Rates Of Skin Flap Necrosis Research Articles

A Meta-analysis Comparing Deep Inferior Epigastric Perforator Flaps and Latissimus Dorsi Flaps in Breast Reconstruction.

Deep inferior epigastric perforator (DIEP) flaps and latissimus dorsi (LD) flaps are two widely used breast reconstruction techniques, each with distinct advantages and limitations. This meta-analysis aims to compare patient satisfaction and incidence of complications between these two techniques to inform clinical decision-making. PubMed, Scopus, and Web of Science were searched for relevant studies. We included studies with data comparing DIEP and LD flaps, BREAST-Q patient satisfaction, and complications. Statistical analyses were performed using RevMan 5.4. The search yielded 788 studies, of which 13 were included in the meta-analysis. A total of 2128 patients were analyzed, with 1378 undergoing DIEP flap reconstruction and 750 receiving LD flap reconstruction. The analysis showed greater improvement with DIEP flaps in breast satisfaction [mean difference (MD) = 9.48, 95% confidence interval (CI) = 6.90-12.05, P < 0.00001], physical well-being (MD = 5.95, 95% CI = 2.98-8.92, P < 0.0001), and satisfaction with outcome (MD = 9.36, 95% CI = 3.01-15.71, P = 0.004). Nonetheless, DIEP flaps had higher rates of skin flap necrosis [risk ratio (RR) = 4.27, 95% CI = 2.44 to 7.46, P < 0.00001], wound dehiscence (RR = 5.12, 95% CI = 2.53-10.35, P < 0.00001), and reoperation (RR = 2.24, 95% CI = 1.58 -3.16, P < 0.00001) but lower seroma rates (RR = 0.27, 95% CI = 0.10-0.74, P = 0.01). DIEP flap reconstruction offers superior patient satisfaction compared with LD flap reconstruction, despite a higher incidence of certain complications.

Acellular dermal matrix in direct-to-implant breast reconstruction: univariate and multivariate analysis on potential risk factors

BackgroundAcellular dermal matrices (ADM) are widely used in direct-to-implant breast reconstruction and were introduced as part of the implant-based breast reconstruction within the previous decade. This study presents clinical outcomes of ADM-assisted direct-to-implant breast reconstruction and evaluates the most frequent and severe postoperative complications.MethodsWe performed a retrospective analysis of patients who underwent ADM-assisted submuscular direct-to-implant breast reconstruction from March 2013 to February 2017 at the University Hospital Copenhagen, Rigshospitalet. All postoperative complications were classified using the Clavien Dindo classification of surgical complications. We used univariate and multivariate analyses with Fisher’s exact test and multiple logistic regression to determine potential risk factors.ResultsA total of 102 breast reconstructions were carried out in the inclusion period. The incidence rate of severe skin flap necrosis and surgical site infection was 6% and 4%, respectively. The total rate of skin flap necrosis was 14.7%, surgical site infection 11.8%, rotation of anatomical implants 4.90%, seroma 3.92%, dynamic breast deformity 1.96% and hematoma 1.96%. No patients suffered from red breast syndrome or capsular contracture. Total explantation rate was 4.90%. The median follow-up period was 32 months.ConclusionThis study demonstrates an acceptable rate of explantation in ADM-assisted direct-to-implant breast reconstruction. We found that skin flap necrosis and surgical site infection were the most frequently occurring complications with low rates of severe cases. However, there is a need for larger, controlled studies to further explore the impact of patient and surgery related risk factors.Level of evidenceLevel III, Risk/Prognostic.

Effect of comfort nursing in the perioperative period of free flap transplantation to repair the defects after surgery for malignant head and neck tumors.

