The Effects of Passive Cigarette Smoke Exposure on the Survival of the Reverse Sural Fasciocutaneous Flap

Abstract

Background The possibility of a person who had undergone surgery to be exposed to the ill effects of cigarette smoke is high, more so if the person lives with a smoker. With increasing popularity of reverse sural fasciocutaneous flaps, a surgeon may have to manage a person who lives with a smoker or is exposed to cigarette smoke. A clear understanding of the effects of exposure to cigarette smoke on reverse sural fasciocutaneous flaps is necessary. This study was performed to establish a clearer understanding of the effects of smoking on reverse sural fasciocutaneous flaps and evidence for preoperative patient counseling about smoking and smoke exposure.

Objective The study investigated effects of exposure to cigarette smoke on the survival of the reverse sural fasciocutaneous flap.

Methods This was an experimental observational study conducted at the Laboratory for Animal Research Unit in the Health Campus of Universiti Sains Malaysia. Twelve adult White New Zealand rabbits (Oryctolagus cuniculus) were divided into two groups of six. All 12 rabbits had a 2.5- × 2.5-cm reverse sural fasciocutaneous flap raised on both its hind limbs. The group exposed to cigarette smoke underwent 4 weeks of smoke exposure for 2 hours daily prior to surgery. This was then continued until analysis of the results.

The control group had no intervention. All flaps were analyzed on the seventh postoperative day, after tracing on transparent plastic sheets with the necrotic area marked followed by 2D planimetry done on a grid paper. The flaps were assessed on the total flap area and survival area percentage. It was recorded as mean ± SD. The presence or absence of infection and hematoma was also noted.

Results Twelve flaps were analyzed in each group. Total mean flap area and survival area percentage of the control group were 120.33 ± 31.03 mm² and 80.12 ± 15.75%, respectively, whereas in the cigarette smoke–exposed group, it was 121.83 ± 17.93 mm² and 62.04 ± 34.01%, respectively. The control group had two infections and one hematoma, and the smoking-exposed group had six infections and nine hematomas. The comparison between the groups was made in terms of total flap area, survival percentage, presence of infection, and hematoma for which the p values were 0.886, 0.115, 0.083, and 0.003, respectively. The differences between right and left hind limbs were also analyzed (p = 0.414).

Conclusion There was no statistical difference in the results from the right and left hind limbs. There was no statistical difference in the survival of reverse sural fasciocutaneous flap between the control and smoking-exposed groups.

Keywords

passive cigarette smoke exposure - fasciocutaneous skin flap - rabbit experimentation

• References

• 1 Lim HK, Ghazali SM, Kee CC. , et al. Epidemiology of smoking among Malaysian adult males: prevalence and associated factors. BMC Public Health 2013; 13 (01) 8
• 2 Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg 2012; 147 (04) 373-383
• 3 Talhout R, Schulz T, Florek E, van Benthem J, Wester P, Opperhuizen A. Hazardous compounds in tobacco smoke. Int J Environ Res Public Health 2011; 8 (02) 613-628
• 4 Rahman MM, Elmi S, Chang TK. , et al. Increased vascular contractility in isolated vessels from cigarette smoking rats is mediated by basal endothelin release. Vascul Pharmacol 2007; 46 (01) 35-42
• 5 Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol 1991; 127 (07) 1012-1015
• 6 Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg 2005; 116 (07) 1873-1880
• 7 Uygur F, Sen H, Noyan N, Sahin C. The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flap: an experimental study in rabbits. Burns 2010; 36 (02) 270-276
• 8 Chang SM, Gu Y-D, Li JF. The role of the large superficial vein in survival of proximally based versus distally based sural veno-neuro-fasciocutaneous flaps in a rabbit model. Plast Reconstr Surg 2005; 115 (01) 213-218
• 9 Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34 (02) 215-220
• 10 Bostwick J, Briedis J, Jurkiewicz MJ. The reverse flow temporal artery island flap. Clin Plast Surg 1976; 3 (03) 441-445
• 11 Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds. Plast Reconstr Surg 2002; 110 (07) 1673-1679
• 12 Chang SM, Gu YD, Li JF. Comparison of different managements of large superficial veins in distally based fasciocutaneous flaps with a veno-neuro-adipofascial pedicle: an experimental study using a rabbit model. Microsurgery 2003; 23 (06) 555-560
• 13 IARC. Tobacco smoke and involuntary smoking, in IARC monographs on the evaluation of carcinogenic risks to humans. Mattock H. , ed. International Agency for Research on Cancer; 2004
• 14 Ueng SW, Lin SS, Wang CR, Liu SJ, Tai CL, Shih CH. Bone healing of tibial lengthening is delayed by cigarette smoking: study of bone mineral density and torsional strength on rabbits. J Trauma 1999; 46 (01) 110-115
• 15 Göçmez SS, Utkan T, Duman C. , et al. Secondhand tobacco smoke impairs neurogenic and endothelium-dependent relaxation of rabbit corpus cavernosum smooth muscle: improvement with chronic oral administration of L-arginine. Int J Impot Res 2005; 17 (05) 437-444
• 16 Mays BW, Freischlag JA, Eginton MT, Cambria RA, Seabrook GR, Towne JB. Ascorbic acid prevents cigarette smoke injury to endothelium-dependent arterial relaxation. J Surg Res 1999; 84 (01) 35-39
• 17 Forrest CR, Pang CY, Lindsay WK. Dose and time effects of nicotine treatment on the capillary blood flow and viability of random pattern skin flaps in the rat. Br J Plast Surg 1987; 40 (03) 295-299
• 18 Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg 1992; 89 (02) 181-215
• 19 van Adrichem LN, Hoegen R, Hovius SE. , et al. The effect of cigarette smoking on the survival of free vascularized and pedicled epigastric flaps in the rat. Plast Reconstr Surg 1996; 97 (01) 86-96
• 20 Kool MJF, Hoeks APG, Struijker Boudier HA, Reneman RS, Van Bortel LM. Short- and long-term effects of smoking on arterial wall properties in habitual smokers. J Am Coll Cardiol 1993; 22 (07) 1881-1886
• 21 Mikelsone I, Bormane I, Simone Z, Jurka A, Tretjakovs P. The Acute Effects of Cigarette Smoking on Microvascular Responsiveness and Haemodynamic Measurements in Healthy Male Smokers. Riga, Latvia: Rigas Stradina Universitate; 2012