• Archives of Reconstructive Microsurgery
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• v.23 no.1
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• pp.1-7
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• 2014

Purpose: Recent studies have reported on application of fibrin glue composed of fibrinogen and thrombin to nerve anastomosis, which can be another candidate for vessel anastomosis. However, no research regarding the risk and effectiveness of thrombin in microvascular free tissue transfer has been reported. Therefore, the aim of study is to determine the risk and effectiveness of thrombin on microvascular free tissue transfer through clinical cases. Materials and Methods: Twenty-five patients underwent free flap reconstruction for soft tissue defect or bone exposure in our institute from March 2011 to February 2014. In the group using thrombin, dissolved powder thrombin (5,000 IU/amp) was mixed with 10 mL normal saline. Saline mixed with thrombin was applied on the flap, recipient, and around vessel anastomosis. In the control group, free flap was performed using the same method, except using thrombin. We analyzed the results between the two groups. Results: All flaps survived. The group using thrombin included 14 patients and the control group included 11 patients. Hematoma was found in two cases, respectively, in each group. The group using thrombin showed lower incidence of hematoma than the control group. No difference in survival rate of the flap was observed between the thrombin group and the control group. Conclusion: Results of this study showed that use of saline mixed with thrombin in free tissue transfer may be safe and effective for prevention of hematoma formation in the recipient site.

• Archives of Craniofacial Surgery
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• v.10 no.2
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• pp.127-130
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• 2009

Purpose: In an amputated auricle, a microvascular anastomosis is the best treatment of choice. But, the neartotally amputated auricle which is connected by very narrow tissue pedicle to the head, can survive by simple attachment without a microvascular anastomosis owing to the rich vascular network through the superficial temporal artery and posterior auricular artery. In cases of venous congestion resulting from a lack of vein anastomosis, medical leeches (Hirudo medicinalis) can solve the problem. We are reporting the case of a 6-year-old boy who had a neartotally amputated auricle with successful results by simple closure and medical leech treatment without a microvascular anastomosis. Methods: A 6-year-old male patient had an left auricular injury by an escalator accident. The left auricle was neartotally amputated from the temporal head with connection only by very narrow skin and subcutaneous pedicle (about 1 cm in width) at the helical root of upper and anterior part of auricle. Marginal bleeding from the avulsed auricle was noted and the arterial blood was supplied from a branch of upper auricular branch of the superficial temporal artery. The auricle was repaired by simple closure including cartilage and skin without any vascular anastomosis. After simple closure, the auricle showed good circulation with pink color. But on the 2nd day after the operation, there was a venous congestion with severe swelling, which resulted in a purplish colored auricle. The venous congestion disappeared after using medical leeches by the 5th day after the operation. Results: The repaired auricle showed aesthetically and functionally satisfactory result with normal development at the 9 months follow-up check after the operation. Conclusion: In cases of neartotally amputated auricles of children or crushing injury in which microsurgery is difficult, we can try simple closure with the use of medical leeches in treating a of venous congestion for a successful result.

• Archives of Craniofacial Surgery
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• v.19 no.4
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• pp.304-308
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• 2018

Replantation using microvascular anastomosis is considered to be the optimal method in treating the amputated ear in terms of resulting color, texture, and shape. Only a few cases of ear replantation have been reported because it is anatomically difficult to identify suitable vessels for anastomosis. We successfully replanted the amputated helical rim of the ear using single arterial anastomosis. A 37-year-old man had his helical rim amputated by a human bite. The amputee was about $4{\times}1cm$ in dimension, composed of skin and soft tissue including auricular cartilage. Replantation was performed anastomosing a small artery of the amputee with a terminal branch of the posterior auricular artery. After replantation, intravenous heparinization was performed and prostaglandin E1 and aspirin were administered. Venous congestion was decompressed by stab incisions applied with heparin solution soaked gauze. Venous congestion of the amputee slowly began to resolve at 4 days after the operation. The amputated segment of the helical rim survived completely with good aesthetic shape and color. The authors propose that performing microvascular anastomosis should be attempted especially if it is possible to detect vessels on cut surfaces of ear amputee and stump. Proper postoperative care for venous congestion, arterial insufficiency, and infection should be followed for amputee survival.

• Archives of Plastic Surgery
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• v.32 no.4
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• pp.461-466
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• 2005

Despite the major advances in the microvascular surgery with success rates of up to 98%, failure and vascular complications still remain even in the experienced hands. Failure of blood to flow across an anastomosis is usually caused by three factors: (1) Technical errors; (2) Undetected damage more proximally or via vasospasm; or (3) A clot or a thrombus. The success of a microvascular surgery depends on the severity of the vascular injury and, proper debridement of an injured vessel, and the failure rate of microvascular anastomosis in cases of trauma is higher as the thrombogenic possibility is increased by the endothelial damage. From January to November in 2003, 460 patients were underwent microvascular surgery(270 replantations and 190 free flap transfers) and re-operations were performed in 15 cases. Cases were reviewed by clinical and operative records. In these cases, causes of post-operative circulation insufficiency were identified as 9 vascular spasms and 6 thromboses at the previous anastomotic site. The average of re-operative success rate was 73%(60% in replantations and 100% in free flaps). In conclusion, through precise postoperative monitoring and assessment, immediate surgical re-exploration could be performed when a vascular complication is suspicious, the success rate of microvascular surgery would be increased more.

