Download PDF
J Reconstr Microsurg 2014; 30(06): 405-412
DOI: 10.1055/s-0034-1372481
Original Article WSRM 2013 Scientific Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Predicting Skin Flap Viability Using a New Intraoperative Tissue Oximetry Sensor: A Feasibility Study in Pigs

Robert F. Lohman
1   Department of Head, Neck and Plastic Surgery, Roswell Park Cancer Institute, State University of New York, Buffalo, New York
,
Cemile Nurdan Ozturk
1   Department of Head, Neck and Plastic Surgery, Roswell Park Cancer Institute, State University of New York, Buffalo, New York
,
Risal Djohan
2   Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Hamilton Roger Tang
3   Triple Ring Technologies, Newark, California
,
Hui Chen
3   Triple Ring Technologies, Newark, California
,
Kate L. Bechtel
3   Triple Ring Technologies, Newark, California
› Author Affiliations
Further Information

Publication History

31 October 2013

26 January 2014

Publication Date:
21 April 2014 (online)

    Permissions and Reprints

Abstract

Background Operations for soft-tissue reconstruction, orthopedic, vascular, and other types of surgery can be complicated by unexpected skin flap necrosis. At present, surgeons utilize subjective clinical judgment and physical findings to estimate the potential for tissue compromise. As the validity of these subjective methods is questionable, there is a need for objective, quantitative tools to determine the risk of flap necrosis during surgery.

Methods Three 9-month-old Yorkshire pigs were used for the study. Four laterally based random pattern fasciocutaneous flaps were dissected on each animal. After the flaps were elevated, a prototype oximeter (ViOptix Inc., Fremont, CA), was used to measure tissue oxygenation (StO2) at 2 cm intervals along the flaps. Measurements were performed immediately after the flaps were dissected, and again at the same points after they were sutured. The animals were reevaluated 4 days later, and assessed for areas of tissue necrosis.

Results For each flap, StO2 at the base was compared with StO2 at the more distal points. The median delta StO2, as measured immediately after dissection, was −3.9% points for tissue that remained viable and −34.0% points for tissue that became necrotic (p = 0.039). After the flaps were sutured back to the chest wall, the median delta StO2 for tissue that remained viable was −1.7% points versus −24.7% points for tissue that became necrotic (p = 0.006).

Conclusions This new handheld surface sensor can be used to measure StO2 of skin flaps and may potentially reduce complications associated with unexpected tissue necrosis.

Keywords

tissue oximetry - flap perfusion - spectrophotometry

Notes

Hamilton Roger Tang, Hui Chen, and Kate L. Bechtel are employed by Triple Ring Technologies, a developmental partner of ViOptix (Fremont, CA). Robert F. Lohman and Risal Djohan are paid consultants to ViOptix. Cemile Nurdan Ozturk does not have any disclosures.


 

