation at either the free tissue donor or recipient site. RESULTS 1410 patients at three institutions were included in the analysis. There were 692 (49.1%) RFFF and 718 (50.9%) FFF. Tourniquets were used in 764 (54.1%) cases. There were 121 (8.5%) hematomas. Heparin drips (p < .001) and DVT prophylaxis (p = .03) were significantly associated with hematoma formation (OR 95% CI 12.23 (4.98-30.07), 3.46 (1.15-10.44) respectively) on multivariable analysis. CONCLUSIONS Heparin Drips and DVT prophylaxis significantly increased hematoma rates in free flap patients while tourniquets did not affect rates of hematoma.
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Oh CS, Sa M, Park HJ, Piao L, Oh KS, Kim SH. Effects of remote ischemic preconditioning on regional cerebral oxygen saturation in patients in the beach chair position during shoulder surgery: A double-blind randomized controlled trial. J Clin Anesth 2019; 61:109661. [PMID: 31818636 DOI: 10.1016/j.jclinane.2019.109661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/20/2019] [Accepted: 11/16/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE The beach chair position for shoulder surgery induces cerebral hypoperfusion. We evaluated the effects of remote ischemic preconditioning (RIPC) prior to surgery to ameliorate cerebral desaturation in a double-blind randomized fashion. DESIGN Blinded, prospective, randomized study. SETTING Operating room & postoperative recovery room, tertiary university hospital. PATIENTS Seventy patients scheduled for shoulder surgery were recruited. After excluding 7 patients according to the exclusion criteria, 63 patients were randomized into two groups (control and RIPC). INTERVENTIONS Remote ischemic preconditioning was applied by briefly inflating a tourniquet on the thigh three times just after inducing anesthesia in the RIPC group. MEASUREMENTS The changes in regional cerebral oxygen saturation, hemodynamic values, laboratory values, and serum levels of cytokines including interleukin (IL)-1β, IL-6, IL-10 and transforming growth factor-β were measured. MAIN RESULTS The remote ischemic preconditioning group had higher regional cerebral oxygen saturation just after establishment of the beach chair position (P = 0.002) and lower cerebral desaturation (P = 0.007) during operation than the control group. Hemodynamic and laboratory values did not differ between the groups. There were no significant intergroup differences in cytokine levels. CONCLUSION Remote ischemic preconditioning before surgery ameliorates cerebral desaturation in patients in the beach chair position during shoulder surgery. Trial Registry Number: KCT0001384 (http://cris.nih.go.kr).
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Affiliation(s)
- Chung-Sik Oh
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Mijung Sa
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyun Jun Park
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Liyun Piao
- Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Soo Oh
- Department of Orthopedic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seong-Hyop Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea; Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Republic of Korea; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea.
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Veres TG, Takács I, Nagy T, Jancsó G, Kondor A, Pótó L, Vereczkei A. Pneumoperitoneum induced ischemia-reperfusion injury of the peritoneum - Preconditioning may reduce the negative side-effects caused by carbon-dioxide pneumoperitoneum - Pilot study. Clin Hemorheol Microcirc 2018; 69:481-488. [PMID: 29660910 DOI: 10.3233/ch-170336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Laparoscopy is more beneficial than the conventional open technique, however the pneumoperitoneum created may have an ischemic side effect. OBJECTIVE Our aim was to evaluate the protective effects of preconditioning during laparoscopic cholecystectomies (LC). METHODS 30 patients were randomized into 2 groups: I. PreC (preconditioning: 5 min. inflation, 5 min. deflation, followed by conventional LC), II: LC (conventional LC). Blood samples were taken before hospitalization (C = control), before surgery, after anaesthesia (B.S.), after surgery (A.S.) and 24 hours after the procedure (24 h). Measured parameters were: malondialdehyde (MDA), reduced glutathione (GSH), sulfhydril groups (-SH), superoxide-dismutase (SOD), catalase (CAT), myeloperoxidase (MPO), length of hospitalization and pain (VAS = visual analogue scale). RESULTS Compared to the BS levels, no significant changes were detected in SOD's activity and MDA levels. GSH concentrations were significantly increased in the PreC group after operation. SH-, MPO, CAT and liver function enzymes were not significantly different. Hospitalization was shorter in the PreC group. Based on the VAS score patients had less pain in the PreC group. CONCLUSION Significant differences concerning PreC group were found in GSH values. In the PreC group pain decreased by 2-2.5 units following the procedure, 24 h after surgery, and hospitalisation was also significantly shorter. In our pilot study the potential protective effect of preconditioning could be defined.
