Superficial Epigastric Vessels Research Articles

Pre-epithelialized cryopreserved tracheal allograft for neo-trachea flap engineering.

Background: Tracheal reconstruction presents a challenge because of the difficulty in maintaining the rigidity of the trachea to ensure an open lumen and in achieving an intact luminal lining that secretes mucus to protect against infection. Methods: On the basis of the finding that tracheal cartilage has immune privilege, researchers recently started subjecting tracheal allografts to "partial decellularization" (in which only the epithelium and its antigenicity are removed), rather than complete decellularization, to maintain the tracheal cartilage as an ideal scaffold for tracheal tissue engineering and reconstruction. In the present study, we combined a bioengineering approach and a cryopreservation technique to fabricate a neo-trachea using pre-epithelialized cryopreserved tracheal allograft (ReCTA). Results: Our findings in rat heterotopic and orthotopic implantation models confirmed that tracheal cartilage has sufficient mechanical properties to bear neck movement and compression; indicated that pre-epithelialization with respiratory epithelial cells can prevent fibrosis obliteration and maintain lumen/airway patency; and showed that a pedicled adipose tissue flap can be easily integrated with a tracheal construct to achieve neovascularization. Conclusion: ReCTA can be pre-epithelialized and pre-vascularized using a 2-stage bioengineering approach and thus provides a promising strategy for tracheal tissue engineering.

Step By Step Free Flap Training Based on Inferior Superficial Epigastric Vessels in Rats

Introduction: Skill, knowledge and experience are essential in the field of microsurgery. The repetitive practice of free flaps on reliable models represents a valuable asset for each young surgeon, simulating the challenges of a free flap, before attempting human complex reconstructions. Microsurgery free-flap training is a demanding challenge, with limited options depending on local and regional programs, therefore we comprised a practice system that would add and reinforce microsurgical skills of each aspiring surgeon. Materials and Methods: Wistar rats, weighing 300-400 grams were used, the epigastric flap presenting the advantage of low morbidity with possibility of primary closure, while the donor cervical site represents a recipient area with one of the lowest chances of post-surgical self-mutilation areas in murine models. Results: The aim of this paper is to present a step-wise approach on a reliable training model, using living Wistar rats specimens. Microsurgery and super-microsurgery techniques are trained by harvesting a fascio-cutaneous free flap and transferring it to the cervical area. The aforementioned flap presents a pedicle based on the superficial inferior epigastric vessels at the emergence from the femoral vessels which will be anastomosed to an anterior cervical created defect to the carotid artery end-to-side and to the external jugular vein end-to-end, the epigastric vein presenting a diameter of 0.7-0.8 mm and the epigastric artery a diameter of 0.5-0.6 mm. They can be harvested with patches or stumps of femoral vessels for microsurgical training as an easier entry-level option, or directly for super-microsurgical training. Conclusion: This flap represents a reliable living training model, which can develop microsurgical skills involving raising, transferring and in-setting free flaps, providing ample and valuable knowledge and practice, simulating the challenges of a real-life either microsurgical or super-microsurgical intervention.

Regional Lymphatic Inclusion in Orthotopic Hindlimb Transplantation: Establishment and Assessment of Feasibility in a Rodent Model.

Background.The lymphatic system may play an important role in local immunomodulation in vascularized composite allotransplantation (VCA). Currently, there is no standardized VCA model that includes the regional draining lymphatic tissue. The aim of this study was to develop a rapid and efficient orthotopic hindlimb transplantation model in rats that included the draining lymphatic basin to permit further evaluation of the lymphatic system’s role in VCA.Methods.Thirty transplantations from Brown Norway rats to Lewis rats were performed. To include the regional lymphatic tissue, the superficial epigastric vessels were preserved to allow retrieval of the corresponding inguinal lymph nodes, including the inguinal fat pad, with the hindlimb. A cuff technique was used for the vein, whereas the conventional microsurgical technique was used for the arterial anastomosis. Vascular patency was confirmed through laser Doppler analysis at postoperative day 1 and histological analysis after euthanasia.Results.The presence and vascularization of the inguinal lymph nodes were verified with indocyanine green lymphoscintigraphy at the time of transplantation. Mean total ischemia time was 69 ± 24 minutes, and mean recipient operation time was 80 ± 19 minutes. Overall transplant survival rate was 93.3%. Laser Doppler analysis showed vascular (technical) success, indocyanine green lymphoscintigraphy confirmed the presence of lymph nodes and the histological analysis revealed patent anastomoses.Conclusions.We successfully developed an experimental orthotopic hindlimb transplantation model in rats that includes the draining inguinal lymphatic basin, which is an important asset in further research on lymphatic tissue and its role in VCA.