To explore the effect of comfort nursing in the perioperative period of free flap transplantation to repair defects of malignant head and neck tumors. This retrospective study included 242 patients with postoperative defects of malignant head and neck tumors repaired using free flap transplantation from December 2017 to December 2022. Among them, 113 patients received routine nursing and were included in the control group, and 129 patients received comfort nursing and were included in the observation group. The perioperative indexes of skin flap transplantation, skin flap necrosis, hospital stay, and cortisol levels were compared. Albumin and pre-albumin levels were compared 1 hour before and 24 hours after surgery. The nursing quality, Self-Rating Depression Scale and Self-Rating Anxiety Scale scores, and nursing satisfaction were compared between the 2 groups. The success rate of skin flap transplantation in the observation group was significantly higher than that in the control group, whereas the rates of skin flap necrosis, length of stay, and cortisol levels were significantly lower in the observation group than in the control group. The Albumin and pre-albumin levels in the observation group were significantly higher than those in the control group 24 hours after surgery. The complication rate was significantly lower in the observation group than in the control group. The Self-Rating Depression Scale and Self-Rating Anxiety Scale scores in the observation group were significantly lower than those in the control group 24 hours after surgery. The satisfaction with nursing was significantly higher in the observation group than in the control group. Comfort nursing improved the success rate of free flap transplantation, reduced complications, reduced stress, improved nutritional, and psychological status of patients during the perioperative period, and improved nursing quality and patient satisfaction with nursing.

Double Asymmetric Circular Incision, a New Skin-Sparing Mastectomy Technique: Results and Outcomes of the First 46 Procedures.

Skin-sparing mastectomy (SSM) is a surgical technique that preserves as much of the breast skin as possible. Double asymmetric circular incision (DACI) is a novel immediate breast reconstruction technique for immediate prepectoral implant placement using a titanium-coated polypropylene mesh. The aim of this technique is to optimize the cosmetic benefits of smaller incisions, preserve breast anatomy, avoid breast deformities, and reduce the negative psychological impact on the patient without increasing local recurrence risk. DACI SSM uses a double circular incision: the external drawing contains the nipple-areola complex, while the inner circular skin island is used to provide the skin for the new areola. The authors performed DACI SSM in patients with tumors located within 2 cm of the nipple-areola complex, or in patients with multicentric lesions involving areolar tissue. Forty-six patients underwent DACI SSM at the authors' institutions between February of 2014 and July of 2019. Two patients developed hematoma, and one patient developed seroma. No implant loss was observed. Skin flap necrosis rate was 0%. The BREAST-Q patient-reported outcomes measure was routinely used at the authors' institutions and recorded good aesthetic outcomes and high patient satisfaction. This new technique appears to be safe and easily reproducible in patients with small to medium-sized breasts and with little to moderate ptosis (up to Regnault classification grade II). Therapeutic, IV.

A Comparative Analysis of Risk Factors for Breast Skin Necrosis following Autologous versus Device-Based Breast Reconstruction.

Mastectomy skin flap necrosis often necessitates prolonged wound care, surgical re-excision, and it increases the risk for infection. This study aims to compare rates of skin flap necrosis between autologous and device-based reconstructions and identify risk factors. The authors retrospectively identified patients who underwent immediate breast reconstruction using either the deep inferior epigastric perforator (DIEP) flap (n = 373 breasts, 41%) or tissue expanders (n = 529 breasts, 59%) by two surgeons at a single institution between 2011 and 2021. The rate of skin flap necrosis between autologous and device-based reconstructions was compared and multivariate regression analysis was performed to identify risk factors. There was no significant difference in rates of skin flap necrosis between the two cohorts (26.8 vs. 15.5%, p = 0.052). Across all patients, hypertension and body mass index >30 were significant predictors of necrosis (p = 0.024 and p <0.001, respectively). Within our DIEP cohort, mastectomy specimen weight was a significant risk factor for necrosis (p = 0.001). The DIEP flap weight itself did not confer a higher risk for necrosis (p = 0.8). Immediate autologous reconstruction does not place patients at higher risk of skin necrosis. Hypertension and obesity (body mass index >30) were independent risk factors for necrosis in all patients. Mastectomy specimen weight was a significant predictor of necrosis in DIEP flap patients while the DIEP flap weight itself did not increase the risk for necrosis.