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Affiliation(s)
| | - Ildikó Takács
- Department of Surgical Research and Techniques, University of Pécs, Hungary
| | - Tibor Nagy
- Department of Surgical Research and Techniques, University of Pécs, Hungary
| | - Gábor Jancsó
- Department of Surgical Research and Techniques, University of Pécs, Hungary
| | | | - László Pótó
- Institute of Bioanalysis, University of Pécs, Hungary
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Petrovics L, Nagy T, Hardi P, Bognar L, Pavlovics G, Tizedes G, Takacs I, Jancso G. The effect of trimetazidine in reducing the ischemia-reperfusion injury in rat epigastric skin flaps. Clin Hemorheol Microcirc 2018; 69:405-415. [DOI: 10.3233/ch-170335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Petrovics
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Tibor Nagy
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Peter Hardi
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Laura Bognar
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | | | | | - Ildiko Takacs
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Gabor Jancso
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
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Effects of Remote Ischemic Conditioning Methods on Ischemia-Reperfusion Injury in Muscle Flaps: An Experimental Study in Rats. Arch Plast Surg 2017; 44:384-389. [PMID: 28946719 PMCID: PMC5621827 DOI: 10.5999/aps.2017.44.5.384] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/05/2017] [Accepted: 08/29/2017] [Indexed: 12/21/2022] Open
Abstract
Background The aim of this study was to investigate the effects of remote ischemic conditioning on ischemia-reperfusion injury in rat muscle flaps histopathologically and biochemically. Methods Thirty albino rats were divided into 5 groups. No procedure was performed in the rats in group 1, and only blood samples were taken. A gracilis muscle flap was elevated in all the other groups. Microclamps were applied to the vascular pedicle for 4 hours in order to achieve tissue ischemia. In group 2, no additional procedure was performed. In groups 3, 4, and 5, the right hind limb was used and 3 cycles of ischemia-reperfusion for 5 minutes each (total, 30 minutes) was applied with a latex tourniquet (remote ischemic conditioning). In group 3, this procedure was performed before flap elevation (remote ischemic preconditoning). In group 4, the procedure was performed 4 hours after flap ischemia (remote ischemic postconditioning). In group 5, the procedure was performed after the flap was elevated, during the muscle flap ischemia episode (remote ischemic perconditioning). Results The histopathological damage score in all remote conditioning ischemia groups was lower than in the ischemic-reperfusion group. The lowest histopathological damage score was observed in group 5 (remote ischemic perconditioning). Conclusions The nitric oxide levels were higher in the blood samples obtained from the remote ischemic perconditioning group. This study showed the effectiveness of remote ischemic conditioning procedures and compared their usefulness for preventing ischemia-reperfusion injury in muscle flaps.
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Kolbenschlag J, Sogorski A, Timmermann C, Harati K, Daigeler A, Hirsch T, Goertz O, Lehnhardt M. Ten minutes of ischemia is superior to shorter intervals for the remote ischemic conditioning of human microcirculation. Clin Hemorheol Microcirc 2017; 66:239-248. [DOI: 10.3233/ch-170268] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J. Kolbenschlag
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital Berlin, Berlin, Germany
| | - A. Sogorski
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Surgery, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - C. Timmermann
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - K. Harati
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - A. Daigeler
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG-Trauma Center, Eberhard Karls University Tübingen, Tübingen, Germany
| | - T. Hirsch
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - O. Goertz
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital Berlin, Berlin, Germany
| | - M. Lehnhardt
- Department of Plastic Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
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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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Park UJ, Kim HT, Cho WH, Park JH, Jung HR, Kim MY. Remote Ischemic Preconditioning Enhances the Expression of Genes Encoding Antioxidant Enzymes and Endoplasmic Reticulum Stress-Related Proteins in Rat Skeletal Muscle. Vasc Specialist Int 2016; 32:141-149. [PMID: 28042553 PMCID: PMC5198760 DOI: 10.5758/vsi.2016.32.4.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 01/16/2023] Open
Abstract
Purpose: Ischemic preconditioning (IPC), including remote IPC (rIPC) and direct IPC (dIPC), is a promising method to decrease ischemia-reperfusion (IR) injury. This study tested the effect of both rIPC and dIPC on the genes for antioxidant enzymes and endoplasmic reticulum (ER) stress-related proteins. Materials and Methods: Twenty rats were randomly divided into the control and study groups. In the control group (n=10), the right hind limb was sham-operated. The left hind limb (IscR) of the control group underwent IR injury without IPC. In the study group (n=10), the right hind limb received IR injury after 3 cycles of rIPC. The IscR received IR injury after 3 cycles of dIPC. Gene expression was analyzed by Quantitative real-time polymerase chain reaction from the anterior tibialis muscle. Results: The expression of the antioxidant enzyme genes including glutathione peroxidase (GPx), superoxide dismutase (SOD) 1 and catalase (CAT) were significantly reduced in IscR compared with sham treatment. In comparison with IscR, rIPC enhanced the expression of GPx, SOD2, and CAT genes. dIPC enhanced the expression of SOD2 and CAT genes. The expression of SOD2 genes was consistently higher in rIPC than in dIPC, but the difference was only significant for SOD2. The expression of genes for ER stress-related proteins tended to be reduced in IscR in comparison with sham treatment. However, the difference was only significant for C/EBP homologous protein (CHOP). In comparison with IscR, rIPC significantly up-regulated activating transcription factor 4 and CHOP, whereas dIPC up-regulated CHOP. Conclusion: Both rIPC and dIPC enhanced expression of genes for antioxidant enzymes and ER stress-related proteins.