VS-1-7 Female-to-Male Gender Affirming Surgery: The Pedicled Pubic Phalloplasty and Radial Artery Free-Flap Urethroplasty

The goal of genital female-to-male (FTM) gender affirming surgery is to create an aesthetically acceptable phallus to allow voiding while standing and penetrative sexual intercourse. The radial artery free flap phalloplasty accomplishes these goals but results in significant donor site scarring. The visible scarring can be minimised by incorporating a radial artery free flap urethroplasty inside a previously formed pedicled pubic phalloplasty. This technique combines the less technically challenging phalloplasty with a well-vascularised and stable urethra for voiding. The combined procedure is performed in 4 stages: 1) phallus formation 2) creation of neourethra by free flap microvascular transfer to the recipient site 3) laparoscopic hysterectectomy and bilateral salphingo-oopherectomy, vaginectomy, join-up urethroplasty, burying of clitoris, scrotoplasty and glansplasty 4) penile and testicular prosthesis insertion. Each stage is performed at 6-monthly intervals. Steps: 1) a 13cm by 14cm pedicled pubic flap is raised preserving the superficial epigastric vessels. 2) a 4cm x 17cm free flap neourethra based on the radial artery is raised from the relatively hairless medial forearm and tubularised. A disc of skin is excised at the phallus tip and space dilated to size 20 Hegar. The neourethra is tunnelled through the phallus and a spatulated urethral anastomosis is performed followed by microsurgical vascular and neural anastomoses. The donor forearm is resurfaced with a split thickness skin graft. 3) Modified Norfolk technique glansplasty with urethral lengthening using inner labial and anterior vaginal flaps. 4) Penile prosthesis prepared with polyethylene terephthalate cap and sock and testicular prosthesis inserted via separate groin incisions with placement of the reservoir in an extraperitoneal position.

A novel rat microsurgical model to study the immunological characteristics of male genital tissue in the context of penile transplantation.

Penis transplantation represents an exciting new avenue for restoration of male genitalia and function after devastating tissue loss. This animal model is designed to fill a critical void to study immunologic aspects related to reconstructive transplantation of male genitalia. A rat penile graft dissection was designed based on the internal pudendal arteries and dorsal penile vein and includes the skin of the prepuce. A nonsuture cuff technique was used to anastomose the graft vessels to the recipient superficial epigastric and femoral vessels. Seventy-seven penile transplantations were performed. Graft design yields suitable caliber and length of vessels at the radix of the penis. Anastomosis of the dorsal penile vein and the internal pudendal arteries insures optimal graft perfusion. The nonsuture cuff technique allows for successful microvascular anastomosis by a single surgeon with an average overall operative time of 2.5h. Long-term graft survival (>30days) was observed in syngeneic transplants. We have established a robust murine model with ideal vascular perfusion of penile tissue to study the unique immunobiology of male genitourinary allotransplantation. Heterotopic inset further allows for visual monitoring of graft viability, while the native penis serves as an optimal control.

Large-Volume Vascularized Muscle Grafts Engineered From Groin Adipose Tissue in Perfusion Bioreactor Culture.

Muscle tissue engineering still remains a major challenge. An axial vascular pedicle and a perfusion bioreactor are necessary for the development and maintenance of a large-volume engineered muscle tissue to provide circulation within the construct. This study aimed to determine whether large-volume vascularized muscle-like constructs could be made from rat groin adipose tissue in a perfusion bioreactor. Epigastric adipofascial flaps based on the inferior superficial epigastric vessels were elevated bilaterally in male Lewis rats and connected to the bioreactor. The system was run using a cable pump and filled with myogenic differentiation medium in the perfusion bioreactor for 1, 3, 5, or 7 weeks. The resulting tissue constructs were characterized with respect to the morphology and muscle-related expression of genes and proteins. The histological examination demonstrated intact muscle-like tissue fibers; myogenesis was verified by the expression of myosin, MADS box transcription enhancer factor 2 D, desmin-a disintegrin and metalloproteinase domain (ADAM) 12-and M-cadherin using reverse transcription-polymerase chain reaction. Western blot analysis for desmin, MyoD1, N-cadherin, and ADAM12 was performed to verify the myogenic phenotype of the extracted differentiated tissue and prove the formation of muscle-like constructs. A large-volume vascularized muscle tissue could be engineered in a perfusion bioreactor. The resulting tissue had muscle-like histological features and expressed muscle-related genes and proteins, indicating that the trans-differentiation of adipose tissue into muscle tissue occurred.