Calcium silicate-human serum albumin composite hydrogel decreases random pattern skin flap necrosis by attenuating vascular endothelial cell apoptosis and inflammation

Random pattern skin flaps are commonly used in plastic surgery to repair skin defects. However, as flap survival mainly relies on blood supply from the distal pedicle and the wound bed, the distal part of the flap is prone to necrosis. Subsequent pathological reactions, including inflammatory reactions, cell apoptosis, and oxidative stress, also aggravate skin flap necrosis. Calcium silicate (CS) has gained attention for its multiple bioactive functions, including promoting angiogenesis and decreasing cell apoptosis, as well as its excellent biocompatibility and safety. Meanwhile, human serum albumin (HSA) hydrogel exhibits excellent drug carrier characteristics and good viscosity for clinical applications. Here, CS was incorporated into HSA hydrogel to form a bioactive composite hydrogel and to control its gelling time. PBS, CS-PBS, HSA hydrogel, and CS-HSA hydrogel were injected under skin flaps on day (-1) and skin flap surgery was performed on day 0. On day 7, the skin flap necrosis rate of the CS-HSA hydrogel group was significantly decreased with increased blood perfusion. Si ions were consistently released from the CS-HSA hydrogel under the skin flap 7 days after operation. Histological staining showed significantly increased CD31+ blood vessels, decreased cell apoptosis, and CD68+ macrophage infiltration. In vitro assays showed that low concentrations of CS extracts sustained cell viability, migration, and tube formation ability of human umbilical vein endothelial cells (HUVECs). CS extracts also decreased HUVEC apoptosis under glucose/oxygen-deprived conditions. Under these conditions, the macrophage inflammatory response decreased. Based on these results, composite CS-HSA hydrogel is suitable for clinical application, and can improve random pattern skin flap survival by attenuating vascular endothelial cell apoptosis and inflammation.

Inframammary Fold Incision Can Reduce Skin Flap Necrosis in Immediate Breast Reconstruction With Implant and Conjoined Fascial Flap.

Immediate breast reconstruction with implant (IBRI) can produce good aesthetic results after nipple-sparing mastectomy (NSM). Various surgical incisions can be used for NSM. The purpose of this study is to compare outcomes of using an IBRI with dual-coverage fascial flap after NSM with an inframammary fold (IMF) or a radial (Rd) incision. We retrospectively reviewed the records of 88 women who underwent IBRI with dual-coverage fascial flap from March 2015 to June 2018. Inframammary fold incision was used in 19 patients (22 breasts) and Rd incision in 69 patients (75 breasts). In the dual-coverage method, acellular dermal matrix covered the inferomedial quadrant of the breast, and conjoined fascial flap covered the remaining inferolateral quadrant. Patient-reported satisfaction was assessed using the Breast-Q questionnaire, and plastic surgeons assessed aesthetic postoperative scores. Complications and reoperation rates of 2 incisions were as follows: skin flap necrosis rate showed significant difference between 2 groups (IMF, 0.0% [0/22]; Rd, 16.0% [12/75]; P < 0.05). The other complication rates, hematoma, seroma, infection, capsular contracture, and total reoperations showed no significant difference. Postoperative Breast-Q scores were higher in the IMF group (331.9 ± 10.1) than in the Rd group (311.4 ± 11.0; P < 0.05), indicating higher satisfactory rate in the IMF group than in the Rd group. Surgeon-reported scores for breast symmetry, contour, and scar appearance were also higher in the IMF group (P < 0.05). Immediate breast reconstruction with implant with dual-coverage fascial flap after NSM with IMF incision was associated with a lower rate of postoperative skin flap necrosis and improved patient satisfaction, compared with Rd incision. Inframammary fold incisions were associated with improved scar and breast appearance.

Make Your Own Deep Inferior Epigastric Artery Perforator Flap: Perforator Delay Improves Deep Inferior Epigastric Artery Perforator Flap Reliability.