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Affiliation(s)
- Ui Jun Park
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Hyoung Tae Kim
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Won Hyun Cho
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Jae Hyoung Park
- Department of Physiology, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Hye Ra Jung
- Department of Pathology, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Min Young Kim
- Department of Nursing, University of Ulsan, Ulsan, Korea
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Nouraei SM, Baradari AG, Jazayeri A. Does Remote Ischaemic Preconditioning Protect Kidney and Cardiomyocytes After Coronary Revascularization? A Double Blind Controlled Clinical Trial. Med Arch 2016; 70:373-378. [PMID: 27994300 PMCID: PMC5136438 DOI: 10.5455/medarh.2016.70.373-378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/25/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate efficacy of remote ischaemic preconditioning on reducing kidney injury and myocardial damage after coronary artery bypass grafting surgery (CABG). BACKGROUND Ischaemic preconditioning of a remote organ reduces ischaemia-reperfusion injury of kidney and myocardium after CABG. METHOD To reduce myocardial damage and kidney injury by applying Remote Ischaemic Preconditioning we recruited 100 consecutive patients undergoing elective coronary artery bypass grafting surgery. We applied three cycles of lower limb tourniquet, inflated its cuff for 5 minutes in study group or left un-inflated (sham or control group) before the procedure. The primary outcome was serum creatinine, creatinine clearance and troponin-I Levels at time 0, 6, 12, 24 and 48 h. Secondary outcomes were serum C-reactive protein, inotrope score, ventilation time and ICU stay. Data's were analyzed by MedCalc (MedCalc Software bvba, Acacialaan, Belgium). We compared the two group by student t test, chi-square and Mann-Whitney tests. RESULTS The two groups were not statistically different in terms of age, gender, smoking habits, drug use, hypertension, hyperlipidemia and diabetes mellitus. This study showed a higher CRP level in study group comparing with control group (P=0.003), creatinine clearance was slightly higher in study group specially 24 h after procedure but was not statistically significant (p=0.11). Troponin-I level was significantly lower in study group (p=0.001). CONCLUSION This study showed a lower Troponin-I level in study group which suggest a cardio-myocyte protective function of RIPC. It also showed slightly lower Creatinine clearance in control group, gap between two group increases significantly 24 hours after procedure which may suggest a potential kidney protection by RIPC. Serum CRP level was higher in study group. A multi-center randomized controlled trial with a longer time for creatinine clearance measurement may show the potential effectiveness of this non-invasive inexpensive intervention on reducing kidney injury after CABG.
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Affiliation(s)
- Seyed Mahmoud Nouraei
- Thoracic and cardiovascular surgery department, Mazandran University of Medical sciences, Sari, Iran
| | | | - Asieh Jazayeri
- Student Research Committee, Mazandran University of Medical sciences, Sari, Iran
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Slater NJ, Zegers HJ, Küsters B, Beune T, van Swieten HA, Ulrich DJ. Ex-vivo oxygenated perfusion of free flaps during ischemia time: a feasibility study in a porcine model and preliminary results. J Surg Res 2016; 205:292-295. [DOI: 10.1016/j.jss.2016.06.096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 06/03/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
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Claroni C, Torregiani G, Covotta M, Sofra M, Scotto Di Uccio A, Marcelli ME, Naccarato A, Forastiere E. Protective effect of sevoflurane preconditioning on ischemia-reperfusion injury in patients undergoing reconstructive plastic surgery with microsurgical flap, a randomized controlled trial. BMC Anesthesiol 2016; 16:66. [PMID: 27549313 PMCID: PMC4994173 DOI: 10.1186/s12871-016-0230-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/28/2016] [Indexed: 01/28/2023] Open
Abstract
Background In many clinical conditions that involve free flaps and tissue transplantations the possibility of minimizing ischemia-reperfusion injury can be a determinant factor for the success of the surgery itself. We hypothesize that preconditioning with sevoflurane is a protective factor against ischemia-reperfusion injury. Methods In this randomized controlled trial, patients ASA I-II undergoing breast reconstruction with deep inferior epigastric perforator flaps were allocated into two groups and analyzed: group BAL included patients who received balanced anesthesia with sevoflurane for 30 min before removal of the flap and throughout the surgery. The TCI group included patients who received a total intravenous anesthesia with propofol and remifentanil. We evaluated regional tissue oximetry at the end of the surgery and at 4, 12 and 20 h after surgery. Other assessed parameters were: blood lactate clearance, alanine aminotransferase, aspartate aminotransferase, lactic dehydrogenase, creatine phosphokinase. Results In total 54 patients, twenty-seven per group, were analyzed. There was a significant increase of the average value of regional tissue oximetry measured 4 h after surgery in the BAL group compared to the TCI group: BAL: 84.05 % (8.96 SD); TCI : 76.17 % (12.92 SD) (P = 0.03), but not at the other time frames. The creatine phosphokinase value was significantly lower in the BAL group at the end of surgery, but not at the other time-frames. There were no significant differences in blood levels of other markers. Conclusions From our results, the positive preconditioning impact of sevoflurane on ischemia-reperfusion injury in patients undergoing free flap surgery is expressed in the early postoperative hours, but it does not persist in the long-term. Trial registration ClinicalTrial.gov identifier: NCT01905501. Registered July 18, 2013
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Affiliation(s)
- Claudia Claroni
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy.
| | - Giulia Torregiani
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
| | - Marco Covotta
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
| | - Maria Sofra
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
| | | | - Maria E Marcelli
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
| | - Alessia Naccarato
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
| | - Ester Forastiere
- Department of Anaesthesiology, Regina Elena National Cancer Institute, V. Elio Chianesi 53, 00144, Rome, Italy
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Transplant-related experience in pharyngo-oesophageal reconstruction: use of organ preservation techniques to improve ischaemic tolerance in free jejunal flaps. Br J Oral Maxillofac Surg 2016; 55:287-289. [PMID: 27516161 DOI: 10.1016/j.bjoms.2016.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 07/27/2016] [Indexed: 11/24/2022]
Abstract
Reconstruction of pharyngo-oesophageal defects remains a surgical challenge. Free jejunal flaps, first described by Seidenberg in 1959, are used to reconstruct circumferential defects, but their main disadvantage is sensitivity to ischaemia. Others are secretions, an unpleasant smell, and problems at the donor site. To improve the tolerance of the jejunal segment to ischaemia and to give the surgeon more time, we cool it after harvest and flush it with organ preservation fluid. We describe the technique in a small case series of seven patients.