Reestablishment of Lymphatic Drainage after Vascularized Lymph Node Transfer in a Rat Model.

Vascularized lymph node transfer has recently received attention as a potential surgical treatment for lymphedema. Despite good results in some series, the mechanism and benefits of vascularized lymph node transfer have yet to be fully understood. This study aimed to investigate the reestablishment of drainage into transferred lymph nodes following vascularized lymph node transfer in a rat model. Seven rats underwent vascularized lymph node transfer. The operation performed on each rat consisted of two parts. First, the left groin lymph node basin with superficial epigastric vessels was harvested as a free flap. Second, the flap was reattached in the left groin of the rat by means of end-to-end microvascular anastomoses. Anastomosis patency was assessed immediately postoperatively and at the time of animal sacrifice. The rats were evaluated for reestablishment of lymphatic flow into the transplanted nodes at 1-month intervals for at least 6 months postoperatively. This was accomplished noninvasively by injecting the rats in their flanks with fluorescent indocyanine green, which was detected using a Photodynamic Eye infrared camera. Anastomoses were patent in all seven rats immediately postoperatively. No indocyanine green uptake was seen in the transplanted lymph node basins in the first 2 months postoperatively in any of the rats. In five of seven rats, however, indocyanine green uptake was demonstrated in the transplanted lymph node basin by 6 months (average, 13 weeks). The authors report uptake of indocyanine green in five of seven rats at an average of 13 weeks after lymph node transplantation, consistent with the reestablishment of lymphatic drainage into the transplanted nodes.

The effect of trimetazidine in reducing the ischemia-reperfusion injury in rat epigastric skin flaps.

Ischemia-reperfusion injury may lead to insufficient microcirculation and results in partial flap loss during the free flap surgeries. This study aimed to investigate the effect of trimetazidine (TMZ) on oxidative stress, inflammation and histopathological changes, using the epigastric skin flap model in rats. 40 male Wistar rats were used, that were divided into four groups. Control group, non-treated ischemic (I/R)-group and two trimetazidine treated groups (preischemically, postischemically) were established. To create ischemia in the skin flap, the superficial epigastric vessels were clamped for six hours, followed by twenty-four hours of reperfusion. Blood samples and biopsies from skin flaps were collected at the end of the reperfusion period. The inflammatory response, the degree of oxidative stress (by measuring the plasma level of malondialdehyde (MDA), reduced glutathione (GSH); sulfhydryl (-SH) groups) and histopathological changes were evaluated. Inflammatory response, and oxidative stress were significantly attenuated in the trimetazidine treated groups, compared to the non-treated ischemic group. Histopathological findings were also correlated with the biochemical results. In our study trimetazidine could reduce the ischaemia-reperfusion injury, even after an unexpected ischemic period, so it is a promising drug during free tissue transfer, replantation or during revascularization procedures in the future.

Proper Choice of Vessels for Supermicrosurgery Training: An Experimental Animal study.

Reconstruction using supermicrosurgery, a technique of microneurovascular anastomosis for smaller vessels (< 0.8 mm), has become popular. Experimental animal studies for supermicrosurgery training have been reported; however, there have been few studies performed according to vessel diameter and pedicle length. In this study, the external diameters of four vessels (femoral, superficial epigastric, axillary, and common thoracic) and pedicle length of two flaps (superficial epigastric and common thoracic-long thoracic) were measured. The inguinal and pectoral regions of Sprague-Dawley rats (n = 19) were dissected anatomically, and the external diameters of the four vessels were measured (right and left, artery and vein measured separately). After elevating the superficial epigastric and common thoracic-long thoracic flaps, the pedicle length of the flaps was also measured. Among the 16 vessels examined, the external diameters of 11 and 5 vessels were above and below 0.8 mm, respectively. The external diameters of the superficial epigastric vessel and common thoracic vessel (both arteries and veins) were below 0.8 mm. The external diameters of the femoral and axillary vessels (veins) were above 0.8 mm. The length of the common thoracic-long thoracic pedicle was approximately10 mm longer than that of the superficial epigastric pedicle. The external diameters of the superficial epigastric vessel and common thoracic vessel are small enough for supermicrosurgery training. The pedicle lengths of both the superficial epigastric and common thoracic-long thoracic flaps are sufficient to perform free flap experiments. Supermicrosurgical free flaps using these two vessels and a study of the physiology and pharmacology of the flaps will likely be possible in the future.

