Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 36:
  At each stage in the development and application of microsurgical techniques, from experimental anastomoses to complex clinical free tissue transfers, pharmacologic adjuncts have been used to help ensure vessel patency and tissue survival. Numerous drugs have been applied to the solution of observed or theoretic microsurgical problems, and different microsurgical groups recommend adjunctive pharmacological therapies, ranging from multiple agents1 to no agents.2 Anecdotal reports propose a variety of pharmacologic interventions to reverse threatened failures. 3,4

Understanding the roles of pharmacologic agents in microsurgery requires definition of the pathophysiology of the problems demanding treatment, examination of the mechanism of action of the agents considered, and evaluation of the experimental and clinical evidence supporting the use of each drug. This approach explains the context within which a given agent has been used, provide some understanding of the situational and empiric development of pharmacologic therapy in microsurgery and a framework for evaluation of actual drug use, and define promising areas for further clinical and experimental investigation.

Targets of Pharrnacologic Adjuncts

Ideally, identification of physiologic problems critical to microsurgery should be separate from questions of technical competence or procedure design. Historically, however, recognition of physiologic complications coincided with the evolution of technique, instruments, experimental models, flap designs, replantation strategies, and use of such options as vein grafting and heterotopic replantations.


Different physiologic problems have received more or less attention as the technical aspects of microsurgery have become more reliable and sophisticated. Early experiences with experimental microvascular anastomoses prompted studies of vascular spasm, and the use of topical vasodilating drugs was investigated and reported to be of great value.5-7 Thrombosis of microvascular anastomoses, regarded initially as a factor of evolving skills, techniques and instruments, came to be increasingly studied as a phenomenon related to platelet activity, and pharmacologic alteration of platelet function received detailed attention and widespread use.7 Vasodilating agents, used for salvage of axial and random skin flaps,8 were thought to be useful adjuncts early in the development of clinical free-tissue transfers.9 Experience with prolonged tisssue ischemia10 and extensive tissue injury provoked investigation of metabolic manipulation.11-13 The apparently idiosyncratic use of different drug therapies by different microsurgeons may at least partially reflect the significance attached to specific agents at different levels of technical and clinical development.

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