  • References

  • 1 Hultman CS, Daiza S. Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome. Ann Plast Surg 2003; 50 (3) 249-255 , discussion 255
    CrossrefPubMedGoogle Scholar
  • 2 Meretoja TJ, von Smitten KA, Kuokkanen HO, Suominen SH, Jahkola TA. Complications of skin-sparing mastectomy followed by immediate breast reconstruction: a prospective randomized study comparing high-frequency radiosurgery with conventional diathermy. Ann Plast Surg 2008; 60 (1) 24-28
    CrossrefPubMedGoogle Scholar
  • 3 Carlson GW, Losken A, Moore B , et al. Results of immediate breast reconstruction after skin-sparing mastectomy. Ann Plast Surg 2001; 46 (3) 222-228
    CrossrefPubMedGoogle Scholar
  • 4 Lian G, Cracchiolo III A, Lesavoy M. Treatment of major wound necrosis following total knee arthroplasty. J Arthroplasty 1989; 4 (Suppl): S23-S32
    CrossrefPubMedGoogle Scholar
  • 5 Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 2009; 91 (1) 48-54
    CrossrefPubMedGoogle Scholar
  • 6 Khorgami Z, Shoar S, Laghaie B, Aminian A, Hosseini Araghi N, Soroush A. Prophylactic retention sutures in midline laparotomy in high-risk patients for wound dehiscence: a randomized controlled trial. J Surg Res 2013; 180 (2) 238-243
    CrossrefPubMedGoogle Scholar
  • 7 van Ramshorst GH, Nieuwenhuizen J, Hop WC , et al. Abdominal wound dehiscence in adults: development and validation of a risk model. World J Surg 2010; 34 (1) 20-27
    CrossrefPubMedGoogle Scholar
  • 8 Webster C, Neumayer L, Smout R , et al; National Veterans Affairs Surgical Quality Improvement Program. Prognostic models of abdominal wound dehiscence after laparotomy. J Surg Res 2003; 109 (2) 130-137
    CrossrefPubMedGoogle Scholar
  • 9 Preminger BA, Pusic AL, McCarthy CM, Verma N, Worku A, Cordeiro PG. How should quality-of-life data be incorporated into a cost analysis of breast reconstruction? A consideration of implant versus free TRAM flap procedures. Plast Reconstr Surg 2008; 121 (4) 1075-1082
    CrossrefPubMedGoogle Scholar
  • 10 Thoma A, Veltri K, Khuthaila D, Rockwell G, Duku E. Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis. Plast Reconstr Surg 2004; 113 (6) 1650-1661
    CrossrefPubMedGoogle Scholar
  • 11 Conlon KC, Sclafani L, DiResta GR, Brennan MF. Comparison of transcutaneous oximetry and laser Doppler flowmetry as noninvasive predictors of wound healing after excision of extremity soft-tissue sarcomas. Surgery 1994; 115 (3) 335-340
    PubMedGoogle Scholar
  • 12 Vonlanthen R, Slankamenac K, Breitenstein S , et al. The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 2011; 254 (6) 907-913
    CrossrefPubMedGoogle Scholar
  • 13 Hemmila MR, Jakubus JL, Maggio PM , et al. Real money: complications and hospital costs in trauma patients. Surgery 2008; 144 (2) 307-316
    CrossrefPubMedGoogle Scholar
  • 14 Olsen MA, Chu-Ongsakul S, Brandt KE, Dietz JR, Mayfield J, Fraser VJ. Hospital-associated costs due to surgical site infection after breast surgery. Arch Surg 2008; 143 (1) 53-60 , discussion 61
    CrossrefPubMedGoogle Scholar
  • 15 Sood M, Glat P. Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction. Ann Surg Innov Res 2013; 7 (1) 9-1164
    CrossrefPubMedGoogle Scholar
  • 16 Jonsson K, Jensen JA, Goodson III WH , et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Ann Surg 1991; 214 (5) 605-613
    CrossrefPubMedGoogle Scholar
  • 17 Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg 2010; 125 (4) 1065-1073
    CrossrefPubMedGoogle Scholar
  • 18 Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast 2011; 20 (1) 21-25
    CrossrefPubMedGoogle Scholar
  • 19 Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60 (1) 27-40
    PubMedGoogle Scholar
  • 20 Agarwal T, Hultman CS. Impact of radiotherapy and chemotherapy on planning and outcome of breast reconstruction. Breast Dis 2002; 16: 37-42
    PubMedGoogle Scholar
  • 21 Chang DW, Reece GP, Wang B , et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105 (7) 2374-2380
    CrossrefPubMedGoogle Scholar
  • 22 Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg 2003; 111 (6) 2082-2087 , discussion 2088–2089
    CrossrefPubMedGoogle Scholar
  • 23 Holstein P. Ischaemic wound complications in above-knee amputations in relation to the skin perfusion pressure. Prosthet Orthot Int 1980; 4 (2) 81-86
    PubMedGoogle Scholar
  • 24 Nahabedian MY, Mont MA, Orlando JC, Delanois RE, Hungerford DS. Operative management and outcome of complex wounds following total knee arthroplasty. Plast Reconstr Surg 1999; 104 (6) 1688-1697
    CrossrefPubMedGoogle Scholar
