Pediküllü fleplerdeki skarların flep yaşamına etkileri

Yıl 2020, , 803 - 812, 18.09.2020

Ramazan Hakan Özcan

https://doi.org/10.31362/patd.788093

Öz

Amaç: Skar, doku bütünlüğünün bozulması sonucu yara iyileşme mekanizmalarının devreye girmesiyle meydana gelen ve oluştuğu bölgede kan akımını olumsuz etkileyen bir patolojidir. Bu çalışmada diğer flep seçeneklerinin başvurulmasına sebep olan, flep planlanacak bölgedeki skarların olumsuz etkilerini ve skarın yönünün değişmesiyle ne gibi farklılıklar olacağı araştırıldı.
Gereç ve yöntem: Çalışmada 24 adet Wistar Albino cinsi dişi rat kullanıldı. Ratların sırt bölgesinde ortadaki 1cm lik sağlam deri adasının her iki tarafında 2x6cm lik kaudal tabanlı flepler planlandı. İlk 12 ratta transvers skar içeren sol flep transvers skar grubu ve skar içermeyen sağ flep kontrol grubu olarak değerlendirildi. Diğer 12 ratta oblik skar içeren sol flep oblik skar grubu ve skar içermeyen sağ flep kontrol grubu olarak değerlendirildi. Flep araştırması için oluşturulan gruplar 1. Grup kontrol grubu (n=24) 2. Grup transvers skar grubu (n=12) 3. Grup oblik skar grubu (n=12) olarak adlandırıldılar. Sol flep pedikülünde transvers ve oblik skar oluşturulmasını takiben 30. günde kontrol grubunu oluşturan sağ flepler ile çalışma grubunu oluşturan sol flepler eleve edildi ve kaldırıldıkları bölgeye sütüre edildi. 4. günün sonunda ratlara eter ile anestezi ve ötenazi uygulandı. Her iki tarafta canlı kalan flep alanları milimetrik olarak ölçüldü. Skarıda içine alacak şekilde histopatolojik inceleme için çalışma ve kontrol fleplerinden biyopsiler alındı.
Bulgular: Her bir flebin toplam alanı 1200mm2 ve 1000mm2 dir. Transvers skar içeren ratlarda skarlı fleplerde nekroz olan flep alanı ortalaması % 80,8 iken skarsız fleplerde bu oran % 57,6 olarak bulundu. Oblik skar içeren ratlarda skar grubunda nekroza uğrayan flep alanı ortalaması % 83.9 iken skarsız kontrol grubunda % 63,3 tür. Histopatolojik bulgu olarak skarsız kontrol grubunda normal yapıda epidermis ve dermiş komponentleri görülürken her iki skar grubunda da epidermis ve dermiste atrofi, adneksiyal yapıların kaybı, retiküler dermisi tutan fibrozis görüldü.
Sonuç: Skar random flep canlılığını olumsuz yönde etkileyen bir faktördür. Skar yönü nekroz oranını değiştirmemiştir. Skar distalinde kalan bir deri flebinin normalde yaşaması gereken kısmının ancak yarısının yaşayabileceği sonucuna varılmıştır.

