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Cirugía y cirujanos

versión On-line ISSN 2444-054Xversión impresa ISSN 0009-7411

Cir. cir. vol.91 no.5 Ciudad de México sep./oct. 2023  Epub 30-Oct-2023

https://doi.org/10.24875/ciru.22000203 

Original articles

Protective effect of nitroglycerin ointment and dimethyl sulfoxide on necrosis of skin flaps in rats

Efecto protector del unguento de nitroglicerina y el dimetilsulfoxido en la necrosis de colgajos cutáneos en ratas

Miguel L. De la Parra-Marquez1  2  * 

Abril Peralta-Enriquez1  2 

Victor G. Peña2 

Sergio Charles-Lozoya1  2 

1Departament of Reconstructive and Plastic Surgery, Unidad Médica de Alta Especialidad No. 21. Instituto Mexicano del Seguro Social (IMSS)

2Departamento de Enseñanza, Universidad de Monterrey. Monterrey, Nuevo León, México


Abstract

Objective:

To compare the protective effect of nitroglycerin ointment 2% and Dimethylsulfoxide (DMSO) in dorsal flaps of the rat.

Methods:

A blind, experimental study was conducted in 24 male Wistar rats, with a mean weight of 320 (286-376) grams. Group 1: Control. Petrolatum jelly (Vaseline), n = 8, Group 2: Nitroglycerin (NTG) ointment 2% (Nitro-Bid, Altana Co.) n = 8, and Group 3: DMSO gel 90% (Neogen corp. Lexington KY, 40611), n = 8.

Results:

A total of 24 rats were operated on in the 6-month period of this study. Using a non-parametric Mann–Whitney U-test analysis, a statistically significant p was obtained between the control group and 2% NTG ointment, both in the area of necrosis and in the healthy area (p = 0.026). In contrast, the comparison between DMSO [CH3) 2SO] and the control group (p = 0.180) and between both study groups, with a p = 0.18, was not significant.

Conclusions:

Our study concluded that there is a protective effect of 2% NTG ointment for flap survival in relation to the control group (petrolatum). DMSO administered topically did not show a protective effect, compared to the control group.

Keywords Dimethyl sulfoxide; Nitroglycerin ointment; Flap necrosis

Resumen

Objetivo:

Comparar el efecto protector del ungüento de nitroglicerina 2% y el dimetilsulfoxido 90% en colgajos dorsales en ratas.

Métodos:

Se realizó un estudio experimental ciego en 24 ratas Wistar macho, con un peso medio de 320 gramos. Grupo 1: Control. Petrolato n = 8, Grupo 2: Nitroglicerina unguento al 2 % (Nitro-Bid, Altana Co.), n = 8, Grupo 3. Dimetilsulfóxido al 90% (Neogen corp. Lexington KY.), n = 8.

Resultados:

Un total de 24 ratas fueron operadas en el período de 6 meses de este estudio. Mediante un análisis no paramétrico de la prueba U de Mann Whitney, se obtuvo una p estadísticamente significativa entre el grupo control y la pomada de nitroglicerina al 2%, tanto en el área de necrosis como en el área sana (p = 0.026). Por el contrario, la comparación entre DMSO y el grupo control (p = 0.180) y entre ambos grupos de estudio, con una p = 0.18, no fue significativa.

Conclusiones:

Nuestro estudio concluyó que existe un efecto protector de la pomada de nitroglicerina al 2% para la supervivencia del colgajo en relación al grupo control (vaselina). El DMSO administrado por vía tópica no mostró un efecto protector, en comparación con el grupo de control.

Palabras clave Dimetilsulfóxido; Pomada de nitroglicerina; Necrosis del colgajo

Introduction

The survival of the fasciocutaneous flaps is dependent on the adequate supply of oxygen from blood flow, throughout the entirety of the flap. The main challenge is in the distal areas of the flap, which suffer from a decreased supply, generating tissue ischemia1. Nitric oxide acts as a tissue protector by inhibiting aggregation of thrombocytes, leukocyte adhesion to the endothelium, eradicating free radicals, maintaining vascular permeability, regulating vascular tone, and stimulating the regeneration of vascular endothelium, among others2-7.

