Non-invasive physical therapy as salvage measure for ischemic skin flap: A literature review

Table 1 Reported studies of physical therapies for managing ischemic flaps

Physical method	Year	Research species	Main findings	Ref.
Hyperbaric oxygen	1989	Rats	HBO treatment increased the percentage of surviving axial pattern skin flap when administered during or immediately after total flap ischemia. The improved flap survival appeared to be a systemic and not a local effect	Zamboni et al[7]
	1992	Rats	HBO treatment of ischemic rat skin flaps improved distal microvascular perfusion as measured by laser Doppler flowmetry. This effect was observed for HBO treatment given either during or immediately after prolonged global ischemia	Zamboni et al[8]
	1993	Rats	HBO treatment did not exacerbate reperfusion injury but rather appeared to protect the microcirculation by reducing venular leukocyte adherence and inhibiting progressive adjacent arteriolar vasoconstriction	Zamboni et al[16]
	2002	Rats	HBO treatment increased the survival length and mean LD flows of axial pattern skin flaps with all types of vascular insufficiency	Ulkür et al[9]
Electrical nerve stimulation	1988	Rats	High-intensity (20 mA), high-frequency (80 Hz) TENS applied segmentally at the base of the flap was shown to be the most effective treatment for increasing the flap survival	Kjartansson et al[31]
	1988	Human	ENS increased peripheral blood flow and prevented necrosis in ischemic flaps	Lundeberg et al[34]
	1990	Human	Local blood flow in skin flaps was significantly increased by ENS, but not by placebo. Repeated ENS treatment reduced stasis and edema significantly, and the capillary refill was also significantly improved	Kjartansson et al[35]
	1997	Rats	The flap survival area did not increase with EA but increased significantly with TENS treatment, and blood flow in the periphery was significantly greater than that at the base	Niina et al[32]
	2003	Rats	TENS was significantly more effective at increasing the survival of random-pattern skin flaps than topical nitroglycerin or nothing	Atalay et al[30]
	2006	Rats	TENS with an amplitude of 15 mA (80 Hz) produced a lower necrotic area than observed in the control group and was efficient at increasing random skin flap viability	Liebano et al[33]
	2008	Rats	Low-frequency (2 Hz, 15 mA) TENS treatment was effective at improving the viability of ischemic skin flaps	Liebano et al[57]
	2015	Rats	Electrical stimulation applied to the normal area before flap elevation increased flap survival	Doğan et al[4]
Heat stress preconditioning	2004	Pigs	Local heat preconditioning may be helpful for reducing wound healing complications related to ischemia following surgical dissection. The effect may be mediated by the induction of HSP70 expression	Harder et al[39]
	2005	Mice	Local heat preconditioning of myocutaneous tissue markedly increased flap survival by maintaining adequate nutritive perfusion rather than inducing ischemic tolerance. The protection was caused by increased arteriolar blood flow due to significant arteriolar dilation, which was mediated through the carbon monoxide-associated vasoactive properties of HSP32	Harder et al[45]
Phototherapy	2018	Rats	Photobiomodulation therapy with an 810-nm near infrared laser enhanced ischemic flap revascularization and increased flap viability	Ma et al[47]
	2019	Rats	Laser photobiomodulation at three points of the flap cranial base was more effective than at that 12 points for reducing the necrotic area	Martignago et al[48]
Shock wave therapy	2009	Rats	Preoperative ESWT may enhance skin flap survival in a rodent model	Reichenberger et al[55]
	2011	Rats	Preoperative ESWT improved skin flap survival through enhanced topical blood perfusion and neovascularization via elevation of angio-active factors	Keil et al[54]
Cold therapy	2005	Mice	Experimental cooling-induced preconditioning attenuates skin flap failure; this was associated with the increased expression of HO-1	Kubulus et al[56]

EA: Electroacupuncture; ENS: Electrical nerve stimulation; ESWT: Extracorporeal shock wave therapy; HBO: Hyperbaric oxygen; HO-1: Hemeoxygenase-1; LD: Laser Doppler; TENS: Transcutaneous electrical nerve stimulation.