Purpose: Scar is a pathology that occurs when the wound healing mechanisms take action as a result of the deterioration of tissue integrity and that adversely a!ects the blood flow in the region where it occurs. In this study, we investigated the negative effects of the exisiting scars in the area of scheduled flap, which led to the consideration of other flap options, and investigated the differences that would arise with the change of the direction of the scar.
Materials and Methods: Twenty-four female Wistar Albino rats were used in the study. In the back region of the rats, a 2x6cm caudal-based flaps were planned on both sides of a 1 cm intact skin island. In the first 12 rats, the left flaps with transverse scar were included in the Group with transverse scar, and the right flaps without scar were included in the control group. In the other 12 rats, the left flaps with an oblique scar were included in the Group with oblique scar and the right flaps without scar were included in the control group.
The groups created for flap investigation were named as follows:
Group 1: The control group (n=24)
Group 2: The group with transverse scar (n=12)
Group 3: The group with oblique scar (n=12)
Following transverse and oblique scar formation in the left flap pedicle, the right flaps forming the control group and the left
flaps forming the study group were elevated on the 30th day, and they were sutured in the site where they were elevated. At the
end of the 4th day, rats were anesthetized with ether and euthanized. The surviving flap areas on both sides were measured in
millimeters. Biopsies including the scars were taken from the study and control flaps for histopathological examination.
Results: The total area of each flap was 1200 mm2 and 1000mm2. While the mean flap area with necrosis in scarred flaps was 80.8% in the rats with transverse scars, this ratio was found as 57.6% in scarless flaps. In the rats with oblique scar, the mean flap area with necrosis was 83.9% in the scar group whereas it was 63.3% in scarless control group. As histopathological findings; while epidermis and dermis components in normal structure were seen in the scarless control group, atrophy in epidermis and dermis, loss of adnexal structures, and fibrosis involving reticular dermis were seen in both scar groups.