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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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Abstract
BACKGROUND Advances in the treatment of ischemia- reperfusion injury have created an opportunity for plastic surgeons to apply these treatments to flaps and implanted tissues. We examined the capability of adipose derived stem cells (ADSCs) to protect tissue against IRI using an extended inferior epigastric artery skin flap as a flap ischemia- reperfusion injury (IRI) model. METHODS ADSCs were isolated from Lewis rats and cultured in vitro. Twenty- four rats were randomly divided into three groups. Group I was the sham group and did not undergo ischemic insult; rather, the flap was raised and immediately sutured back (non-ischemic control group). Group II (ischemia control) and group III (ADSCs treatment) underwent 3 h of ischemic insult. During reperfusion group III was treated by intravenous application of ADSCs and group II was left untreated. Five days postoperatively, flap survival and perfusion were assessed. Microvessel density was visualized by immunohistochemistry and semi- quantitative real-time polymerase chain reaction addressed differential gene expression. RESULTS Treatment with ADSCs significantly increased flap survival (p<0.001) and flap perfusion (p<0.001) when compared to the control group II. Microvessel- density in ADSCs treated group was not significantly increased in any group. No significant differences showed the comparison of the experimental group III and the sham operated control group I. ADSCs treatment (Group III) was accompanied by a significantly enhanced expression of pro-angiogenic and pro-inflammatory genes. CONCLUSION Overall, our study demonstrates that ADSCs treatment significantly enhances skin flap survival in the aftermath of ischemia to an extent that almost equals surgical results without ischemia. This effect is accompanied with a pronounced and significant angiogenic response and an improved blood perfusion.
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The effectiveness of pedicled groin flaps in the treatment of hand defects: results of 49 patients. J Hand Surg Am 2012; 37:2088-94. [PMID: 22939822 DOI: 10.1016/j.jhsa.2012.07.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 07/12/2012] [Accepted: 07/15/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite the growing number of free and local flaps used for repairing defects of the hand, groin flaps are also still widely used. The aims of this study were to evaluate the outcome of a large series of patients whose defects were covered by pedicled groin flaps, and to find out whether it is still indicated in replacing damaged soft tissue of the hand in the era of microsurgery. METHODS From 1982 to 2009, we treated 85 patients with soft tissue defects on the hand and distal forearm with pedicled groin flaps in our department and recorded them in a prospective database. We interviewed and examined 49 patients in this cohort. RESULTS The mean age of the 85 patients was 33 years, the male/female ratio was 4:1, the mean hospital stay was 29 ± 13 days, and the mean follow-up was 9 years. The duration to flap division was 24 ± 5 days. Altogether, we performed a mean of 4.6 operations per patient, including thinning of the flap, deepening of the interdigital fold, and stump and flap revisions. One flap loss occurred. Of the 49 patients, results were mostly classified as good, and 82% of patients would undergo the procedure again. The mean Disabilities of the Arm, Shoulder, and Hand score value was 23 ± 17. The Vancouver Scar Scale showed nearly normal height and vascularity of the groin flap (0.2 ± 0.4 and 0.3 ± 0.6, respectively), pigmentation was slightly abnormal (0.8 ± 0.6), and pliability was evaluated between "supple" and "yielding" (1.5 ± 1.2). CONCLUSIONS Results achieved with the groin flaps were positive. Most patients were satisfied with the results, and the operation was easily performed when McGregor's recommendations were followed. Nevertheless, considering the high number of secondary operations, the long hospital stay, and immobilization of the arm, groin flaps should be used only when free flaps or regional pedicle flaps are either not feasible or not indicated. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Knobloch K, Herold C, Vogt PM. [Free latissimus dorsi flap transfer for reconstruction of soft tissue defects of the lower extremity]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:122-30. [PMID: 22446843 DOI: 10.1007/s00064-011-0094-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Sustainable and durable soft tissue coverage at the lower extremity following trauma, tumor resections, sequelae of radiation therapy or osteomyelitis using free latissimus dorsi muscle transfer is provided by a free latissimus dorsi muscle flap. INDICATIONS Soft tissue defects at the lower extremity following trauma, tumor resections, and sequelae of radiation therapy or osteomyelitis. CONTRAINDICATIONS Thoracotomy with incision of the latissimus dorsi muscle; a relative contraindication in wheelchair drivers as well as in overhead athletes due to potential diminished strength and shoulder proprioception following latissimus dorsi muscle transplantation. SURGICAL TECHNIQUE Under general anesthesia the patient is positioned laterally, and a substantial and meticulous debridement of the defect is performed, as is the identification and preparation of the target vessel, which is preferentially the posterior tibial artery at the calf, or more proximally the popliteal or femoral artery from the medial side as well as concomitant veins/the great saphenous vein. A tailored latissimus dorsi musculocutaneous flap is harvested with subsequent microsurgical anastomosis to the target vessel with preferential end-to-side anastomosis of the artery and end-to-end anastomosis of one or two veins. POSTOPERATIVE MANAGEMENT A 24-h intermediate care unit, clinical flap monitoring for at least 5-7 days, dangling of the flap using an elastic bandage for an initial 3 times 5 min starting on POD 7, compression stockings for at least 6 months subsequently. RESULTS From 2001-2007 75 free latissimus dorsi flaps were performed (53 ± 17 years) for soft tissue coverage at the lower extremity. In 58% the target vessel was the posterior tibial artery, in 11% the femoral artery, in 8% the anterior tibial artery and in 8% the popliteal artery. In 15% an arteriovenous (AV) loop was applied. Overall free flap survival was 95%. We encountered four total flap losses, exclusively in complex reconstructions with AV-loop situations.