Background:Abdominal-based autologous breast reconstruction remains a conflict between blood supply and donor site complication. Optimizing esthetics and minimizing recovery and postoperative pain add further complexity. We present a 2-stage technique of deep inferior epigastric artery perforator flap reconstruction to (1) reliably harvest single-vessel flaps while minimizing fat necrosis, (2) decrease abdominal wall morbidity, and (3) improve breast and donor site esthetics.Methods:Female subjects presenting between August 2017 and January 2019 to the senior surgeon for abdominal-based breast reconstruction were included. After mastectomy, the subjects underwent subcutaneous placement of tissue expanders and in situ selection of a low, centrally located perforator based on preoperative computed tomographic angiography imaging through an infraumbilical “T” incision with ligation of all other perforators and superficial system. Subjects underwent tissue expander explant and flap transfer at a second stage.Results:One hundred thirty-five subjects undergoing 215 free flaps met criteria. Mean age and body mass index were 52.1 years and 29.3 kg/m2, respectively. Seven perforator complications (3.3%) occurred with 2 (0.9%) total and 5 (2.3%) partial flap losses. There were 20 (14.8%) readmissions and 26 (19.3%) reoperations. Breast complications included arterial thrombosis (0.5%), venous congestion (1.9%), and fat necrosis (5.1%). The mastectomy skin flap necrosis rate decreased from 14.9% to 2.3% following staged reconstruction. Abdominal donor site complications included delayed healing (11.1%), seroma (5.9%), and hematoma (2.2%).Conclusions:The 2-stage delayed deep inferior epigastric artery perforator flap technique represents a safe, efficacious modality to allow for reliable harvest of single-vessel flaps with low rates of fat necrosis while improving donor site esthetics and morbidity.

Self-Healing and Injectable Hydrogel for Matching Skin Flap Regeneration.

The fabrication of highly biocompatible hydrogels with multiple unique healing abilities for the whole healing process, for example, multifunctional hydrogels with injectable, degradation, antibacterial, antihypoxic, and wound healing–promoting properties that match the dynamic healing process of skin flap regeneration, is currently a research challenge. Here, a multifunctional and dynamic coordinative polyethylene glycol (PEG) hydrogel with mangiferin liposomes (MF‐Lip@PEG) is developed for clinical applications through Ag–S coordination of four‐arm‐PEG‐SH and Ag+. Compared to MF‐PEG, MF‐Lip@PEG exhibits self‐healing properties, lower swelling percentages, and a longer endurance period. Moreover, the hydrogel exhibits excellent drug dispersibility and release characteristics for slow and persistent drug delivery. In vitro studies show that the hydrogel is biocompatible and nontoxic to cells, and exerts an outstanding neovascularization‐promoting effect. The MF‐Lip@PEG also exhibits a strong cytoprotective effect against hypoxia‐induced apoptosis through regulation of the Bax/Bcl‐2/caspase‐3 pathway. In a random skin flap animal model, the MF‐Lip@PEG is injectable and convenient to deliver into the skin flap, providing excellent anti‐inflammation, anti‐infection, and proneovascularization effects and significantly reducing the skin flap necrosis rate. In general, the MF‐Lip@PEG possesses outstanding multifunctionality for the dynamic healing process of skin flap regeneration.

The Effect of Low-Dose Nitroglycerin Ointment on Skin Flap Necrosis in Breast Reconstruction after Skin-Sparing or Nipple-Sparing Mastectomy.

BackgroundSkin flap necrosis is a common complication after mastectomy and breast reconstruction. It has been proven that nitroglycerin ointment, as a topical vasodilator, can decrease the rate of skin flap necrosis after mastectomy and breast reconstruction. However, nitroglycerin can cause several side effects, including headache, dizziness, and hypotension. The purpose of this study was to evaluate whether the application of a low dose of nitroglycerin ointment reduced the rate of skin flap necrosis in breast reconstruction after skin-sparing or nipple-sparing mastectomy.MethodsA total of 73 cases of breast reconstruction after nipple-sparing and skin-sparing mastectomy at our institution from March 2012 to January 2017 were retrospectively studied. Of these patients, 52 received nitroglycerin ointment (4.5 mg) application to the skin around the nipple-areolar complex from August 2015 to January 2017, while 21 received fusidic acid ointment from March 2012 to August 2015. The number of patients who experienced necrosis of the breast skin flap was counted in both groups.ResultsSkin flap necrosis developed in 2 (3.8%) patients who were treated with nitroglycerin ointment and 5 (23.8%) patients who did not receive nitroglycerin ointment treatment. Patients who did not receive nitroglycerin ointment treatment had a significantly higher risk of mastectomy skin flap necrosis than patients who did (odds ratio=7.81; 95% confidence interval, 1.38 to 44.23; P=0.02).ConclusionsLow-dose nitroglycerin ointment administration significantly decreased the rate of skin flap necrosis in patients who underwent breast reconstruction after skin-sparing or nipple-sparing mastectomy, without increasing the incidence of the side effects of nitroglycerin.

