Document Detail

Why haematomas cause flap failure: An evidence-based paradigm.
MedLine Citation:
PMID:  22226889     Owner:  NLM     Status:  Publisher    
BACKGROUND: Haematomas compromise flaps in the absence of a pressure effect and pedicle thrombosis. While animal models confirmed the toxic effect of whole blood on adjacently sited random pattern flaps, our understanding of this phenomenon remains incomplete. Our aim was to identify mechanisms by which a subjacent haematoma leads to flap compromise to inform clinical practice. METHODS: A literature review was conducted of all peer-reviewed publications relating haematoma to tissue compromise including free transferred tissue, vascularised flap models and brain injury. Clinical correlation was made with free vascularised flaps and rhytidectomy skin flaps. RESULTS: Haematomas compromise around 2-4% of free tissue transfers and local flaps. We propose that several mechanisms are responsible. Cytokines, generated by platelet degradation, recruit neutrophils, releasing both reactive oxygen species and proteolytic enzymes. Reactive oxygen species (ROS), including superoxide (O(2)(-)) and hydroxyl (OH-) are also produced by ATP degradation, promoted by NAD+ sequestration. Additionally, the complement cascade is triggered by thrombin. Ferrous ions, freed by complement-mediated lysis of erythrocytes and degradation of haemoglobin also promote generation of ROS. Reactive oxygen species, complement and activated neutrophils cause endothelial cell disruption, leading to activation of pro-thrombotic mechanisms and small vessel occlusion, with consequent tissue ischaemia, which in turn generates further ROS. CONCLUSION: Haematomas cause tissue injury by a complex sequence of inter-related biochemical and cellular processes merging on a common pathway of local tissue ischaemia which the overlying tissue is unable to regulate. Emergent evacuation of haematoma must be considered irrespective of envelope tension.
Graeme E Glass; Jagdeep Nanchahal
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-1-5
Journal Detail:
Title:  Journal of plastic, reconstructive & aesthetic surgery : JPRAS     Volume:  -     ISSN:  1878-0539     ISO Abbreviation:  -     Publication Date:  2012 Jan 
Date Detail:
Created Date:  2012-1-9     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101264239     Medline TA:  J Plast Reconstr Aesthet Surg     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Copyright Information:
Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Imperial College, London, UK; Kennedy Institute of Rheumatology, University of Oxford, UK.
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