A vascularized preputial free flap for labial reconstruction in a dog.

To describe the clinical application of a vascularized preputial free flap in the reconstruction of a large facial-labial defect. Case report. An adult neutered male mongrel dog with a large left facial-labial defect. A preputial free flap was created by elevating the cranial part of the prepuce, using the ipsilateral caudal superficial epigastric vessels as a vascular pedicle. The flap was transferred to the facial-labial defect and the donor vessels anastomosed to the sublingual artery and vein, using standard microvascular technique. The free flap survived, leading to good cosmetic and functional outcomes. No major complications were encountered at either the donor or recipient sites after 2 years of follow-up. Vascularized preputial free flaps can be used to manage composite facial and oral cavity defects involving large areas of skin and mucosa.

Impact of groin flap ischemia-reperfusion on red blood cell micro-rheological parameters in a follow-up study on rats.

Flap hypoperfusion or ischemia-reperfusion (I/R) may occur during preparation-transposition procedures and by postoperative thrombotic complications. Behind the microcirculatory disturbances micro-rheological alterations are also supposed. We aimed to investigate the groin flap I/R with following-up micro-rheological parameters. Anesthetized rats were subjected to Control or I/R groups. Groin flaps were prepared bilaterally, pedicled on the superficial epigastric vessels. In the Control group the flaps were re-sutured after one hour, while in I/R group microvascular clips were applied on the pedicles for 60 minutes, then the flaps were repositioned. Besides daily wound control, before the operation and on the 1st, 3rd, 5th, 7th and 14th postoperative days blood samples were collected for testing red blood cell (RBC) deformability (rotational ektacytometry) and aggregation (light-transmission aggregometry). RBC deformability significantly worsened by the 3rd-7th postoperative day in I/R group. RBC aggregation enhanced significantly by the 1st day, in I/R group it remained elevated on the 3rd day as well. In a complicated case with unilateral flap necrosis, RBC deformability and aggregation worsening was outlined from its group (base, 1st, 3rd day). Wound healing affected micro-rheological parameters in the early postoperative period. Flap I/R exacerbated the alterations. The parameters markedly worsened in case of flap necrosis.

A different technique in gasless laparoendoscopic single-site hysterectomy

The aim of this study was to show a different technique for a gasless laparoendoscopic single-site (LESS) hysterectomy and to present advantages and limitations of this technique. Women undergoing gasless LESS hysterectomy with a different technique were evaluated. A total of 14 LESS hysterectomies were performed using this gasless technique and rigid laparoscopic instruments by one surgeon. The mean age of the patients was 48.6 (±4.6). The average blood loss was 80 ± 35 ml. The average time between an umbilical incision and starting hysterectomy was 5 (±2,1) min. The time between starting hysterectomy and umbilical incision closure was 120 (±24) min in the laparoscopic suture group and 88 (±16) min in the vaginal suture group. The mean uterus weight was 188 (±95) g. In conclusion, this different technique is feasible and low cost, especially in non-obese patients. But further studies with large participants are needed to elucidate the safety.Impact statementConventional CO2 pneumoperitoneum has many adverse effects on cardiopulmonary function, haemodynamic, metabolic and neurologic systems due to high-intraperitoneal pressure. The usage of gasless technique eliminates these adverse effects and postoperative shoulder pain. The satisfaction of patients is higher in laparoendoscopic single-site (LESS) hysterectomy due to improved cosmesis and reduced postoperative analgesic requirements.In the literature, there are a few studies showing techniques combining LESS and gasless laparoscopy for hysterectomy. In this study, a different approach for creating operational space in gasless laparoscopy is described. Creation of intraabdominal operational space is convenient and takes a short time in this technique. The average time between an umbilical incision and starting a hysterectomy is five minutes. Additional training is not needed for experienced surgeons in LESS. Also, cost-effectiveness is one of important advantages. It is quite safe, no possibility of vascular injury, including inferior epigastric or superficial epigastric vessels. Also suturing the vaginal cuff and knot tying is easier in this technique.This technique can be used safely in patients with poor cardiopulmonary reserve. Also, by means of its cost effectiveness, it can be preferred in developing countries. As a result, it may be a good alternative to conventional LESS hysterectomy.

