Local heat preconditioning to prevent wound breakdown and skin necrosis: A translational study Department for Plastc Surgery and Handsurgery Laboratory for Microcirculation and Regenerative Medicine Klinikum rechts der Isar Technische Universität München Ismaninger Strasse 22 D-81675 Munich, Germany D. Schmauß, T. Finck, S. Mehta, J. Farhadi, T. Egana, H.-G. Machens, Y. Harder 101 st Annual Meeting of the Swiss Surgical Society 21 st – 23 rd May 2014, Kursaal Bern Daniel.Schmauss@mri.tum.de
Department of Plastic Surgery and Handsurgery Technische Universität München Disclosures Y. Harder is consultant for Hilotherm GmbH Local heat preconditioning & breast surgery 2 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München The clinical problem Ischaemically challenged tissue Wound breakdown: up to 39% 1 Skin flap necrosis: up to 54% 2 [ 1 Zoumaras J et al.: Aesthet Surg J. 2008 ] [ 2 Sotheran WJ et al.: Ann R Coll Surg Engl. 2004 ] Local heat preconditioning & breast surgery 3 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Surgical delay pO 2 day 0 ~ day 7 ~ day 14 [ Reinisch JF: Plast Reconstr Surg, 1974 ] Local heat preconditioning & breast surgery 4 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Surgical delay pO 2 day 0 ~ day 7 ~ day 14 [ Reinisch JF: Plast Reconstr Surg, 1974 ] Invasive and time-consuming Local heat preconditioning & breast surgery 5 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Tissue preconditioning as alternative Application of supraphysiologic stress to tissue prior to surgery • Maintenance of microcirculation • Increase of ischaemic tolerance of the tissue Local heat preconditioning & breast surgery 6 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Tissue preconditioning as alternative • “True” preconditioning (PC) • Ischaemic [ Murry CE et al: Circ Res, 1990 ] • “Remote” ischemic [ Przyklenk K et al: Circulation, 1993 ] • Systemic pharmacological PC • Monophosphoryl Lipid A [ Harder Y et al.: Anesth & Analg, 2005 ] • Erythropoietin [ Harder Y et al: Surgery, 2009 ] • Ghrelin [ Rezaeian F & Harder Y et al: Am J Physiol, 2012 ] • Local physical PC • Shock-wave [ Tobalem M & Harder Y et al: J Surg Res, 2013 ] • Cooling [ Yunoki M et al: J Neurosurg, 2002 ] • Heat [ Yamashita N et al: Circulation, 1998; Harder Y et al: Ann Surg, 2005] Local heat preconditioning & breast surgery 7 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Study aim Effectiveness of repetitive local heat preconditioning Incidence of • Wound break down • Skin flap necrosis Local heat preconditioning & breast surgery 8 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Methods 1. Skin Sparing Mastectomy and immediate breast reconstruction • 25 patients: Local heat preconditioning • 25 patients: No preconditioning (control) 2. Reduction Mammaplasty (RMP) • 15 patients: Local heat preconditioning of one breast No preconditioning of the other breast (control) Local heat preconditioning & breast surgery 9 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Methods [ Hilotherm GmbH, Deutschland ] Local heat preconditioning & breast surgery 10 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Methods PC initiated 18 hours prior to surgery Perfusion measurements Skin flap necrosis? Wound breakdown? 43 ° C 43 ° C 43 ° C 30’ 30’ 30’ 30’ 30’ Mastectomy / Breast reduction 14 days Local heat preconditioning & breast surgery 11 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results. Overall • No burns were noticed • Heat-induced hyperaemia completely vanished prior to surgery Local heat preconditioning & breast surgery 12 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results: Skin Sparing Mastectomy Skin perfusion Left breast Right breast 1 hour after mastectomy 1 hour after mastectomy un-preconditioned preconditioned [ Farhadi J & Harder Y et al: J Plast Reconstr Aesthet Surg, 2013 ] Local heat preconditioning & breast surgery 13 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results: Skin Sparing Mastectomy Skin flap necrosis [ % ] * Mean * p < 0.05 vs. control [ Farhadi J & Harder Y et al: J Plast Reconstr Aesthet Surg, 2013 ] Local heat preconditioning & breast surgery 14 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results: Skin Sparing Mastectomy Length of hospital stay * [ Days ] Mean ± SD * p < 0.05 vs. control [ Farhadi J & Harder Y et al: J Plast Reconstr Aesthet Surg, 2013 ] Local heat preconditioning & breast surgery 15 10 November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results: Reduction Mammaplasty Wound breakdown [ % ] Local heat preconditioning & breast surgery 16 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Results: Reduction Mammaplasty Wound drainage [ ml/24hrs ] Mean ± SD Local heat preconditioning & breast surgery 17 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Summary Local heat preconditioning Can be translated into daily clinical surgery • • Increases perfusion in ischaemically challenged tissue • Significantly decreases skin flap necrosis • Reduces wound breakdown • Reduces length of hospital stay • Does not increase postoperative drainage Local heat preconditioning & breast surgery 18 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Conclusions Local heat preconditioning in specific breast procedures • Safe • Simple • Efficient • Applicable briefly prior to surgery • Cost-effective Local heat preconditioning & breast surgery 19 10. November 2015
Department of Plastic Surgery and Handsurgery Technische Universität München Perspectives LOCAL HEAT!!! Local heat preconditioning & breast surgery 20 10 November 2015
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