Mastectomy technique using a self-designed self-retaining retractor system.

Mastectomy is one of the most common procedures for treating breast cancer. It is often performed by a breast surgeon with an assistant holding the retractor to provide adequate tension for dissection of the skin flap. However, the technique is highly dependent on the retraction from the assistant. We herein describe a novel technique using a self-retained retractor system with a specially designed retractor ring and elastic stay hooks to allow adequate and constant tension of retraction throughout the entire mastectomy procedure. This new technique was introduced at our breast center in 2008, and the skin flap necrosis rate and time required for skin flap dissection remain comparable to those in other regions. The retractor ring costs less than $200 USD, and the disposable elastic hooks cost around $50 USD. In conclusion, this new technique is simple, versatile, and effective.

Nipple sparing mastectomy: Surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period

BackgroundNipple sparing mastectomy is deemed surgically and oncologically safe based on a long lasting literature data from reviews of single institution series. This study aims at evaluating surgical and oncological outcomes of NSM on a large multi-institutional scale, by means of the Italian National registry. MethodsIn July 2011 a panel of Italian specialists agreed upon and designed a National database of NSM. Centers with at least 150 cancers per year and following the National follow-up schedule guidelines could participate inserting any NSM case performed, retrospectively and prospectively from that moment on. In March 2015 analysis of data was accomplished. Dataset for this study consists of cases performed in the period between January 1st 2009 and December 31st 2014. Results913 Women were included in the analysis, for a total of 1006 procedures. Prophylactic mastectomies were 124 (12.3%). MRI utilization increased over time. NSM failure rate, with NAC removal for any reason was 11.5%. NAC necrosis rate was 4.8%. Larger skin-flap necrosis rate was 2.3%. Major surgical complications rate was 4.4%. Oncological outcomes were calculated among primitive EBC cases only: locoregional recurrences rate was 2.9%, NAC recurrence 0.7%. Systemic recurrence rate was 1.0%. Five deaths (0.7%) were registered. ConclusionsMore than 10% of NSM procedures are prophylactic mastectomies. MRI is gaining more importance over time. Surgical and oncological results show that NSM is effective. This National multicentric analysis enables a comparison of results with no geographical differences and a “safe” state of the art of NSM in Italy.

Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study.

Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis. Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.

Total Skin-Sparing Mastectomy

Despite the potential aesthetic and psychological benefits of total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex (NAC) skin, there is still reluctance to use the technique due to concern for increased recurrence rates or higher postoperative complication rates. The rapidly expanding literature describing outcomes after TSSM enables a comprehensive review of recurrence rates and surgical complications. Studies describing nipple-sparing or TSSM were identified from the MEDLINE and Cochrane databases. Studies that reported oncologic outcomes and/or data on postoperative complications were included. Twenty-seven studies were identified that met inclusion criteria, representing a total of 3331 mastectomies. Review of oncologic outcomes in the 10 studies (representing 1148 mastectomies) with documented mean/median follow-up of 2 years demonstrated an overall local-regional recurrence rate of 2.8%. Ischemic complications involving the NAC were reported in 24 studies (representing 3091 mastectomies), with 9.1% of cases reported to have some degree of NAC necrosis and 2.0% of cases complicated by complete necrosis leading to NAC loss. Sixteen studies (representing 2213 mastectomies) reported rates of skin flap necrosis, which occurred in 9.5% of cases. Eighty-one percent of the total cases reviewed involved expander-implant reconstruction; in the 16 studies (representing 2343 reconstructions) that reported outcomes after expander-implant reconstruction, overall expander-implant loss was 3.4%. There is now a significant body of literature demonstrating low rates of early local-regional recurrence and postoperative complications after TSSM. These data support the use of TSSM techniques, which improve psychological and aesthetic outcomes without compromising therapeutic efficacy.