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Affiliation(s)
- K Knobloch
- Plastische Hand- und Wiederherstellungschirurgie, Med. Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Dragu A, Taeger CD, Buchholz R, Sommerfeld B, Hübner H, Birkholz T, Kleinmann JA, Münch F, Horch RE, Präbst K. Online oxygen measurements in ex vivo perfused muscle tissue in a porcine model using dynamic quenching methods. Arch Orthop Trauma Surg 2012; 132:655-61. [PMID: 22246464 DOI: 10.1007/s00402-011-1458-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Transplantation of autologous free tissue flaps is the best applicable technique for treating large and complex tissue defects and still has one major failure criterion. Tissue--and in particular muscle tissue--is strongly sensitive to ischemia, thus after a critical period of oxygen depletion the risk of a partial or total flap loss is high. MATERIALS AND METHODS For that reason a miniaturized ex vivo perfusion system has been developed, that supplies the tissue during operational delays. The purpose of this study was to determine the oxygenation levels during such a perfusion using different perfusates and therefore to objectify if a complementary oxygenation unit is required to improve perfusion quality. The oxygen levels of the tissue, as well of the perfusate, were measured by using minimal invasive optical oxygen sensors that are based on dynamic quenching. The ex vivo perfused tissue was the porcine rectus abdominis muscle. RESULTS Results show, that during perfusion with heparinized crystalloid fluid (Jonosteril) and heparinized autologous whole blood, additional oxygenation of the perfusion reactor led to different ex vivo oxygen tissue saturations, which can be detected by dynamic quenching. CONCLUSION Dynamic quenching methods are a promising and valuable technique to perform online oxygen measurements in ex vivo perfused muscle tissue in a porcine model.
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Affiliation(s)
- Adrian Dragu
- Department of Plastic and Hand Surgery, Friedrich-Alexander-University of Erlangen-Nürnberg, University Hospital, Krankenhausstrasse 12, 91054 Erlangen, Germany.
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Abstract
Enhancement of flap survival through extracorporeal shock wave treatment (ESWT) is a promising new technique; however, no attempt has been made to define the optimal time point and frequency of ESWT to optimize treatment with ESWT for ischemic indications. Twenty-eight male Wistar rats were randomized into 4 groups and an oversized, random-pattern flap was raised and reattached in place in each animal. ESWT was applied 7 days before (group E7) or immediately after the surgical intervention (group E0). The third group was treated with ESWT 7 days before and additionally immediately after the operation (group E7/0). The fourth group served as a control group and did not receive any ESWT (group C). Seven days after flap harvest the results of flap survival, perfusion, microvessel density, and vascular endothelial growth factor concentrations were assessed. Flap survival was significantly increased in all ESWT groups as compared with the control group. The groups (E7 and E0) that received ESWT pre- or postoperatively showed a significant increase in flap perfusion and microvessel density. Combined pre- and postoperative ESWT application (group E0/E7) did not demonstrate a cumulative effect in any evaluation. In this study, we were be able to prove the effectiveness of ESWT in the protection of ischemic tissue flaps. This study suggests that single postoperative application is the most efficacious protocol for clinical applications of ESWT in the treatment of ischemic tissue.
