Transdermal Nitroglycerine Patch: An Optional Device to Reduce Flap Venous Congestion? A Case Report

doi:10.4236/mps.2013.34024

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Modern Plastic Surgery, 2013, 3, 120-122

http://dx.doi.org/10.4236/mps.2013.34024 Published Online October 2013 (http://www.scirp.org/journal/mps)

Transdermal Nitroglycerine Patch: An Optional Device to

Reduce Flap Venous Congestion? A Case Report

Sara Di Lorenzo, Bartolo Corradino, Adriana Cordova

Department of Surgi cal Oncology, Pla stic Surgery Unit, University of Palermo, Palermo, Italy.

Email: [email protected], [email protected]

Received August 1st, 2013; revised September 1st, 2013; accepted September 8th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Sometimes in free flap there is a venous congestion without an obstruction of the venous anastomosis or other organic

causes of reduction venous drainage (haematoma, seroma compressing the pedicle). In these cases the authors suggest

the application of nitrog lycerine patch in the cong ested area of the fla p few hours befor e the surgical ex ploration of the

anastomosis. If there is a fast improvement of the clinical feature of the flap, the surgical exploration could be avoided.

The authors underline that applying the nitroglycerin patch should not be regarded in any way as a therapy of a free flap

venous thrombosis but only as an useful device, an option to be taken only when the surgeon is undecided whether to

revisit the anastomosis or not.

Keywords: Free Flap Failure; Venous Congestion; Vascular Pedicle Thrombosis; Microsurgical Complications

1. Introduction

The majority of surgical complications after tissue trans-

fer surgery are related to vascular thrombosis, which

usually occur within 3 days of surgery, but sometimes

thrombosis can occur later.

There are many techniques available for evaluation of

flap viability. The most common technique is clinical

observation and Doppler vascular pedicle monitoring.

The clinical observation is very useful when the flap has

a skin island.

Venous thrombosis occurs more frequently because of

its low-flow, low-pressure nature, and because it may

evolve over se ver al h ours.

A venous congestion usually results in oedema and

darkening of the skin colour.

During early venous obstruction a needle stick will

cause a rapid bleeding of dark blood. The capacity to

understand and id entify the early signs of flap suff erance

is important in order to decide if surgical explorations,

and an additional pharmacological therapy or something

else are necessary.

If a flap’s vascular integrity is in question, if there is a

doubt of venous thrombo sis at the anastomosis, a prompt

surgical exploration is mandatory [1].

Surgical exploration is still mandatory when there are

haematoma and seroma that could make a compression

on the vascular pedicle.

Sometimes there is a venous congestion of the flap

without an obstruction of the venous vessel at the anas-

tomotic site. In the surgical exploration sometimes there

is no problem at the anastomotic site or other organic

causes of reduction venous drainage.

This kind of insufficient venous drainage may cause a

slow partial flap loss that may require further surgical

steps, multiple debridements to remove necrotic tissue

and prevent further complications as infections, and to

improve the outcome.

Authors expose their experience with a nitroglycerine

plaster applied on flap in order to reduce the venous

congestion of a free DIEP flap. It begun in the 5th day

after surgery.

2. Clinical Case

The patient is a 38-year-old female undergone a right

mastectomy for a ductal carcinoma and a quadrantec-

tomy on the left breast for a dysp lasia.

A delayed free Diep Flap reconstruction of the right

breast was performed using the internal mammary ves-

sels, as recipient vessels. The ischemia time was less than

2 hours.

The flap seemed well perfused.

The patient didn’t smoke and hadn’t risk factor or sys-

temic disease.

On 5th day after surgery the patient presented an

Transdermal Nitroglycerine Patch: An Optional Device to Reduce Flap Venous Congestion? A Case Report 121

alarming violaceous area in the medial region of the flap,

interesting quickly almost half of the flap (Figures 1(a)

and (b)). This area corresponded to the area called III of

the tram flaps.

The Doppler signal was good and the needle pricked

caused the exit o f red blood in the lateral area o f the flap,

black blood in the medial area.

The surgeons told the patient that it could be necessary

an exploration of th e anastomotic site in operating room,

but the patient refused the surgical exploration abso-

lutely.

The authors decided to wait for some hours in order to

evaluate the evolution of the clinical deterioration of the

flap and in order to exclude the possibility that this cya-

notic feature was caused by a temporary problem, as pa-

tient position et al.