Dimethyl sulfoxide [CH3) 2SO] (DMSO) is a small polar molecule that contains sulfur at its center, 2 methyl groups, and oxygen at its tips. Due to its characteristics, it is one of the most common solvents, having the ability to penetrate membranes in skin, cells, and organelles. It can associate with various components including water, proteins, carbohydrates, nucleic acids, and ionic substances. Absorption capacity in humans has been demonstrated, and 5 min after topical application, it is detectable in blood8. With a peak at 4-8 h in serum after topical application or oral intake, elimination is registered 120 h after application. Its elimination route is through the kidneys9,10.

Various investigations have been carried out in rats regarding the attributes and different dosages of DMSO, seeking to quantify the optimal doses to obtain maximum benefit and minimum toxicity11. Among its qualities, it has been shown that, at low doses, it inhibits platelet aggregation, decreases pathological deposition of collagen in fibrotic tissue (without affecting the normal balance of collagen in healthy tissue)12, accelerates wound healing through the activation of fibroblast proliferation, mediated Akt/mTOR activation, leading to translation of proteins, such as collagen, and the secretion of TGF-β1 by fibroblasts, indirectly increases keratinocyte migration, stimulated by the increase imTGF-β113. It has a vasodilator effect by releasing a response similar to the release of histamine in the area of application. It is anti-inflammatory, by reducing the production of lymphocytes, neutrophils, IFN-γ, TNF-α, NF-KB, IL-8, IL-2, and prostaglandin E214. Analgesic, due to its ability to block C fibers of peripheral nerves15. It was identified to be effective when applied to pressure ulcers at an early stage, allowing a reduction in their torpid evolution, as well as analgesia of the affected area, reducing inflammatory signs such as redness, pain, heat, and increase in volume.

Nitroglycerin (NTG) increases prostacyclin synthesis by endothelial cells and acts as nitric oxide, whose main function is as a vasodilator and antithrombotic at the microvascular level. It acts both at the arterial and venous levels, its effect being more accentuated at the venous level16-18. It generates vascular dilation by relaxing smooth muscle, without altering pre- and post-capillary resistance19. In ointment form, it is safe, inexpensive, easy to apply, and fast-acting. In topical use, various studies have observed improvement of flaps that present ischemic signs. It has been used for multiple pathologies including coronary syndromes and anal fissures20,21.

Rohrich, in 1984, reported its topical use and effect on flaps in animal models, where he observed increased survival of the flap after the application of NTG22. Research has been carried out on its use in the area of breast reconstruction, taking into account that cutaneous necrosis after mastectomy is relatively frequent, occurring in between 2.5% and 60% of all patients. These studies showed improvement in the evolution and/or prevention of tissue ischemia. The latter presenting as a partial and full-thickness necrosis. Its use showed better effectiveness with serial application compared to a single dose. According to research in breast reconstruction, the dose that has proven to be safe and significant is 5.5 mg applied once a day every 48 h.

Methods

This project was approved by the Mexican Institute of Social Security animal care and ethical committee. Based on some articles published previously4,22,23, a blind, experimental study was conducted in 24 male Wistar rats, with a mean weight of 320 (286-376) grams.

The population was divided into 3 groups with 8 rats each one (n = 24):

  • – Group 1: control: Petrolatum jelly (Vaseline), n = 8 (Fig. 1)

  • – Group 2: NTG ointment 2% (Nitro-Bid, Fougera, Altana Co, Melville, NY, USA), n = 8 (Fig. 2)

  • – Group 3: DMSO gel 90% (Neogen corp. Lexington KY, 40611), n = 8 (Fig. 3).

Figure 1 Control group. 

Figure 2 Nitroglycerin ointment group. 

Figure 3 Dimethyl sulfoxide group. 

Surgical technique

Anesthesia: 6.5% sodium pentobarbital was used, injected directly, intraperitoneally using a 1 mL syringe with a 25 Gg needle, at a dose of 50 mg/kg of weight.