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Mansour Z, Bouitbir J, Charles AL, Talha S, Kindo M, Pottecher J, Zoll J, Geny B. Remote and local ischemic preconditioning equivalently protects rat skeletal muscle mitochondrial function during experimental aortic cross-clamping. J Vasc Surg 2012; 55:497-505.e1. [DOI: 10.1016/j.jvs.2011.07.084] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/30/2022]
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Dragu A, Birkholz T, Kleinmann JA, Schnürer S, Münch F, Cesnjevar R, Schmidt J, Taeger C, Kneser U, Horch RE. Extracorporeal perfusion of free muscle flaps in a porcine model using a miniaturized perfusion system. Arch Orthop Trauma Surg 2011; 131:849-55. [PMID: 21188393 DOI: 10.1007/s00402-010-1251-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The development of techniques in transplantation medicine--including various aspects--has made extraordinary progress within the past three decades. However, the transplantation of free tissue flaps with the common problem of limited ischemia time frames remains an area in which the understanding of mechanism during ischemia and reperfusion is still limited. Thus, similar to other organ transplantations, the prolongation of ischemic time and the possibility to perform an ex vivo perfusion is desirable. The purpose of this study was to create a closed and steady ex vivo perfusion system in order to analyze the possibility of using a miniaturized perfusion system for free muscle flaps that could also be clinically used for other solid organ transplantation. MATERIALS AND METHODS The rectus abdominis muscles of six german pigs were used in the study. Each of these free muscle flaps was perfused for a period of 2 h using a pulsatile and closed pump perfusion system by cannulating the arterial and venous vessels of the flap pedicle. During the ex vivo perfusion parameters such as arterial and venous pressures were measured continuously. RESULTS A total of six ex vivo, closed and steady perfusions have been successfully performed. The optimal arterial flow rate of ex vivo perfusion of rectus abdominis muscle flaps was evaluated to be 10 ml/min. The constant measurement of arterial (46 ± 13 mmHg) and venous (-1 ± 1 mmHg) pressure in this ex vivo setting showed steady parameters during a period for up to 2 h. CONCLUSION The data of this study indicate that the ex vivo perfusion of free muscle flaps is technically feasible and a closed and steady circulation is manageable for a period of up to 2 h.
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Affiliation(s)
- Adrian Dragu
- Department of Plastic and Hand Surgery, University Hospital, Friedrich-Alexander-University of Erlangen-Nürnberg, Krankenhausstrasse 12, 91054 Erlangen, Germany.
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Keil H, Mueller W, Herold-Mende C, Gebhard MM, Germann G, Engel H, Reichenberger MA. Preoperative shock wave treatment enhances ischemic tissue survival, blood flow and angiogenesis in a rat skin flap model. Int J Surg 2011; 9:292-6. [PMID: 21256991 DOI: 10.1016/j.ijsu.2011.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 11/18/2010] [Accepted: 01/10/2011] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Extracorporeal shock wave treatment (ESWT) has recently been shown to enhance skin flap survival. However, the bio-mechanisms operating during preoperative ESWT remain unclear. The aim of our study was to investigate whether preoperative ESWT can improve blood flow in ischemic skin flaps and to elucidate its possible mechanisms. METHODS 14 male-rats were randomized into two groups and an oversized ventral random-pattern flap was raised. Experimental group received extracorporeal shock-wave treatment (ESWT) with an energy of 500 mJ/mm(2) seven days prior to total flap elevation, while control group received no treatment prior to total flap elevation. Seven days postoperatively, surviving flap area, perfused flap area, microvessel density and VEGF concentration were measured. RESULTS Surviving flap area (59.43 ± 14.72 % to 42.71 ± 10.75 %, p = 0.026), perfused flap area (62.00 ± 8.58 % to 45.14 ± 10.50 %, p = 0.007), microvessel density (18.13 ± 5.11 to 11.09 ± 1.12, p = 0.016) and VEGF to total protein ratio (0.2107 ± 0.0935 to 0.0123 ± 0.0069, p = 0.008) were significantly elevated in the ESWT group. CONCLUSION Preoperative ESWT can improve skin flap survival through enhanced topical blood perfusion and neovascularization via elevation of angio-active factors.
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Affiliation(s)
- Holger Keil
- Clinic for Plastic and Reconstructive Surgery, Aesthetic and Preventive Medicine at Heidelberg University Hospital - ETHIANUM, Voßstr 6, 69115 Heidelberg, Germany
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Civelek B, Selcuk T, Bilgen E, Demirbag E, Celebioglu S. Intermittent ischaemia of skin flaps shortens time taken to divide pedicles: an experimental study in rats. ACTA ACUST UNITED AC 2010; 43:241-4. [PMID: 19863425 DOI: 10.3109/02844310903138906] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ischaemic preconditioning increases the survival of flaps. Random-pattern McFarlane dorsal flaps were raised in 30 female Wistar rats, which were divided into three groups. An ischaemic conditioning protocol with clamping of the pedicle was used. No clamping was used in the control group, and the pedicle was clamped for 15 minutes in the second group and 20 minutes in the third group daily to see if the duration of ischaemia had any effects on the viability of the flaps. The pedicles were divided earlier in the clamped groups than in the control group. The size of necrotic areas of the flaps in the clamped groups was smaller than on the control group. Daily postoperative intermittent ischaemic conditioning in the pedicles of the flaps had a protective effect on their survival and led to earlier division of the pedicles.
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Affiliation(s)
- Birol Civelek
- Department of Plastic and Reconstructive Surgery, Diskapi Y. Beyazit Training and Research Hospital, Ankara, Turkey.