Anahtar Kelimeler

flep, nekroz, pedikül, skar

Kaynakça

• 1. Converse M J. Intraduction to plastic surgery. In: Reconstructive plastic surgery. Philadelphia: W. B. Saunders Company, 1977; Vol.I, 3-69.
• 2. Cormack GC, Lamberty BGH. Introduction:the arterial anatomy of skin flaps. 1nd ed. Edinburgh, London, Melbourne and New York: Churchill Livingstone, 1986;1-9.
• 3. Çağdaş A, Akın Y, Songür E. Plastik ve rekonstrüktif cerrahiye giriş. İzmir: Ege Ünv. Yayın. 1988;1-15.
• 4. Daniel RK, Kerrigan CL. Principles and physiology of skin flap surgery. Plastic Surgery. Philadelphia: W. B. Saunders Company, Vol. 1,1990;275-281.
• 5. Fisher J, Gingrass MK. Basic principles of skin flaps. Plastic, maxillofacial and reconstructive surgery. 3nd ed. Baltimore: Williams & Wilkins, 1997;19-30
• 6. Jankauskass S, Cohen IK, Grabb WC. Basic techniques of plastic surgery. Grabb and Smith, Plactic Surgery 4nd ed. Boston, Toronto, London: Little Brown and Company, 1991;1-91.
• 7. McCarthy JG. Introduction to plastic surgery. Philadelphia: W. B. Saunders Company, 1990; Vol. 1, 1-20
• 8. George B, Lamberty H. Flaps: Physiology, principles of design and pitfalls. Mastery of plastic and reconstructive surgery. Boston,New York,Toronto, London: Little, Brown and Company. 1994: Vol. 1. 56-70.
• 9. Grabb WC. Smith JW. Basic techniques of plastic surgery. 2nd ed. Boston,New York,Toronto,London: Little, Brown and Company, 1973;81-89.
• 10. Strauc MF, Strauc WE. Tubed skin flaps.1nd ed. Boston, Toronto, London: Little, Brown and Company, 1975;405-409.
• 11. Callegari PR, Taylor GI, Caddy CM, Minabe T. An anatomic review of the delay phenomenon: I. Experimental studies. Plast Reconstr Surg 1992;89:397-407.
• 12. Dunn R. M, Mancoll J. Flap models in the rat. A review and reappraisal . Plast Reconstr Surg 1992;90:319-28.
• 13. Cohen IK, Mast BA. Models of wound healing. The J. of Trauma. 1990;30(12): 149-55.
• 14. Clarke HM, Howard CR, Pynn BR, Et all. Delayed neovascularization in free skin flap transfer to irradiated beds in rats. Plast Reconstr Surg 1985;75(4):560-4. https://doi.org/10.1097/00006534-198504000-00021.
• 15. Sefarin D, Shearin C, Georgiade NG. The Vascularization of free flaps. Plast Reconstr Surg 1977;60:233-41. https://doi.org/10.1097/00006534-197708000-00010.
• 16. Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps: Route and timing. Plast Reconstr Surg 1980;66(1):85-90. https://doi.org/10.1097/00006534-198007000-00017.
• 17. Connelly JR. Reconstructive procedures of the lower extremity. Plastic Surgery. 2nd ed. Baltimore: J. W. 1973;919-924.
• 18. Morgan SC, Zbylski JR. Repair of massive soft tissue defects by open jump flaps. Plast Reconstr Surg 1972;50(3):265-9. https://doi.org/10.1097/00006534-197209000-00012.
• 19. Gibraiel EA. The jump flap procedure in the treatment of burn scar contractures of the neck. Br J Plast Surg 1971;24(3):289-92. https://doi.org/10.1016/s0007-1226(71)80072-3.
• 20. Alexander M, Guba Jr. Study of delay phenomenon in axial pattern flaps in pigs. Plast Reconstr Surg 1979;63(4):550-4. https://doi.org/10.1097/00006534-197904000-00018.
• 21. Finseth F, Cutting C. An experimental neurovascular island skin flap for the study of the delay phenomenon. Plast Reconstr Surg 1978;61(3):412-20. https://doi.org/10.1097/00006534-197803000-00016.
• 22. Thomson FM, Beracha GJ, Goodhrie RP. The effective duration of the delay phenomenon in the rat. Plast Reconstr Surg 1977;60(3):384-9.
• 23. Reinisch JF. Pathophysiology of skin flap circulation. Plast Reconstr Surg 1974; 54(5):585-98. https://doi.org/10.1097/00006534-197411000-00010.
• 24. Monteiro DT, Santamore WP, Nemir P. The influence of pentoxifylline on skin flap survival. Plast Reconstr Surg 1986;77(2):277-81. https://doi.org/10.1097/00006534-198602000-00019.
• 25. Chu BC, Deshmukh N. The lack of effect of pentoxifylline on random skin flap survival. Plast Reconstr Surg. 1989;83(2):315-8. https://doi.org/10.1097/00006534-198902000-00021.
• 26. Emery FM, Kodey TR, Bomberger RA, Mc Gregor DB. The Effect of nifedipine on skin flap survival. Plast Reconstr Surg 1990;85(1):61-3. https://doi.org/10.1097/00006534-199001000-00011.
• 27. Nakatsuka T, Pang CY, Neligan P, et all. Effect of glucocorticoid treatment on skin capillary blood flow and viability in cutaneous and myocutaneous flaps in the pig. Plast Reconstr Surg 1985;76(3):374-85. https://doi.org/10.1097/00006534-198509000-00006.
• 28. Silverman DG, La Rossa, DD, Barlow CH, et all. Quantification of tissue fluorescein delivery and prediction of flap viability with the fiberoptic dermofluorometer Plast Reconstr Surg 1980;66(4):545-53. https://doi.org/10.1097/00006534-198010000-00007
• 29. Snell P. M. The pig as an experimental model for skin flap behaviour: A reappraisal of previous studies Br J Plast Surg 1977 Jan;30(1):1-8. https://doi.org/10.1016/s0007-1226(77)90026-1
• 30. Morita D, Numajiri T, Nakamura H. et al. Two cases of the vascular territory of a single-pedicled deep inferior epigastric perforator flap with a vertical midline abdominal scar. Plast Reconstr Surg 2020;8(3): e2684. https://doi.org/10.1097/GOX.0000000000002684
• 31. Nykiel M, Hunter C, Lee GK. Algorithmic approach to the design and harvest of abdominal flaps for microvascular breast reconstruction in patients with abdominal scars. Ann Plast Surg 2015;74 Suppl 1:33-40. https://doi.org/10.1097/SAP.0000000000000509
• 32. Yılmaz KB, Gurunluoglu R, Bayramiçli M. Flap survival after previous vascular pedicle division and preexisting scar formation at the pedicle site: An experimental study. Ann Plast Surg 2014;73(4):434-40. https://doi.org/10.1097/SAP.0b013e31827fb346