Once deep anesthesia had been verified by the absence of painful stimuli, a modified McFarlane flap23 for Wistar rats was designed with an indelible marker to be 3 cm × 10 cm with a cephalic base. Trichotomy, asepsis, and antisepsis of the area were performed with povidone-iodine.

Incision was made with a No. 15 scalpel blade and dissected with scissors until the entire flap was completed suprafascially. Subsequently, it was sutured with simple stitches using 4-0 nylon.

The ointment was applied by a researcher other than the main author, who carried out the statistical analysis and review of the results (blind). Topical application was carried out immediately after surgery and subsequently every 12 h for 5 days.

The survival and necrosis of the flaps were evaluated at 7 days using a transparent acetate sheet squared every 5 mm, to complete a total area of 3000 mm2, for subsequent analysis.

For the statistical analysis, measures of central tendency and dispersion were used, as well as the non-parametric Mann-Whitney's U-test, using the Statistical Package for the Social Sciences 10.0 program for windows (IBM; Armonk NY), taking as significant a p ≤ 0.05.

Results

A total of 24 rats were operated on in the 6-month period of this study, in the microsurgery laboratory of the UMAE 21 (High Specialty Medical Unit 21) of the IMSS (Mexican Institute of Social Security), in Monterrey NL.

The average weight was 320 g (limits 286-376 gr).

All the rats that participated in the study survived the observation period (7 days). The total area of the flap was 3000 mm2 in all experimental animals.

In the control group (petroleum jelly), mean necrosis of 1041.67 mm2 was observed, in Group I (NTG ointment) 616.67 mm2 and in Group 2 (DMSO) of 800 mm2 table 1.

Table 1 Flap survival and necrosis (in mm) by groups 

Group n Lower (mm2) Higher (mm2) Mean (mm2) SD
Control 8
Necrosis 600 1400 1041.67 304.001
Healthy tissue 1400 2400 1958.33 304.001
Nitroglycerin 8
Necrosis 350 850 616.67 183.485
Healthy tissue 2150 2650 2383.33 183.485
DMSO* 8
Necrosis 450 1100 800 221.359
Healthy tissue 1900 2550 2200 221.359

*DMSO: Dimethyl sulfoxide; SD: Standard deviation.

Using a non-parametric Mann–Whitney U-test analysis, a statistically significant p was obtained between the control group and 2% NTG ointment, both in the area of necrosis and in the healthy area (p = 0.026). In contrast, the comparison between DMSO and the control group (p = 0.180) and between both study groups (DMSO- NTG), with a p = 0.18, was not significant table 2.

Table 2 Statistical significance by groups 

Group Necrosis (p) Healthy tissue (p)
Control/Nitroglycerin 0.026 0.026
Control/DMSO 0.180 0.180
Nitroglycerin/DMSO 0.180 0.180

*DMSO: Dimethyl sulfoxide.

Discussion

The vascularity of fasciocutaneous flaps has been extensively studied in recent decades; however, interest in them has increased exponentially since the 1987 work of Ian Taylor on skin territories and angiosomes24. Simultaneously, with the evolution of reconstructive microsurgery, multiple studies have been added about improvement in the survival of flaps. It is well known that the surgical technique at the time of flap dissection and the microvascular anastomosis are the most important prognostic factors for its success. However, there are many studies that look at adjuvant medications that can be used to increase local and systemic capillary vascularity1,2,4,6,11,15,17,19,20,22,23.

Two drugs widely known to be local and systemic vasodilators were used in our study: DMSO and NTG.

We found a difference in the means of necrosis between the control group (1041.67 mm2) and the NTG group (616.67 mm2). The results were favorable for 2% NTG ointment, with a statistically significant p compared to the control group (p = 0.026).

Since 1984, Rohrich et al.22 had already used NTG in experimental animals, also obtaining favorable results; however, unlike our study, he used axial flaps with a wider base (8 cm × 8 cm) based on the ventral inguinal vessels. In addition, some clinical studies in mastectomized patients have also shown a favorable response to NTG ointment17,19,20. Conversely, a study published by Nichter et al.21 concluded that NTG does not increase the survival of flaps in rats. However, this study used prolonged-release NTG skin patches (transderm-nitro 5), their main indication being for systemic absorption rather than local effect.