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Steensrud T, Li J, Dai X, Manlhiot C, Kharbanda RK, Tropak M, Redington A. Pretreatment with the nitric oxide donor SNAP or nerve transection blocks humoral preconditioning by remote limb ischemia or intra-arterial adenosine. Am J Physiol Heart Circ Physiol 2010; 299:H1598-603. [PMID: 20802131 DOI: 10.1152/ajpheart.00396.2010] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We have previously shown that remote ischemic preconditioning (rIPC) by transient limb ischemia leads to the release of a circulating factor(s) that induces potent myocardial protection. Intra-arterial injection of adenosine into a limb also leads to cardioprotection, but the mechanism of its signal transduction is poorly understood. Eleven groups of rabbits received saline control or rIPC or adenosine administration with additional pretreatment with the nitric oxide (NO) synthase blocker N(G)-nitro-l-arginine methyl ester, the NO donor S-nitroso-N-acetylpenicillamine, its non-NO-donating derivative N-acetylpenicillamine, or femoral nerve section. Blood was then drawn from each animal, and the dialysate of the plasma was used to perfuse a naïve heart from an untreated donor. Infarct size was measured after 30 min of global ischemia and 120 min reperfusion. When compared with that of the control, mean infarct size was significantly smaller in groups treated with rIPC alone (P < 0.01) and intra-arterial adenosine (P < 0.01). Pretreatment with N(G)-nitro-l-arginine methyl ester or N-acetylpenicillamine did not affect the level of protection induced by rIPC (P = not significant, compared with rIPC alone) or intra-arterial adenosine (P = not significant, compared with intra-arterial adenosine alone), but prior femoral nerve transection or pretreatment with S-nitroso-N-acetylpenicillamine abolished the cardioprotective effect of intra-arterial adenosine and rIPC. Intra-arterial adenosine, like rIPC, releases a blood-borne cardioprotective factor(s) that is dependent on an intact femoral nerve and is inhibited by pretreatment with a NO donor. These results may be important when designing or assessing the results of clinical trials of adenosine or rIPC cardioprotection, where NO donors are used as part of therapy.
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Affiliation(s)
- Tor Steensrud
- Department of Cardio-Thoracic and Vascular Surgery, University Hospital North Norway, Tromsø, Norway
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Sammour T, Mittal A, Loveday BPT, Kahokehr A, Phillips ARJ, Windsor JA, Hill AG. Systematic review of oxidative stress associated with pneumoperitoneum. Br J Surg 2009; 96:836-50. [DOI: 10.1002/bjs.6651] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Abstract
Background
There have been several reports of ischaemic complications after routine laparoscopy. The aim of this review was to investigate the relationship between this oxidative stress and pneumoperitoneum.
Methods
Medline, Medline in-process, The Cochrane Library, PubMed and EMBASE were searched for papers on oxidative stress and pneumoperitoneum, from 1947 to March 2008 with no language restriction or restriction on trial design. Papers that did not investigate pneumoperitoneum as a causative factor, or did not report outcome measures related to oxidative stress, were excluded.
Results
A total of 73 relevant papers were identified: 36 animal studies, 21 human clinical trials, nine case reports, five review articles and two comments. Pneumoperitoneum causes a reduction in splanchnic blood flow, resulting in biochemical evidence of oxidative stress in a pressure- and time-dependent manner. There is evidence that the use of carbon dioxide for insufflation is contributory. Several measures proposed to minimize the oxidative stress have shown promise in animal studies, but few have been evaluated in the clinical setting.
Conclusion
There is an increasing body of evidence, mainly from animal studies, that pneumoperitoneum decreases splanchnic perfusion with resulting oxidative stress. It is now appropriate to investigate the clinical significance of pneumoperitoneum-associated oxidative stress.
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Affiliation(s)
- T Sammour
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Mittal
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - B P T Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Kahokehr
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A R J Phillips
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - J A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Eichhorn W, Blake FA, Pohlenz P, Gehrke G, Schmelzle R, Heiland M. Conditioning of myocutaneous flaps. J Craniomaxillofac Surg 2009; 37:196-200. [DOI: 10.1016/j.jcms.2008.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 10/31/2008] [Accepted: 11/27/2008] [Indexed: 12/19/2022] Open
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TOLL-LIKE RECEPTOR 2 AND 4 RESPONSE AND EXPRESSION ON MONOCYTES DECREASE RAPIDLY IN PATIENTS UNDERGOING ARTERIAL SURGERY AND ARE RELATED TO PREOPERATIVE SMOKING. Shock 2009; 31:21-7. [DOI: 10.1097/shk.0b013e31817d43bf] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Massey MF, Gupta DK. The Effects of Systemic Phenylephrine and Epinephrine on Pedicle Artery and Microvascular Perfusion in a Pig Model of Myoadipocutaneous Rotational Flaps. Plast Reconstr Surg 2007; 120:1289-1299. [PMID: 17898602 DOI: 10.1097/01.prs.0000279371.63439.8d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anesthesiologists and reconstructive surgeons have differing views regarding the control of rotational flap perfusion. Anesthesiologists view the entire body as having flow that is dependent on systemic perfusion pressure, whereas plastic surgeons conjure that systemic administration of vasoactive agents causes vasoconstriction of the pedicle artery and the microvasculature. The aim of this study was to investigate the effects of systemically administered phenylephrine and epinephrine on rotational myocutaneous flap perfusion. METHODS After institutional animal care and use committee approval, seven vertical rectus abdominal myocutaneous (VRAM) flaps were created in six pigs. Under 1.0 minimum alveolar concentration isoflurane anesthesia, pedicle artery blood flow (transit time flow probe) and microvascular perfusion (laser Doppler flow probe) were recorded at baseline and after achieving steady hemodynamics with the systemic intravenous administration of phenylephrine (20, 40, and 80 microg/minute) and epinephrine (0.5, 1, and 2 microg/kg/minute). RESULTS Under stable physiologic conditions, phenylephrine consistently decreased the pedicle artery blood flow and the microvascular perfusion of porcine VRAM rotational flaps, whereas epinephrine consistently increased both flows across the entire dose range studied. Furthermore, epinephrine-induced increases in cardiac output correlated well with the observed increases in pedicle artery blood flow and microvascular perfusion. CONCLUSIONS With the systemic delivery of phenylephrine, rotational myocutaneous flaps react in a manner described by the surgeon. In contrast, the anesthesiologist's model of the hemodynamics is correct for low to moderate doses of epinephrine. Therefore, epinephrine may be the vasoactive agent of choice for treating perioperative hypotension without harming the rotational flap blood flow.
