Ed surgery vascular reconstructive surgery: Vascular Reconstructive Surgery for Erectile Dysfunction
Avoiding Penile Surgery – Vascular Reconstructive Surgery
Penile Surgery – a Medical View
While surgery should never be the first choice when it comes to erectile issues many sufferers, frustrated by the apparent lack of options, end up turning to surgery to remedy the condition. However, the surgical options aren’t quite as effective as some believe, and alternate options can often be far more effective.
There are several major forms of surgery to restore erectile function, with each option having its own advantages and drawbacks:
Vascular Reconstructive Surgery: With blood flow to the penis being one of the major physical issues preventing people from gaining erections, this surgery is designed to bypass certain arteries, restoring the flow of blood to the penis. During the surgery, an artery from a muscle in the stomach is transferred to one in the penis. This creates a path for blood to move around the problem area.
Doctors rarely recommend the operation and it’s very much a last option for most, since it’s technically difficult, costly, and doesn’t always work. It may be a good alternative for those who are younger and have ED because of an injury to the penis and/or the area around it. With a relatively low success rate for this kind of surgery, it’s very much a last option for most.
Penile Prosthesis Options: While there are various kinds of penile prosthesis available, from rod-based treatments to inflatable options, penile prosthesis surgery involves a prosthesis being surgically inserted into the penis to restore sexual function. With this type of implant, the penis is always semi-rigid and merely needs to be lifted or adjusted into the erect position to initiate sex. A penile implant is typically only used when there is a clear medical cause for ED and when the problem is unlikely to resolve or improve naturally with other treatments. Sometimes a penile prosthesis is implanted during surgery to reconstruct the penis when scarring has caused erections to curve (Peyronie’s disease).
This option works for most, but may put some off, with some prostheses significantly altering how the penis looks and feels (particularly with the permanent semi-rigidity of the rod prosthetic.
Non-Surgical Alternatives for Penile Issues
Considering the costs and potential risks of surgery, the majority of specialists will only recommend it as a last alternative. However, that doesn’t necessarily mean that you’re being given the full list of potential ways to improve your condition.
Vacuum Pumps: Helping approximately 9 out of 10 users recover full sexual capacity, vacuum pumps are a frequently overlooked way to improve the ability to gain and maintain an erection. When used, vacuum erection devices create a vacuum around the penis, quickly drawing in blood, resulting in an erection.
Vacuum pumps can make a real difference: we make the very best options available. Built to remove the key issues people report with standard vacuum pumps, VaxAid Trainer and VaxAid Deluxe Pumps can be used in water. Safely expanding the corpora cavernosa in a consistent vacuum, 90% of men report an improvement in sexual capacity. The devices can also be used in air for sexual spontaneity.
VaxAid delivers more vacuum power than many other pumps, with many users reporting that this leads to quicker (and longer lasting) erections.
We guarantee that VaxAid will make a difference for you, with our 60-day satisfaction promise including a full refund if you’re not impressed.
Vascular Reconstructive Surgery
Because the procedure is very difficult to perform, expensive, and does not always work, it is very selectively performed.
Advantages of the surgery include:
- The restoration of natural erections if successful
- A natural appearance
- No implant required
- If unsuccessful, does not interfere with other treatments
Only a very small percentage of men are eligible for the surgery, particularly young men who are suffering from erectile dysfunction as a result of trauma to the penis or perineum. If you fall in this group and would once again like the ability to get an erection, talk to your doctor about the possibility of vascular reconstructive surgery.
Extensive testing is required for men prior to undergoing this surgery, including vascular radiology studies, such as angiogram and duplex ultrasonography of the penis and its blood vessels.
During the surgery, the blocked arteries are bypassed by transferring an artery from an abdominal muscle to a penile artery or to a penile vein that is then modified to act like an artery. This way, a path to the penis is created that bypasses the area of the blockage that is inhibiting blood flow to the penis; therefore, blood makes it to the penis, and an erection can occur and/or last.
