None of these drugs has been reported in association with any aspect of clinical microsurgery except for anecdotal use of steroids in scalp replantation.40 They are used in experiments that attempt to produce models of prolonged tissue ischemia or try to investigate specific metabolic sequences, such as cyclic AMP production as an indicator of metabolic activity in flaps.51 No direct clinical implications are immediately evident from these initial studies, but numerous areas of biologic interest in cellular and circulatory physiology are being painstakingly explored and described. These studies may identify agents that are useful in aborting or modifying the processes leading to the no-reflow phenomenon and tissue death.

AGENTS INVESTIGATED AS DETRIMENTAL TO VASCULAR PATENCY AND/OR TISSUE SURVIVAL (TABLE 36-5)

We consider nicotine a complicating agent in microsurgery and strongly advise our patients against smoking perioperatively. Continued tobacco use is for us a relative contraindication to elective microsurgery. Experimental evidence describing the effects of tobacco and nicotine in microsurgery generally supports the contention that smoking is compromising, 88-91 as do clinical reports of skin loss following facelifting,92 and circulatory failure of replanted digits in patients who smoked postoperatively.3

Arteriography dye, once suspected as a source of endothelial injury,93 is now used preoperatively without concern because of experimental94 and clinical evidence2 testifying to the absence of significant vascular damage following its use.

Current Drug Therapies

Since 1972, the Microsurgical Replantation Transplantation Department of the Ralph K. Davies Medical Center in San Francisco has managed over 1000 patients requiring microsurgical procedures, including replantation,l-40,58,70 free tissue transfer,30 and toe-to-hand transfers.32 Our use of pharmacologic adjuncts has evolved from this extensive clinical experience, primary research,6,9,11,45,60,61,95 and examination of reported studies.

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