Unlike 2% NTG ointment, dimethyl sulfoxide did not reduce the risk of flap necrosis (p = 0.18), behaving similar to the animals in the control group, despite showing a decrease in the mean necrosis in relation to the control group (800 mm2 vs. 1041.67 mm2). We also found no statistically significant difference between the DMSO and NTG ointment groups (p = 0.18) (mean 800 mm2 vs. 616.67 mm2).

There are many studies in animal models that demonstrate a protective effect of DMSO in random flaps, based on the decrease in systemic pro-inflammatory factors (IFNg, TNF-α, NF-KB, IL-8, IL-2, and E2 prostaglandin). However, in many of them, DMSO is administered orally2,4 or injected subcutaneously11. In our study, we found that there is no such protective effect using topically applied DMSO ointment. Although flap survival improved in some of the rats, the difference compared to the control group and the NTG group was not statistically significant.

In clinical practice, the use of NTG ointment has been found useful to improve the survival of flaps5,8,17,19,20, these studies looked at flaps based on random circulation, where flap circulation is from capillaries and not from a main pedicle. In the case of axial microvascular flaps, where distress is mainly due to problems with the vascular pedicle, either at the level of the anastomosis or farther away due to torsion or kinking, the use of NTG ointment will not be useful, and the indication to reexamine the flap is the best salvage option.

Conclusions

Our study concluded that there is a protective effect of 2% NTG ointment for flap survival in relation to the control group (petrolatum). DMSO administered topically did not show a protective effect, compared to the control group.

References

1. Ellabban MA, Fattah IO, Kader GA, Eldeen OS, Mehana AE, Khodeer DM, et al. The effects of sildenafil and/or nitroglycerin on random-pattern skin flaps after nicotine application in rats. Sci Rep. 2020;10:3212. [ Links ]

2. da Silva I, de Carvalho HF, Ferreira LM. Effect of dimethyl sulphoxide on necrosis of skin flaps in rats. Can J Plast Surg. 1998;6:93-7. [ Links ]

3. van den Heuvel MG, Buurman WA, Bast A, van der Hulst RR. Review:ischaemia-reperfusion injury in flap surgery. J Plast Reconstr Aesthet Surg. 2009;62:721-6. [ Links ]

4. Leite MT, Gomes HC, Percário S, Russo CR, Ferreira LM. Dimethyl sulfoxide as a block to the deleterious effect of nicotine in a random skin flap in the rat. Plast Reconstr Surg. 2007;120:1819-22. [ Links ]

5. Navarro-Triviño FJ, Hernandez-Godoy J, Vega-Castillo J, Ruiz-Villaverde R. Role of tropical nitroglycerin in the survival of flaps with cutaneous suffering. Piel. 2020;35:136-8. [ Links ]

6. de Abreu Costa L, Henrique Fernandes Ottoni M, Dos Santos MG, Meireles AB, Gomes de Almeida V, de Fátima Pereira W, et al. Dimethyl sulfoxide (dmso) decreases cell proliferation and TNF-a, IFN-g, and IL-2 cytokines production in cultures of peripheral blood lymphocytes. Molecules. 2017;22:1789. [ Links ]

7. da Silva Duarte I, Gragnani A, Ferreira LM. Dimethyl sulfoxide and oxidative stress on cultures of human keratinocytes. Can J Plast Surg. 2004;12:13-6. [ Links ]

8. Young VL, Boswell CB, Centeno RF, Watson ME. DMSO:applications in plastic surgery. Aesthet Surg J. 2005;25:201-9. [ Links ]

9. Yi X, Liu M, Luo Q, Zhuo H, Cao H, Wang J, et al. Toxic effects of dimethyl sulfoxide on red blood cells, platelets, and vascular endothelial cells in vitro. FEBS Open Bio. 2017;7:485-94. [ Links ]

10. Jacob SW, Wood DC. Dimethyl sulfoxide (DMSO). Toxicology, pharmacology, and clinical experience. Am J Surg. 1967;114:414-26. [ Links ]