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Sir: We thank Drs. Longo and Santanelli for their critical evaluation. We are pleased that our article generated such thoughtful inquiry and hope our correspondence will create increased interest in this area of research. Our study population had a mean body mass index of 27, with 54 percent of patients having a body mass index greater than 25. In patients with pendulous hypertrophic breasts, type IV skin-sparing mastectomy using the Wise-pattern technique has documented efficacy regarding breast shape, achieving symmetry and reducing excess skin.1,2 We fully appreciate the special surgical considerations for this patient demographic, but we also recognize that nearly half of our patients had a normal body mass index and thus would not likely benefit from the Wise-pattern technique. Drs. Longo and Santanelli assert that the Wise-pattern skin-sparing mastectomy reduces ischemic complications. However, complication rates approaching 30 percent have been observed with this approach, most often involving skin necrosis at the T-junction.1–3 Our experience mirrors these data, and we do not commonly use the Wise-pattern technique because of a high rate of skin flap necrosis in the triangular flaps. When indicated, a vertical reduction pattern was used, which is associated with significantly reduced ischemic complications of mastectomy skin flaps while retaining the benefits of excess skin removal and excellent aesthetic outcomes.4 Longo and Santanelli state that using Wise-pattern skin-sparing mastectomy would reduce the variability of our results, yet the described modifications to this technique introduce tremendous variability regarding both mechanism of implant coverage and random flap length. Furthermore, standardization of a procedure not indicated in nearly half our patients would contribute little to study homogeneity. The purpose of this study was to identify key risk factors that predict a poor postoperative outcome. Elucidation of the potential influence of skin-sparing mastectomy technique, breast size, or surgical experience on outcomes was beyond the scope of this study and remains of great interest for future investigations. We document that breast radiotherapy had a significant association with implant loss. As we noted in the article, radiotherapy cannot be established as a risk factor for implant loss on the basis of our data alone, given the noted weaknesses in this analysis. We present these data not to establish recommendations but rather to incite further research on the impact of breast radiotherapy on outcomes. In logistic regression, it is suggested that the ratio of events to variables should be at least 10:1 for improved logistic regression modeling, and this ratio in our analysis of implant loss was approximately 4 and 7 for patient- and procedure-related factors, respectively.5 However, studies evaluating small data sets (violating the 10:1 rule) have suggested that this rule is somewhat arbitrary, in part because of its disregard for key parameters such as total sample size.5 All other outcome analyses involved a ratio greater than 10:1. We fully acknowledge the limitations imposed by study design and statistical analysis. However, we feel our data contribute important information to the literature on risk factor identification that will assist in development of criteria permitting preoperative risk stratification. We send our best regards to Drs. Longo and Santanelli. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Edward M. Kobraei, B.S. Brian D. Rinker, M.D. Division of Plastic Surgery University of Kentucky Lexington, Ky.

The effects of gingko biloba extract and deferoxamine on flap viability

It has been claimed that pretreatment of tissues with a variety of agents can minimize the production of oxygen radicals and improve tissue survival after an ischemic insult. In this study, the effects of two different free radical scavengers, ginkgo biloba extract-EGb 761, and deferoxamine, were compared in a rat groin island skin flap model. The rates of skin flap necrosis were determined and biochemical enzymes including malonyldialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) levels were measured. The biopsy specimens were evaluated electron microscopically. The rates of skin flap necrosis in the treated groups were found to be lower than those in control groups (p<0.001). The biopsy specimens from radical scavenger treated groups showed that the ginkgo biloba and deferoxamine treated rat samples had significantly lower MDA; SOD, GSH-Px levels on the 2nd, 6th, 10th experiment days when compared with the results of control groups (p<0.001). However, in magnitude this marked decrease in MDA, SOD, and GSH-Px levels which was detected after 2nd, 6th and 10th days in ginkgo biloba treated group were found to be lower than in deferoxamine treated ones (p<0.05). The electron microscopic investigation also showed that the ginkgo biloba treated rat biopsy specimens had more normal tissue ultrastructures than the deferoxamine treated rat samples.