• Archives of Plastic Surgery
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• v.44 no.1
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• pp.12-18
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• 2017

Background Nonliving chickens are commonly used as a microvascular anastomosis training model. However, previous studies have investigated only a few types of vessel, and no study has compared the characteristics of the various vessels. The present study evaluated the anatomic characteristics of various chicken vessels as a training model. Methods Eight vessels-the brachial artery, basilic vein, radial artery, ulnar artery, ischiatic artery and vein, cranial tibial artery, and common dorsal metatarsal artery-were evaluated in 26 fresh chickens and 30 chicken feet for external diameter (ED) and thicknesses of the tunica adventitia and media. The dissection time from skin incision to application of vessel clamps was also measured. Results The EDs of the vessels varied. The ischiatic vein had the largest ED of $2.69{\pm}0.33mm$, followed by the basilic vein ($1.88{\pm}0.36mm$), ischiatic artery ($1.68{\pm}0.24mm$), common dorsal metatarsal artery ($1.23{\pm}0.23mm$), cranial tibial artery ($1.18{\pm}0.19mm$), brachial artery ($1.08{\pm}0.15mm$), ulnar artery ($0.82{\pm}0.13mm$), and radial artery ($0.56{\pm}0.12mm$), and the order of size was consistent across all subjects. Thicknesses of the tunica adventitia and media were also diverse, ranging from $74.09{\pm}19.91{\mu}m$ to $158.66{\pm}40.25{\mu}m$ (adventitia) and from $31.2{\pm}7.13{\mu}m$ to $154.15{\pm}46.48{\mu}m$ (media), respectively. Mean dissection time was <3 minutes for all vessels. Conclusions Our results suggest that nonliving chickens can provide various vessels with different anatomic characteristics, which can allow trainees the choice of an appropriate microvascular anastomosis training model depending on their purpose and skillfulness.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.35 no.5
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• pp.284-293
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• 2013

Purpose: For reconstruction of craniomaxillofacial defects caused by tumor, trauma, infection etc, free flap transplantation with microvascular surgery is a very useful method. Thrombus formation at the anastomosis site is the major cause of graft failure. 4-Hexylresorcinol (4-HR) is generally known as an antiseptic and antiparasitic agent. This study was conducted in order to evaluate the effect of 4-HR on blood coagulation in vitro. In addition, we investigated thrombus formation and endothelial repair of an injured vessel in an animal model. Methods: In the in vitro experiment, we compared blood coagulation time between the 4-HR treated group and normal blood. Thirty rats were used for in vivo animal experiments. After exposure of the right femoral vein, a micro vessel clamp was placed and the femoral vein was intentionally cut. Microvascular anastomosis was performed on all rats using 10-0 nylon under microscopy. The animals were divided into two groups. In the experimental group (n=15), 4-HR (250 mg/kg) mixed with olive oil (10 mL/kg) was administered per os daily. Animals in the control group (n=15) were given olive oil only. The animals were sacrificed at three days, seven days, and fourteen days after surgery and rat femoral vein samples were taken. Vascular patency and thrombus formation were investigated just before sacrifice. Histologic analysis was performed under a microscope. Results: Results of an in vitro blood coagulation test showed that coagulation time was delayed in the 4-HR treated group. The results obtained from an in vivo 4-HR administered rat model showed that the patency of all experimental groups was better at thirty minutes, seven days, and fourteen days after microvascular anastomosis than that of the control group at seven and fourteen days after anastomosis, and the amount of thrombus in the experimental groups was much less than that of the control group. Endothelial repair was observed in the histologic analysis. Conclusion: Findings of this study demonstrated that blood coagulation was delayed in the vitro 4-HR treated group. In addition, good vascular patency, anti-thrombotic effect, and repair of venous endothelial cells were observed in the vivo 4-HR administered rat group.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• v.29 no.4
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• pp.232-238
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• 2003

This study was performed to evaluate the effect of topical and intravenous heparin on thrombosis and patency in the microvascular anastomosis of the traumatized veins. Nine white rabbits weighing about 2 kg were used. After exposure of both femoral veins, the veins were crushed by the jaws of smooth needle holder in order to create a thrombosis model. Transectional incision was made in the vein. The animals were then divided into 3 groups based on the administration method of heparin: 1) Experimental Group I, topical irrigation of lumen with heparin saline solution (n=6); 2) Experimental Group 2, topical irrigation of lumen with heparin saline solution and intravenous injection of heparin (0.75 mg/kg) via the marginal ear vein for 3 days; 3) Control Group, topical irrigation of lumen with saline solution (n=6). The patency was evaluated with empty-and-refill test and thrombus formation was judged by surgical microscope. The results were as follows: 1. Thirty minutes after microvascular anastomosis, the patency of all Experimental Groups was better than Control group. However, there was no significant difference among groups. 2. Three days after anastomosis, the patency of all Experimental Groups was much more improved than that of Control Group (P<0.05). There was no significant difference between Experimental Group 1 and 2. 3. Three days after anastomosis, the amount of thrombus in all Experimental Groups was much less than that of Control Group (P<0.05). 4. In histologic findings a lot of luminal thrombus were observed around sutured area in Control Groups. Few luminal thrombus was observed in all Experimental Groups. Mild necrosis in the vessel wall was observed around sutured area in all specimens. These results indicate that topical irrigation of heparin may improve the patency and inhibit the formation thrombus in the microvascular anastomosis of the traumatized veins.