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Affiliation(s)
- Marga F Massey
- Salt Lake City, Utah From the Division of Plastic Surgery and Department of Anesthesiology, University of Utah
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Engel H, Sauerbier M, Germann G, Küntscher MV. Dose-Dependent Effects of a Nitric Oxide Donor in a Rat Flap Model. Ann Plast Surg 2007; 58:456-60. [PMID: 17413891 DOI: 10.1097/01.sap.0000239803.18914.f9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Previous studies have proven the effectiveness of nitric oxide (NO) donors to enhance flap survival in experimental models. The purpose of this study was to determine the ideal dose of the NO donor spermine/nitric oxide complex (Sper/NO) with respect to flap survival and hemodynamic side effects. Additionally, the influence of the type of application (systemically versus intra-arterial into the flap artery) was observed.Seventy-two male Wistar rats were divided into 9 experimental groups. An extended epigastric adipocutaneous flap (6 x 10 cm) based on the left superficial epigastric artery and vein was raised in each animal. The average percentage of flap necrosis was 69.8% in the control group with ischemia and 29.8% in the non ischemic controls. The average necrosis areas in the 3 groups after preischemic intravenous (i.v.) application of Sper/NO (250, 500, and 750 nmol/kg body weight) were 63.5%, 33.8%, and 38.4%, respectively. The application of similar doses into the flap artery resulted in 63.5%, 72.3%, and 64.3% flap necrosis; 52.7% average flap loss was observed in an additional group receiving Sper/NO adjusted to flap weight (500 nmol/kg flap weight). Only the intravenous application of 500 and 750 nmol/kg resulted in a significant reduction of flap necrosis compared with the ischemic controls (P < 0.01). The drop in mean arterial pressure was less after i.v. application of 500 nmol/kg Sper/NO compared with 750 nmol. Our data show that the preischemic intravenous application of 500 nmol/kg Sper/NO achieved the best results with acceptable side effects. A dose of 250 nmol/kg i.v., as well as the application of Sper/NO into the flap artery, was demonstrated to be ineffective.
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Affiliation(s)
- Holger Engel
- Department of Plastic and Hand Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany.
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Aller MA, Arias JL, Arias JI, Sánchez-Patán F, Arias J. The inflammatory response recapitulates phylogeny through trophic mechanisms to the injured tissue. Med Hypotheses 2006; 68:202-9. [PMID: 16963191 DOI: 10.1016/j.mehy.2006.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 06/16/2006] [Accepted: 07/05/2006] [Indexed: 10/24/2022]
Abstract
The post-traumatic local acute inflammatory response is described as a succession of three functional phases of possible trophic significance: 1. Nervous or immediate (ischemia-reperfusion); 2. Immune or intermediate (infiltration by inflammatory and bacterial cells) and 3. Endocrine or late (angiogenesis with regeneration and/or cicatrization). Each of these phases emphasizes the trophic role of the mechanisms in the damaged tissue. Hence, the nervous phase is predominated by nutrition by diffusion; in the immune phase trophism is mediated by inflammatory cells and bacteria and, finally, in the endocrine phase, the blood circulation and oxidative metabolism play the most significant nutritive role. Since these trophic mechanisms are of increasing complexity, progressing from anoxia to total specialization in the use of oxygen to obtain usable energy, it could be speculated that they represent the successive reappearance of the stages that take place during the evolution of life on Earth, from ancient times without oxygen. In this sense, the inflammatory response could recapitulate phylogeny through the successive expression of pathophysiologic mechanisms that have a trophic meaning to the injured tissue.
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Affiliation(s)
- M A Aller
- Surgery Department, School of Medicine, Complutense University of Madrid, Spain
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Abstract
Our cells and tissues are challenged constantly by exposure to extreme conditions that cause acute and chronic stress. Wounding at the cellular level is a common event, and results from cell exposure to supra-physiologic forces, or is the consequence of action by reactive chemical agents. An individual cellular wound results from either the alteration of protein or DNA structure, or the disruption of molecular assemblies, the most important of which is the cell's membranes. Tissue healing at the macroscopic level is a complex and coordinated process involving many different cell types while, in contrast, the wounds of individual cells heal primarily via biomolecular interactions. Like tissue wound healing, cellular wound healing involves the upregulation or acceleration of processes that are constitutively expressed in routine physiologic repair of cellular structures In addition, recent advances have been made in the identification of pharmaceutical strategies to aid the cellular repair response. Many of these strategies offer promise for augmenting the already present cellular repair mechanisms.
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Affiliation(s)
- Jayant Agarwal
- Section of Plastic and Reconstructive Surgery, University of Chicago Hospitals, 5841 S. Maryland Ave., MC 6035, Chicago, IL 60637, USA
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