  • 25 Endara M, Masden D, Goldstein J, Gondek S, Steinberg J, Attinger C. The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control. Plast Reconstr Surg 2013; 132 (4) 996-1004
    CrossrefPubMedGoogle Scholar
  • 26 Franz MG, Robson MC, Steed DL , et al; Wound Healing Society. Guidelines to aid healing of acute wounds by decreasing impediments of healing. Wound Repair Regen 2008; 16 (6) 723-748
    CrossrefPubMedGoogle Scholar
  • 27 McPhail R, Cooper LT, Hodge DO, Cabanel ME, Rooke TW. Transcutaneous partial pressure of oxygen after surgical wounds. Vasc Med 2004; 9 (2) 125-127
    CrossrefPubMedGoogle Scholar
  • 28 Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013; 29 (1) 51-56
    PubMedGoogle Scholar
  • 29 Lin SJ, Nguyen MD, Chen C , et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (3) 1080-1085
    CrossrefPubMedGoogle Scholar
  • 30 Rao R, Saint-Cyr M, Ma AM , et al. Prediction of post-operative necrosis after mastectomy: a pilot study utilizing optical diffusion imaging spectroscopy. World J Surg Oncol 2009; 7: 91-7819
    CrossrefPubMedGoogle Scholar
  • 31 Newman MI, Samson MC, Tamburrino JF, Swartz KA. Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg 2010; 26 (7) 487-492
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Tindholdt TT, Saidian S, Tønseth KA. Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction. J Plast Surg Hand Surg 2011; 45 (3) 143-147
    CrossrefPubMedGoogle Scholar
  • 33 Zdolsek JM, Droog EJ, Thorfinn J, Lidman D. Laser Doppler perfusion imaging of the radial forearm flap: a clinical study. Scand J Plast Reconstr Surg Hand Surg 2006; 40 (2) 101-105
    CrossrefPubMedGoogle Scholar
  • 34 Tenorio X, Mahajan AL, Wettstein R, Harder Y, Pawlovski M, Pittet B. Early detection of flap failure using a new thermographic device. J Surg Res 2009; 151 (1) 15-21
    CrossrefPubMedGoogle Scholar
  • 35 Scheufler O, Exner K, Andresen R. Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography. Plast Reconstr Surg 2004; 113 (1) 141-152 , discussion 153–155
    CrossrefPubMedGoogle Scholar
  • 36 Payette JR, Kohlenberg E, Leonardi L , et al. Assessment of skin flaps using optically based methods for measuring blood flow and oxygenation. Plast Reconstr Surg 2005; 115 (2) 539-546
    Google Scholar
  • 37 Mothes H, Dönicke T, Friedel R, Simon M, Markgraf E, Bach O. Indocyanine-green fluorescence video angiography used clinically to evaluate tissue perfusion in microsurgery. J Trauma 2004; 57 (5) 1018-1024
    CrossrefPubMedGoogle Scholar
  • 38 Krishnan KG, Schackert G, Steinmeier R. The role of near-infrared angiography in the assessment of post-operative venous congestion in random pattern, pedicled island and free flaps. Br J Plast Surg 2005; 58 (3) 330-338
    CrossrefPubMedGoogle Scholar
  • 39 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (5) 538-543
    CrossrefPubMedGoogle Scholar
  • 40 Hölzle F, Loeffelbein DJ, Nolte D, Wolff KD. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg 2006; 34 (1) 25-33
    PubMedGoogle Scholar
  • 41 Holm C, Mayr M, Höfter E, Becker A, Pfeiffer UJ, Mühlbauer W. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg 2002; 55 (8) 635-644
    CrossrefPubMedGoogle Scholar
  • 42 de Weerd L, Mercer JB, Setså LB. Intraoperative dynamic infrared thermography and free-flap surgery. Ann Plast Surg 2006; 57 (3) 279-284
    CrossrefPubMedGoogle Scholar
  • 43 Ashitate Y, Lee BT, Ngo LH , et al. Quantitative assessment of nipple perfusion with near-infrared fluorescence imaging. Ann Plast Surg 2013; 70 (2) 149-153
    CrossrefPubMedGoogle Scholar
  • 44 Jöbsis FF. Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters. Science 1977; 198 (4323) 1264-1267
    CrossrefPubMedGoogle Scholar
  • 45 Thorniley MS, Sinclair JS, Barnett NJ, Shurey CB, Green CJ. The use of near-infrared spectroscopy for assessing flap viability during reconstructive surgery. Br J Plast Surg 1998; 51 (3) 218-226
    CrossrefPubMedGoogle Scholar
  • 46 Irwin MS, Thorniley MS, Doré CJ, Green CJ. Near infra-red spectroscopy: a non-invasive monitor of perfusion and oxygenation within the microcirculation of limbs and flaps. Br J Plast Surg 1995; 48 (1) 14-22
    CrossrefPubMedGoogle Scholar
  • 47 Kamolz LP, Giovanoli P, Haslik W, Koller R, Frey M. Continuous free-flap monitoring with tissue-oxygen measurements: three-year experience. J Reconstr Microsurg 2002; 18 (6) 487-491 , discussion 492–493
    Google Scholar
  • 48 Hunt TK, Rabkin J, Jensen JA, Jonsson K, von Smitten K, Goodson III WH. Tissue oximetry: an interim report. World J Surg 1987; 11 (2) 126-132