• Archives of Reconstructive Microsurgery
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• v.9 no.2
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• pp.179-185
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• 2000

In the field of microsurgery, the vascular obstruction of the microvascular anastomosis by thrombus is one of the most important complication. The purpose of this study is to compare the effect between aspirin and prostaglandin $E_1$($PGE_1$) which act as the peripheral vasodilatation and platelet disaggregation. We have used total 48 white male rats and divided them into three gruoups(A, B and C group). Each group consists of 16 rats respectively. A group is as control, B group is medicated with aspirin(3.0mg/kg/day) and C group with $PGE_1(1.2{\mu}g/kg/day)$. The gross and histopathologic findings at anastomosed site were observed on 3, 5, 10 and 15 days after vascular anastomosis and the results were obtained as the followings. 1. The microvascular patency rate is 81.2% in control group, 93.8% in aspirin group and 100% in $PGE_1$ group. 2. On the histologic examination, the formation of mural thrombus is decreased both in the aspirin and $PGE_1$ group as comparing with the control group and also the hypertrophy of the intima forming from media is less formed in $PGE_1$ group than aspirin group and the degree of thickeness is also less. 3. The fibrosis of media is less observed in $PGE_1$ group than aspirin group. According to the above results, the application of $PGE_1$ to the microsurgery is considered to be effective on the prevention of the thrombus formation and on providing high patency rate.

• Archives of Plastic Surgery
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• v.35 no.5
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• pp.626-629
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• 2008

Purpose: We investigate the possibility of vessel preservation with glycerol and evaluate the potential of preserved gastroepiploic artery as a tool for the microsurgical practice. Methods: In 5 early gastric cancer patients, IRB(No. C-0603-040-170), we gained gastroepiploic artery specimens(5 segments, about 10 cm) after gastrectomy. Each segment was rinsed in a normal saline and subsequently placed in a bottle, containing 50 mL anhydrous glycerol (87%). The bottles were refrigerated at $4^{\circ}C$, the longest preservation time being 5 months. Results: At first glance, no fragmentation was detected and the surface of vessel seemed mild sclerotic. In histological examination, vascular structures remained intact though preservation with glycerol led to a mild atrophy of the smooth muscle in the tunica media. Especially, we found out the elastic fibers and endothelial lining of the intima were preserved until 5 months. Adequate status for using microsurgical practice was also maintained and leakage test was performed successfully with gentian violet ink. Conclusion: Based on the results obtained in this study, the gastroepiploic artery preservation with glycerol as a training model for microvascular anastomosis is a technically very simple procedure and useful for the novice microsurgeon.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.22 no.1
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• pp.22-32
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• 2000

Purpose : Histopathologic observation was performed in order to determine which type of suture material is superior in microvascular anastomoses. Materials & Methods : The interrupted end to end anastomosis of the transected carotid arteries of 105 Sprague-Dawley rats, weighing 180 to 200g, were performed using 9-0 polypropylene ($Prolene^{TM}$, Ethicon, U.K.), 9-0 polyglactin 910 monofilament($Vicryl^{TM}$, Ethicon, U.K.), and 9-0 polyamide($Ethilon^{TM}$, Ethicon, U.K.) under intramuscular Ketamine and Xylazine anesthesia(5mg/100g). In all cases, 10 to 12 sutures were placed to complete the anastomoses. The specimens were obtained at 1, 2, 3 days, and 1, 2, 4 and 6 weeks after the surgery and prepared with H&E and Van-Gieson stains and investigated the histologic changes in anastomotic sites under light microscope. The histologic changes we were concerned about were followings- thrombus formation, intimal edema, infiltration of inflammatory cells in media and adventitia, proliferation of endothelial cells and subintimal hyperplasia. Results : 1. All of the anastomosed arteries were patent when they were exposed for examination. 2. Thrombus formation and intimal edema were most severe in Vicryl group, followed by Ethilon, Prolene group in order. 3. The inflammatory cells infiltrated to the media and the adventitia most severely in Ethilon group, followed by Vicryl, Prolene group in order. 4. There was little difference in proliferation of endothelial cells in each group. 5. Subintimal hyperplasia was greater in Vicryl group than the others, but there was no significant difference between the Prolene and Ethilon groups. Conclusions : On the basis of these observations, we could conclude that Prolene may be the better suture material for microvascular anastomoses regarding the tissue responses than Ethilon and Vicryl.