Experimental Rat Skin Flap Model That Distinguishes between Venous Congestion and Arterial Ischemia: The Reverse U-Shaped Bipedicled Superficial Inferior Epigastric Artery and Venous System Flap.

The commonly used flap models have drawbacks that limit their usefulness. In the random skin flap model, flap necrosis is caused by both arterial and venous insufficiency. In the axial skin flap model, flap viability is easily affected by the pedicle blood flow and can result in complete necrosis. This study aimed to establish a new rat skin flap model that has a consistent flap survival rate and in which venous congestion and arterial ischemia can be readily distinguished macroscopically. Rats underwent reverse U-shaped bipedicled superficial epigastric artery flap elevation. The right superficial epigastric vessels formed the pedicle. In the control rats (n = 3), the left superficial epigastric vessels were left intact. In the ischemia group (n = 10), the left superficial epigastric artery was ligated. In the congestion group (n = 10), the left superficial epigastric vein was ligated. The flap was returned to the original site and sutured. The surrounding neovascularization was blocked by polyurethane film. Flap survival rates were evaluated on postoperative day 3. The flaps in the ischemia and congestion groups were noticeably pale and violet, respectively. Flap necrosis was noted in the contralateral distal zone only. It started on postoperative day 2 in the ischemia and congestion groups. The mean flap survival rates of the control, ischemia, and congestion groups were 100 percent, 61.8 percent (range, 56.9 to 67.1 percent), and 42.3 percent (35.7 to 48.7 percent), respectively (all p < 0.001). The flap facilitated discrimination of the effects of ischemia and congestion. This new rat skin flap model is simple and easy to construct, and has a consistent flap survival rate.

Особенности вариантной анатомии поверхностных надчревных сосудов и их значение в реконструктивной хирургии молочной железы

Особенности вариантной анатомии поверхностных надчревных сосудов и их значение в реконструктивной хирургии молочной железы

Using the internal inguinal ring as a landmark for the safe placement of secondary trocars at laparoscopy

Aim Avoidance of injury to the epigastric vessels is an important safety consideration in siting secondary ports at laparoscopy. We evaluated trans-illumination, direct visualization of vessels and using the internal inguinal ring, which has a constant relationship with the inferior epigastric vessels as an anatomical landmark to locate these vessels. Methods Ninety consecutive women undergoing laparoscopy were recruited for the study. The Ability to trans-illuminate the superficial and inferior epigastric vessels, to visualize inferior epigastric vessels and to locate the round ligament entering the internal inguinal ring were documented. The body mass index (BMI) was noted. The association of the body mass index (BMI) with these variables was calculated by simple regression analysis. Results Ability to visualize the internal inguinal ring was significantly higher than that of locating the superficial or inferior epigastric vessels by trans -illumination or by directvisualization. p Ability to visualize and to trans -lluminatethe inferior epigastric vessels decreased with increasing BMI (p Conclusion Locating the deep inguinal ring and using it as an anatomical landmark and placing the lateral trocars lateral to a saggital line originating from the internal ring is a reliable and useful method in preventing unintended injury to anterior abdominal wall vessels during secondary trocar placement

Ventral Midline Preputial Approach to the Caudal Abdomen in Male Dogs.

To describe a ventral midline preputial approach to the caudal abdominal cavity of male dogs. Retrospective clinical study. Client-owned dogs (n=12). Medical records of dogs which underwent a ventral midline preputial approach to the caudal abdominal cavity were reviewed. The procedure, outcome, and complication were recorded. Dogs underwent the preputial approach to the caudal abdominal cavity for various conditions. All dogs had an uneventful postoperative recovery and no major complications were recorded until suture removal at 10-14 days postoperative. Two dogs had minor complications treated conservatively which resolved. The use of ventral midline preputial approach is an option for access to the caudal abdomen. The approach preserves the protractor preputii muscles, obviates ligation of the branches of the caudal superficial epigastric vessels and eliminates the need for extensive subcutaneous dissection.

Monitoring the primo vascular system in lymphatic vessels by using window chambers.

