Principles of Microvascular Surgery.

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Tissue response to ischemia and hypoxia • Cooling prolongs tolerance to ischemia in all types of tissues. » Donski, Br J Plast Surg 1980 - effect of cooling on groin flaps in rabbit - 86% survival after cooling for 1-3 days. » Anderl, 1977 - stored a human groin flap for 24h. » Cooley, J Microsurg 1981 - in rats, max ischemia 6h at body temp and 48h if cooled. » Walkinshaw, PRS 1988 - proximal bowel segments are more resistant to warm ischemia at 2h. Tissue response to ischemia and hypoxia Tissue Warm Cold Skin & subcutaneous t. 4-6h Up to 12h Muscle
The no-reflow effect • Ames, Am J Pathol 1968 - studied the effect of ischemia on rabbit brains. » Some ischemic organs failed to reperfuse after their blood supply was reestablished. » Called this - the no-reflow phenomenon. • Mechanism - » Cellular swelling in the vascular endothelium. » Intravascular platelet aggregation. » Leakage of intravascular fluid to the interstitial space. • Clinical observations - The no-reflow effect » Excellent blood flow immediately after anastomosis. » Decrease in blood flow shortly after. » The low flow state triggers intravascular thrombosis. » Flap ischemia. • May, PRS 1978 - no-reflow in groin flap in rabbits- » Mild obstruction to blood flow 1h post ischemia. » Increasing severity at 8 and 12h. » Histologic changes reversible at 4 and 8h. 23
Page 1 and 2: Principles of Microvascular Surgery
Page 3 and 4: History • Malt & McKhann, 1962 -
Page 5 and 6: History • Danil & Taylor + O’br
Page 7 and 8: Basic Science Concepts in Microsurg
Page 9 and 10: Vessel Injury and Regeneration •
Page 11 and 12: Vessel Wall Healing • At the time
Page 13 and 14: Damage from needles, sutures and te
Page 15 and 16: The clotting mechanism • Platelet
Page 17 and 18: Antithrombotic therapy Heparin (con
Page 19 and 20: Antithrombotic therapy Low molecula
Page 21: Antithrombotic therapy conclusions:
Page 25 and 26: • Treatment - The no-reflow effec
Page 27 and 28: • Loupes… • Or microscope? Mi
Page 29 and 30: • Key sutures - Anastomotic techn
Page 31 and 32: End-to-end, end-to-side and end-in-
Page 33 and 34: Laser anastomosis • Various exper
Page 35 and 36: Monitoring perfusion • Doppler ul
Page 37 and 38: The influence of patient factors
Page 39 and 40: Free flaps • Twenty years ago - f
Page 41 and 42: • Free groin flap - Free flaps -
Page 43 and 44: Free flaps - fascia • Useful wher
Page 45 and 46: Free flaps - muscle • Free latiss
Page 47 and 48: Free fibula flap 47

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