In addition to very few men being candidates for the surgery, there are very few health centers across the United States with the experience and expertise necessary for performing vascular reconstructive surgeries. Complications may include over-engorgement of the glands of the penis or clotting off of the blood vessel bypass.
PENILE VEIN LIGATION
Another vascular surgery for the penis is penile vein ligation performed to block the leakage of blood out of an erection. Some men have erectile dysfunction, because the veins allow the blood to drain out of the penis too easily, and they cannot generate or hold an erection. The surgery is considered investigatory, because the best technique has not definitively been established. The immediate success of this surgery is unpredictable, and the long term failure rate is high. Complications may include over-engorgement of the glands of the penis, eventual scarring, and shortening or numbness of the penis.
Erectile Dysfunction – What is Erectile Dysfunction? Best Doctors
Treatment of Erectile Dysfunction – The Men’s Clinic at UCLA
What is Erectile Dysfunction?
Erectile dysfunction is defined as the inability to achieve or maintain an erection. Chronic erectile dysfunction affects approximately 5 percent of men in their 40s and 15 to 25 percent of men over the age of 65. Transient erectile dysfunction can affect up to 50 percent of men between the ages of 40 and 70.
Under normal physiological conditions, neurotransmitters in the brain initiate an erection by sending messages to the vascular (blood) system to increase blood flow to the penis. The corpora cavernosa (tubes of connective tissue) and erectile tissue in the penis expand as a result of the increased blood flow and pressure. Following ejaculation, pressure in the penis decreases to reduce blood flow and allow the penis to resume its normal shape.
Erectile dysfunction may be caused by the following conditions:
- Nerve damage
- Reduced blood flow to the penis
- Vascular disease
- Venous leak (vein leakage)
- Diabetes and other hormonal disorders
- Neurologic conditions
- Pelvic trauma
- Damage from surgery or radiation therapy
- Peyronie’s disease (scarring of erectile tissue)
- Psychological conditions
- Certain prescription drugs
Patients suffering from erectile dysfunction often experience negative psychological side effects. They may have low self esteem or feel inadequate as a sexual partner. Partners of patients suffering from erectile dysfunction may also feel the emotional strain of the diagnosis.
Erectile Dysfunction: Causes and Treatment
Specific laboratory tests may be performed to determine the cause of erectile dysfunction including:
- Blood Tests – These tests may involve checking hormone levels, cholesterol, blood sugar, liver and kidney function and thyroid function.
- Urinalysis – This procedure is used to analyze protein, sugar and hormone levels that can indicate diabetes, kidney problems and testosterone deficiency.
- Nocturnal penile tumescence (NPT) – This procedure is used to measure changes in penile rigidity and circumference during nighttime erection, as men typically have erections five to six times a night.
Treatment of erectile dysfunction begins with non-surgical procedures. If a patient suffers from erectile dysfunction because of a psychological problem, they often have success through visits with sex therapists. Medication for erectile dysfunction caused by physiological conditions can include oral enzyme inhibitors such as Viagra, Levitra and Cialis, self-injected medication, urethral suppositories or vacuum erection devices.
Surgical treatment for erectile dysfunction may include penile implants or vascular reconstructive surgery.
Vascular reconstructive surgery can be performed to improve blood flow to the penis. Penile implantation is a surgical procedure where malleable or inflatable rods are inserted into the penis. There are three forms of penile prostheses: semi-rigid prostheses, inflatable prostheses and self-contained prostheses.
- Semi-rigid prostheses involve the surgical implantation of a silicon-covered flexible metal rod that provides rigidity for intercourse.
- Inflatable penile prostheses involve the surgical implantation of two soft silicone or plastic tubes into the penis, a small reservoir in the abdomen and a small pump in the scrotum. A patient produces an erection with this prosthesis by squeezing the pump in the scrotum to move sterile liquid from the reservoir in the abdomen into the tubes. A valve moves fluid back to the reservoir to stop the erection.