11. Almeida KG, Oliveira RJ, Dourado DM, Filho EA, Fernandes WS, Souza AS, et al. Morphological study of rat skin flaps treated with subcutaneous dimethyl sulfoxide combined with hyperbaric oxygen therapy. Genet Mol Res. 2015;14:18160-71. [ Links ]

12. Sari E, Bakar B, Dincel GC, Budak Yildiran FA. Effects of DMSO on a rabbit ear hypertrophic scar model:a controlled randomized experimental study. J Plast Reconstr Aesthet Surg. 2017;70:509-17. [ Links ]

13. Guo W, Qiu W, Ao X, Li W, He X, Ao L, et al. Low-concentration DMSO accelerates skin wound healing by Akt/mTOR-mediated cell proliferation and migration in diabetic mice. Br J Pharmacol. 2020;177:3327-41. [ Links ]

14. Rawls WF, Cox L, Rovner ES. Dimethyl sulfoxide (DMSO) as intravesical therapy for interstitial cystitis/bladder pain syndrome:a review. Neurourol Urodyn. 2017;36:1677-84. [ Links ]

15. Sari E, Bakar B, Sarkarati B, Bozdogan O, Cavusoglu T. Effectiveness of dimethylsulfoxide on the survival and volume preservation of autologous fat graft tissue:a preliminary study. Aesthet Surg J. 2016;36:P58-67. [ Links ]

16. Capriotti K, Capriotti JA. Dimethyl sulfoxide:history, chemistry, and clinical utility in dermatology. J Clin Aesthet Dermatol. 2012;5:24-6. [ Links ]

17. Yun MH, Yoon ES, Lee BI, Park SH. The Effect of low-dose nitroglycerin ointment on skin flap necrosis in breast reconstruction after skin-sparing or nipple-sparing mastectomy. Arch Plast Surg. 2017;44:509-15. [ Links ]

18. Atalay C, Koçkaya EA, Cetin B, Kismet K, Akay MT. Efficacy of topical nitroglycerin and transcutaneous electrical nerve stimulation on survival of random-pattern skin flaps in rats. Scand J Plast Reconstr Surg Hand Surg. 2003;37:10-3. [ Links ]

19. Wang P, Gu L, Qin Z, Wang Q, Ma J. Efficacy and safety of topical nitroglycerin in the prevention of mastectomy flap necrosis:a systematic review and meta-analysis. Sci Rep. 2020;10:6753. [ Links ]

20. Vania R, Pranata R, Irwansyah D, Budiman. Topical nitroglycerin is associated with a reduced mastectomy skin flap necrosis-systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73:1050-9. [ Links ]

21. Nichter LS, Sobieski MW, Edgerton MT. Efficacy of topical nitroglycerin for random-pattern skin-flap salvage. Plast Reconstr Surg. 1985;75:847-52. [ Links ]

22. Rohrich RJ, Cherry GW, Spira M. Enhancement of skin-flap survival using nitroglycerin ointment. Plast Reconstr Surg. 1984;73:943-8. [ Links ]

23. Van YR, Wald G, Lu C, Samadi A, Wright M, Lara D, et al. The effect of topical tacrolimus on pedicled flap survival. Ann Plast Surg. 2020;85:S118-21. [ Links ]

24. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body:experimental study and clinical applications. Br J Plast Surg. 1987;40:113-41. [ Links ]

FundingThe authors did not receive any funding for this study.

Ethical disclosures

Protection of human and animal subjects. The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data. The authors declare that no patient data appear in this article.

Right to privacy and informed consent. The authors declare that no patient data appear in this article.

Use of artificial intelligence for generating text. The authors declare that they have not used any type of generative artificial intelligence for the writing of this manuscript, nor for the creation of images, graphics, tables, or their corresponding captions.

Received: April 06, 2022; Accepted: July 23, 2022

* Correspondence: Miguel L. de la Parra-Marquez E-mail: drdelaparra@yahoo.com.mx

Conflicts of interest

The authors declare no conflicts of interest.

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license