Floor plan - 2013 Annual Meeting - American Association for Hand ...

Understanding the Physiologic Process Behind VAC®: Comparison of Wound Healing
Markers with Non-VAC® Treated Wounds
Institution where the work was prepared: Penn State College of Medicine, Hershey, PA, USA
Rachel H. Noone, BA; Robert Grunfeld, MA; Sprague W. Hazard, MD; Noel B. Natoli, MD; Justin Zelones, BS; Brad Morrow,
BS; Jason Hancey, MD; Paul Ehrlich, PhD; Donald R. Mackay, MD; Reza Miraliakbari, MD; Penn State College of Medicine
INTRODUCTION:
The success of Vacuum Assisted Closure (VAC®) in treatment of wounds is evidenced by its popularity and wide spectrum of clinical
application. Recent studies have examined the effect of VAC® on the biochemical composition of wound fluids by cytokine assay. No
direct data exist as how these findings are different from the non-VAC treated fluid. We propose to study the effect of VAC by comparing
physiologic assays (fibroblast migration and proliferation) as well as the cytokine profiles of wound fluid from patients treated with
VAC®, to closed wounds treated with closed suction JP (Jackson-Pratt) systems.
METHODS:
Wound fluid was collected from 34 VAC® treated patients, and 11 patients with JP drains. Diabetic patients were purposely excluded.
Wound fluid was collected from VAC® canisters and JP bulbs roughly every two days for a period of 7 days (at least three collections).
VEGF, IL-1, MMP-13, collagen type I and EDA-Fibronectin levels were analyzed. Also, effects of wound fluid on cultured fibroblast migration
and proliferation were tested on all samples.
RESULTS:
VAC® treated wound fluid showed a significant increase in IL-1 (p = 0.0027). and VEGF (p = 0.016) levels at all time points compared
to JP drained wounds There were no significances detected when comparing the two wound fluids with respect to collagen, fibronectin,
MMP13, or cultures fibroblast migration or proliferation.
CONCLUSIONS:
The mechanism for VAC® treatment's success is undefined. This study reports significant elevation of IL-1 and VEGF in VAC treated
wounds compared to non treated wounds. These findings, viewed in isolation, may speak to VAC®'s success. However, once the larger
picture (wound fluid effects on cultured cells) is taken into account, more questions will be raised, regarding the mechanism for
VAC®'s success. Non- VAC® treated wounds did not differ from VAC® treated wounds in regard to: cell migration, proliferation, collagen
and fibronectin production, as well as MMP13 levels. Further wound fluid analysis is underway to clarify the physiological processes
underlying VAC®'s effectiveness in promoting wound closure.
Cold Ischemia Facilitates Free TRAM and DIEP Flap Breast Reconstruction
Institution where the work was prepared: Stanford University, Palo Alto, CA, USA
Ali Salim, MD; Gordon K. Lee; Stanford University
INTRODUCTION:
The free TRAM flap is a well-established method of autologous tissue breast reconstruction. A drawback to this and other microvascular-based
approaches is the length of operation, which may be 6 hours for unilateral and 8 hours for bilateral breast reconstruction.
Longer operative times have been reported for perforator-based reconstructions, including the DIEP flap. As this may take a significant
physical toll on the surgical team, we have adopted a two-surgeon protocol in which flaps are placed under cold ischemia immediately
after harvest. We believe this (a) reduces surgeon fatigue by facilitating performance of the operation and (b) is a safe modification
which does not increase operative time or compromise flap viability.
METHODS:
We performed 84 consecutive breast reconstructions (free TRAM, muscle-sparing TRAM, and DIEP flaps) over 36 months. All flaps were
exposed to post-harvest cold ischemia as follows: immediately after harvest, each flap was wrapped in a moist sponge, sealed in a
bowel bag, and placed in an ice slush bath. With the flap(s) on ice, one member of the team proceeds with closure of the abdominal
fascia while the other member takes a break. The surgeons then alternate roles, such that by the time the microvascular anastomosis is
performed, both surgeons are refreshed mentally and physically for this delicate part of the operation. A second assistant can close the
skin layer of the abdomen and perform the umbilicoplasty at the same as the microsurgery. We then retrospectively reviewed flap
ischemia times, operative times, and the rate of complications including flap loss, microvascular thrombosis, and fat necrosis evident
upon physical exam.
RESULTS:
Average cold ischemia time for unilateral reconstruction was 1 hour 45 minutes, and for bilateral reconstruction was 2 hours 5 minutes
for the first flap and 3 hours 35 minutes for the second flap. There was 1 flap loss (1.2%) which was due to vascular thrombosis; this complication
was not associated with a statistically significant increase in ischemia time. Fat necrosis rate was 3% and average patient follow-up
was 22 months.
CONCLUSION:
As our operative times and complication rates compare to other large published series, we believe that cold ischemia is well-tolerated
by the free TRAM flap, and in fact facilitates the operation significantly by contributing to decreased surgeon fatigue.
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