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The TRAM Flap for Breast Reconstruction. Studies on Perioperative Cutaneous Blood Flow, Vasoconstriction, and Indices of Obesity

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The TRAM Flap for Breast Reconstruction. Studies on Perioperative Cutaneous Blood Flow, Vasoconstriction, and Indices of Obesity Department of Anesthesiology and Intensive Care Medicine Department of Plastic Surgery Helsinki University Central Hospital University of Helsinki Finland The TRAM fl ap for breast reconstruction Studies on perioperative cutaneous blood fl ow, vasoconstriction, and indices of obesity Hanna Tuominen Academic Dissertation To be presented, with the permission of the Faculty of Medicine of the University of Helsinki, for public examination in Lecture Room I, Töölö Hospital, on October 31st, 2008, at 12 noon. Helsinki 2008 Supervised by Nils Svartling, M.D., Ph.D. Department of Anesthesiology and Intensive Care Medicine and Professor Sirpa Asko-Seljavaara Department of Plastic Surgery and Professor Erkki Tukiainen Department of Plastic Surgery Helsinki University Central Hospital University of Helsinki Helsinki, Finland Reviewed by Docent Paula Mustonen Department of Plastic Surgery Kuopio University Hospital University of Kuopio Kuopio, Finland and Docent Hannu Toivonen Department of Anesthesiology and Intensive Care Medicine Helsinki University Central Hospital University of Helsinki Helsinki, Finland Opponent Docent Outi Kaarela Department of Plastic Surgery Oulu University Hospital University of Oulu Oulu, Finland Hanna Tuominen M.D., Anesthesiologist Special interests: Neuroanesthesiology, Anesthesia for reconstructive plastic surgery Helsinki University Central Hospital Töölö Hospital, Topeliuksenkatu 5, 00029 HUS Helsinki, Finland hanna.tuominen@hus.fi ISBN 978-952-92-4568-0 (paperback) ISBN 978-952-10-5021-3 (PDF) http://ethesis.helsinki.fi Layout Lifeteam Oy • Cover Jari Salo Helsinki University Printing House Helsinki 2008 To my family Contents Abstract ...................................................................................................................................6 List of original publications ...................................................................................................8 Abbreviations ..........................................................................................................................9 1 Introduction ....................................................................................................................10 2 Review of the literature ..................................................................................................11 2.1. Breast cancer ................................................................................................................. 11 2.1.1. Incidence .............................................................................................................................................11 2.1.2. Manifestations .................................................................................................................................11 2.1.3. Treatment .............................................................................................................................................11 2.1.4. Prognosis .............................................................................................................................................13 2.2. Breast reconstruction ....................................................................................................14 2.2.1. Indications ..........................................................................................................................................14 2.2.2. Principles of breast reconstruction ..........................................................................................14 2.2.3. Nonautologous breast reconstruction ....................................................................................15 2.2.4. Autologous breast reconstruction ............................................................................................16 2.2.5. The TRAM fl ap ...................................................................................................................................18 2.2.6. Surgical complications of the TRAM fl ap ..............................................................................20 2.3. Blood fl ow in surgical fl aps .........................................................................................22 2.3.1. Blood fl ow of the skin ....................................................................................................................22 2.3.2. Regulation of cutaneous blood fl ow .......................................................................................22 2.3.3. Principles of blood fl ow in fl aps ...............................................................................................23 2.3.4 Blood fl ow in the TRAM fl ap ........................................................................................................26 2.3.5. Temperature and the cutaneous blood fl ow ........................................................................28 2.3.6. Effect of general anesthesia on thermoregulation and cutaneous blood fl ow ....28 2.4. Monitoring of blood fl ow in fl aps ...............................................................................29 2.4.1. Methods used to measure blood fl ow in surgical fl aps ..................................................29 2.5. Endothelin .....................................................................................................................32 2.5.1. Endothelin and vasoconstriction ..............................................................................................32 2.5.2. Effect of different substances on endothelin levels..........................................................32 2.5.3. Endothelin and surgical fl aps .....................................................................................................32 2.6. Effect of different interventions on blood fl ow in the fl ap ......................................33 2.6.1. Calcium antagonists and cutaneous blood fl ow ..............................................................33 2.7. Effect of overweight on fl ap blood fl ow ...................................................................34 4 2.7.1. Measurement of obesity ..............................................................................................................34 2.7.2. Overweight and complications in TRAM fl aps ...................................................................35 2.7.3. Overweight and cutaneous necrosis in surgical fl aps ....................................................35 3 Aims of the study .......................................................................................................... 37 4 Patients and methods .................................................................................................... 38 4.1. Patients ..........................................................................................................................38 4.2. Methods .........................................................................................................................38 4.2.1. Study designs ....................................................................................................................................38 4.2.2. Anesthetic management ..............................................................................................................40 4.2.3. Surgical technique........................................................................................................................... 41 4.2.4. Measurements...................................................................................................................................42 4.2.5. Statistical analyses .........................................................................................................................45 5 Results ............................................................................................................................ 46 5.1. Perioperative changes of cutaneous blood fl ow in TRAM fl aps (I, II) ......................46 5.1.1. Cutaneous blood fl ow in pedicled TRAM fl aps (I) ..............................................................46 5.1.2. Cutaneous blood fl ow in free TRAM fl aps (II) ......................................................................47 5.2. Prediction of cutaneous necrosis in pedicled TRAM fl aps (I) ...................................49 5.3. Relation of plasma ET-1 concentrations to peripheral vasoconstriction, blood pressure, heart rate, and cutaneous or fat necrosis (III) .........................................50 5.4. Effect of felodipine on plasma ET-1 concentrations, peripheral vasoconstriction, postoperative PtcO2, and survival of free TRAM fl aps (IV) ................... 51 5.5. Effect of indices of obesity on cutaneous or fat necrosis in pedicled TRAM fl aps (V) ..................................................................................................52 6 Discussion ..................................................................................................................... 54 6.1. Perioperative changes of cutaneous blood fl ow in TRAM fl aps (I, II) ......................54 6.1.1. Pedicled TRAM fl aps (I) ..................................................................................................................54 6.1.2. Free TRAM fl aps (II) .........................................................................................................................56 6.2. Prediction of cutaneous necrosis in pedicled TRAM fl aps (I) ...................................57 6.3. Relation of plasma ET-1 concentrations to peripheral vasoconstriction,
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