This study aims to develop a window chamber system in the skin of rats and to monitor the primo vascular system (PVS) inside the lymphatic vessels along the superficial epigastric vessels. The PVS in lymphatic vessels has been observed through many experiments under in vivo conditions, but monitoring the in vivo PVS in situ inside lymphatic vessels for a long time is difficult. To overcome the obstacles, we adapted the window chamber system for monitoring the PVS and Alcian blue (AB) staining dye solution for the contrast agent. The lymphatic vessels in the skin on the lateral side of the body, connecting the inguinal lymph nodes to the axillary lymph nodes, were the targets for setting the window system. After AB had been injected into the inguinal lymph nodes with a glass capillary, the morphological changes of the stained PVS were monitored through the window system for up to twenty hours, and the changes in the AB intensity in the PVS were quantified by using image processing. The results and histological images are presented in this study.

Temporal Change of Alcian Blue-Stained Primo Vascular System in Lymph Vessels of Rats.

This study aims to investigate the temporal change of a vascular system now known as the primo vascular system (PVS). We used Alcian blue (AB) dye for imaging the distribution of the PVS in lymphatic vessels. The target lymph vessels were chosen as they are easily accessible from the skin, and long-term observation is possible with intact physiological conditions due to a minimal surgical procedure. AB solution was injected into the inguinal lymph node and the target lymph vessels were located along the superficial epigastric vessels. The imaging system allowed processing for extraction of images showing changes in the AB intensity of the visualized PVS components. This newly developed procedure can be used for further study on various dynamic processes of PVS in lymph vessels.

Defining the lymphatic system of the anterior abdominal wall: an anatomical study.

Studies describing recent abdominoplasty modifications have reported a decreased incidence of seroma, attributed to preservation of abdominal lymphatics. However, there are limited anatomical data to support this hypothesis. The authors sought to characterize the lymphatic architecture of the abdominal wall and provide a conceptual basis for further refinement of abdominoplasty techniques. Fifteen tissue samples from five patients undergoing abdominoplasty were sectioned and analyzed. Slides were stained with hematoxylin and eosin, CD31, and D2-40 and assessed by a pathologist and a plastic surgeon for the presence and number of lymphatics. Results were reported as mean percentage of lymphatic-specific antibody per analyzed area. Lymphatic vessels were observed in the dermis, superficial fascia, and loose areolar tissue but not in deep or superficial fat. The highest concentration was in the dermis (mean, 82.6 percent; range, 69 to 89.2 percent). The Scarpa fascia contained 9.4 percent of lymphatics (range, 7.0 to 11.4 percent), whereas the loose areolar tissue at the specimen base contained an average of 7.9 percent (range, 2.6 to 19.5 percent). These lymphatics were consistently located in the deepest third, with the Scarpa fascia lying an average of 34 percent of the total tissue thickness above muscle fascia. Lymphatic prevalence did not increase in specimens near the superficial epigastric vessels. Abdominoplasty flap lymphatics are most common in the dermis, with a significant proportion (approximately 17 percent) also appearing near fascial layers. This confirms the presence of deep lymphatic channels that could potentially be preserved during abdominoplasty or lipoabdominoplasty.

Inflammatory Response and Survival of Pedicled Abdominal Flaps in a Rat Model after Perivascular Application of Botulinum Toxin Type A

In addition to the numerous applications of botulinum toxin type A, the authors have documented improvements in surgical flap survival through vasoactive effects. This study aimed to investigate its effect on the expression of inflammatory mediators. In 54 male Sprague-Dawley rats, cutaneous flaps based on the superficial epigastric vessels were elevated. Botulinum toxin type A, lidocaine, or saline was administered to the vascular pedicle. After 1, 2, and 7 days, mRNA expression for tumor necrosis factor-α, interleukin-1, and vascular endothelial growth factor-165 was compared along with flap survival. Vascular endothelial growth factor-165 mRNA expression was lower in the botulinum toxin type A group compared with (1) the saline group at days 1 and 2 (p < 0.01) and (2) the lidocaine group at day 2 (p < 0.05). The expression of interleukin-1 was significantly less at each time point in the botulinum toxin type A group compared with the lidocaine group (p < 0.02), and at day 2 compared with the saline group (p < 0.01). Tumor necrosis factor-α mRNA expression in the botulinum toxin type A group was lower at 2 days and 7 days compared with both other groups (p < 0.04). Finally, both the botulinum toxin type A and lidocaine groups had a greater survival area (p < 0.05) compared with the saline group. The presence of botulinum toxin type A in the postsurgical flap microenvironment augments tissue perfusion and its inflammatory response and, ultimately, survival.