    CrossrefPubMedGoogle Scholar
  • 49 Steele MH. Three-year experience using near infrared spectroscopy tissue oximetry monitoring of free tissue transfers. Ann Plast Surg 2011; 66 (5) 540-545
    CrossrefPubMedGoogle Scholar
  • 50 Association for assessment and accreditation of laboratory animal care. Available at: http://www.aaalac.org/ . Accessed October 31, 2013
    PubMedGoogle Scholar
  • 51 USDA animal welfare. Available at: http://www.aphis.usda.gov/animal_welfare/awa_info.shtml . Accessed October 31, 2013
    PubMed
  • 52 R project Available at: http://www.r-project.org . Accessed October 31, 2013
    PubMed
  • 53 Schwarte LA, Stevens MF, Ince C. Hepatosplanchnic failure: Splanchnic perfusion and oxygenation in critical illness. In: Vincent JL, , ed. Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer; 2006: 627-40
    CrossrefGoogle Scholar
  • 54 Scheeren TW, Schober P, Schwarte LA. Monitoring tissue oxygenation by near infrared spectroscopy (NIRS): background and current applications. J Clin Monit Comput 2012; 26 (4) 279-287
    CrossrefPubMedGoogle Scholar
  • 55 Murkin JM, Adams SJ, Novick RJ , et al. Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg 2007; 104 (1) 51-58
    CrossrefPubMedGoogle Scholar
  • 56 Austin III EH, Edmonds Jr HL, Auden SM , et al. Benefit of neurophysiologic monitoring for pediatric cardiac surgery. J Thorac Cardiovasc Surg 1997; 114 (5) 707-715 , 717, discussion 715–716
    CrossrefPubMedGoogle Scholar
  • 57 Ali AM, Green D, Zayed H, Halawa M, El-Sakka K, Rashid HI. Cerebral monitoring in patients undergoing carotid endarterectomy using a triple assessment technique. Interact Cardiovasc Thorac Surg 2011; 12 (3) 454-457
    CrossrefPubMedGoogle Scholar
  • 58 Moritz S, Kasprzak P, Arlt M, Taeger K, Metz C. Accuracy of cerebral monitoring in detecting cerebral ischemia during carotid endarterectomy: a comparison of transcranial Doppler sonography, near-infrared spectroscopy, stump pressure, and somatosensory evoked potentials. Anesthesiology 2007; 107 (4) 563-569
    CrossrefPubMedGoogle Scholar
  • 59 Hemmerling TM, Bluteau MC, Kazan R, Bracco D. Significant decrease of cerebral oxygen saturation during single-lung ventilation measured using absolute oximetry. Br J Anaesth 2008; 101 (6) 870-875
    CrossrefPubMedGoogle Scholar
  • 60 Casati A, Fanelli G, Pietropaoli P , et al. Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia. Anesth Analg 2005; 101 (3) 740-747 table of contents
    CrossrefPubMedGoogle Scholar
  • 61 Crookes BA, Cohn SM, Bloch S , et al. Can near-infrared spectroscopy identify the severity of shock in trauma patients?. J Trauma 2005; 58 (4) 806-813 , discussion 813–816
    CrossrefPubMedGoogle Scholar
  • 62 Scheufler O, Andresen R. Tissue oxygenation and perfusion in inferior pedicle reduction mammaplasty by near-infrared reflection spectroscopy and color-coded duplex sonography. Plast Reconstr Surg 2003; 111 (3) 1131-1146
    Google Scholar
  • 63 Harrison DK. Clinical applications of tissue oxygen saturation measurements. In: Wolf M, , ed. Oxygen Transport to Tissue XXXIII, Advances in Experimental Medicine and Biology. New York, NY: Springer Science and Business Media; 2012: 191-195
    CrossrefGoogle Scholar
  • 64 Leichtle SW, Kaoutzanis C, Brandt MM, Welch KB, Purtill MA. Tissue oxygen saturation for the risk stratification of septic patients. J Crit Care 2013; 28 (6) e1-e5
    CrossrefPubMedGoogle Scholar
  • 65 Suffoletto B, Kristan J, Rittenberger JC, Guyette F, Hostler D, Callaway C. Near-infrared spectroscopy in post-cardiac arrest patients undergoing therapeutic hypothermia. Resuscitation 2012; 83 (8) 986-990
    CrossrefPubMedGoogle Scholar
  • 66 Shapiro NI, Arnold R, Sherwin R , et al; Emergency Medicine Shock Research Network (EMShockNet). The association of near-infrared spectroscopy-derived tissue oxygenation measurements with sepsis syndromes, organ dysfunction and mortality in emergency department patients with sepsis. Crit Care 2011; 15 (5) R223
    CrossrefPubMedGoogle Scholar
  • 67 Kyle B, Litton E, Ho KM. Effect of hyperoxia and vascular occlusion on tissue oxygenation measured by near infra-red spectroscopy (InSpectra™): a volunteer study. Anaesthesia 2012; 67 (11) 1237-1241
    CrossrefPubMedGoogle Scholar
  • 68 Wolff KD, Kolberg A, Mansmann U. Cutaneous hemoglobin oxygenation of different free flap donor sites. Plast Reconstr Surg 1998; 102 (5) 1537-1543
    CrossrefPubMedGoogle Scholar
  • 69 Yao FS, Tseng CC, Ho CY, Levin SK, Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2004; 18 (5) 552-558
    CrossrefPubMedGoogle Scholar