During this waiting-time a nitroglycerine plaster was

applied on the flap, exactly on the violaceous and con-

gested area.

The dosage of the plaster was 10 U nitroglycerine. The

limit of the blue area was drawn with a pen in order to

evaluate better the increment or the reduction of the suf-

fering area. 4 hours after the plaster application the flap

became better.

The surgeons decided to wait.

(a)

(b)

Figure 1. (a) Violaceous area presented on Diep Flap in 5th

day after surgery; (b) Alarming violaceous area developed

in few hours, in 5th day post-operative.

The day after, the flap was better than the day before,

it appeared less violaceous and less oedematous.

The patient denied any side effect, onetime headache.

The blood pressure was low (105/70) (Figure 2).

The limit line drawn showed a reduction of 1 cm/die of

the violaceous area, that continued to reduce itself in the

following days. The plaster was applied every day for 7

days, until the flap became almost all pink (Figures 3-5).

After 2 weeks there weren’t signs of congestion and

the flap appeared well, with good colour, texture and

consistence. A small necrotic area (2 cm × 2 cm) re-

mained and was surgically removed. The outcome was

good (Figure 6).

Figure 2. The flap 24 hours after the application of nitro-

glycerine plaster.

Figure 3. The reduction of the suffering area 4 days after

the application of the plaster.

Figure 4. Reduction of the suffering area 5 days after the

application of the plaster.

Transdermal Nitroglycerine Patch: An Optional Device to Reduce Flap Venous Congestion? A Case Report

122

Figure 5. The reduction of the suffering area 6 days after

the application of the plaster.

Figure 6. The outcome after 2 weeks.

3. Conclusion

Despite the variety of anticoagulation protocols, the

studies about the prophylactic anticoagulation therapy

and the almost perfect reconstructive techniques used by

microsurgeons, the reported failure rate among free flap

ranges from 4 % to 10%. The free flap suffering or fail-

ure is a complication that often requires, after a rapid

recognition of the clinical aspect of the flap, the surgical

re-exploration in order to remove haematomas, seroma

over the pedicle or to perform a new anastomoses [2].

Sometime the venous cong estion of the flap is caused by

a temporary problem (spasm) that could not require a

surgical revision of the anastomosis. The authors expose

their experience with a nitroglycerine plaster applied on

flap in order to reduce the venous congestion of a free

DIEP flap. It begun in the 5th day after surgery. The use

of Nitro-derived drugs in the treatment of angina pectoris

is well known. The nitrates caused a d ilatation of the ve-

nous compartment and then a dilatation of arterial com-

partment included coronary arteries. Organic nitrates as

nitroglycerine, are the most employed drugs in cardi-

ological clinical practice. Nitroglycerine is largely given

as a plaster whit transdermal absorption. The mechanism

of action of organic nitrates is well known. They act on

the endothelial layer inducing the production of NO (ni-

tric oxide). This gas, physiologically produced by endo-

thelial cells, white blood cells, muscular cells and brain

cells, caused vasodilatation and reduced the platelet ag-

gregation. NO releasing of endothelial cells (induced by

nitroglycerine) causes an increment of level of GMPc

inside the smooth muscular cells of the vessels, so the

muscular smooth cell relaxation finally causes the vaso-

dilatation of the vessels. The authors expose their ex-

perience; it’s suggested that during the period, the sur-

geon is still evaluating if a reexploration of the flap or of

the anastomotic site is necessary, and applying a nytro-

glicerin patch on the suffering flap without local or sys-

temic side effects is possible. If there is a fast improve-

ment of the clinical feature of the flap, the surgical ex-

ploration could be avoided.

REFERENCES

[1] B. C. D. Evans and G. R. D. Evans, “Microvascular Sur-

gery,” Plastic & Reconstructive Surgery, Vol. 119, No. 2,

2007, pp. 18e-30e.

http://dx.doi.org/10.1097/01.prs.0000246717.81077.e4

[2] M. Askari, C. Fisher, F. G. Weniger, S. Bidic and A. W.

P. Lee, “Anticoagulation Therapy in Microsurgery: A

Review,” Journal of Hand Surgery, Vol. 31, No. 5, 2006,

pp. 836-846.