- Self-contained inflatable prostheses consist of a pair of inflatable tubes inserted into the penis with a pump attached to the end of the implant and a reservoir located in the shaft of the penis.
Scheduling an Appointment
Board-certified urologists staff The Men’s Clinic at UCLA and you can be assured you are getting an experienced physician performing your evaluation and procedure in a relaxed and comfortable environment. For more information and to schedule an appointment, please call the UCLA Urology Appointment line at (310) 794-7700.
Treatments for Venous Leaks | Affirm Clinic
Do you find it difficult to get and maintain an erection when having intercourse? If so, you may have erectile dysfunction—a problem that affects one in five men. One of the possible reasons for this issue is venous leaks.
What Is a Venous Leak?
Your penis needs an increase in blood flow and a decrease in outflow during intercourse to keep an erection. If you have a venous leak, the blood does not stay in your penis, thus causing you to lose your erection. This problem is common in men with high blood pressure, high cholesterol, diabetes, or peripheral vascular disease. Excessive stress and obesity also cause venous leaks. Often, men who have venous leaks may be able to get an erection but lose it quickly.
Treatments for Venous Leaks
If the primary reason for your venous leak is stress, your doctor may recommend you to undergo counseling and practice mindfulness and relaxation exercises. Your counselor will help you deal with your stress, anxiety, fear, or grief. Likewise, they may also recommend you to visit a sex therapist. Successful therapy will help you and your partner understand your problems and learn how to manage them.
Oral medications can inhibit phosphodiesterase-5 (PDE5), an enzyme that destroys the cyclic guanosine monophosphate (cGMP), which causes erections. Some effective examples of these medications are Viagra and Cialis. However, some studies have shown that people with severe venous leakage may not benefit from this treatment. Talk to a urologist about whether oral medications may be useful for you.
An innovative method to treat venous leaks is shockwave therapy. Commonly used to treat kidney stones and clogged arteries, this nonsurgical treatment works by delivering focused shockwaves. It is found to improve blood flow in the area due to a process called neovascularization, which is the formation of new blood vessels. As a result, the restriction in the blood vessels and arteries are also reduced.
Shockwave therapy also stimulates growth factors, thus enhancing tissue growth and repair. It also plays a role in nerve regeneration. Because it is a noninvasive procedure, it does not require the use of topical anesthesia, and it is quick to perform, taking only about 30 minutes per session.
If medication and noninvasive procedures do not work, your doctor may recommend you to undergo surgery. Here are some surgical treatments for venous leaks:
- Penile Vascular Reconstructive Surgery. If your venous leakage is congenital or the result of trauma, this is the recommended treatment for you. This procedure will improve the trapping of blood, helping you maintain an erection.
- Penile Implant. This surgery may also be recommended by your doctor to help you get and maintain an erection. A penile device will be implanted inside the penis to control rigidity during intercourse.
Venous Leak Treatment In Washington
If you are having trouble getting or keeping an erection, consult with a doctor. The experts at Affirm Clinic in Edmonds, Washington, can help. Our team is committed to delivering quality care to help restore your potency. Our clinic offers penile ultrasound to diagnose your issue and focused shockwave therapy for erectile dysfunction.
We also value our client’s privacy and offer private consultations with our providers. Make an appointment today by calling us at (206) 231-6000. You may also request an appointment online.
Penile Implant Cost & Insurance Coverage
In an ever-changing healthcare environment, many patients are frustrated by the financial aspects of medical care and surgical treatment. This frustration is particularly pronounced when it comes to the treatment of erectile dysfunction, which is often not covered by insurance carriers. Some men are shocked by the cost of ED treatment options and many patients do not know what the average cost for a penile implant is. For men whose doctors recommend penile prosthetic surgery as the best treatment option for erectile dysfunction, concerns over “how to pay” for the surgery can be distressing. Fortunately, unlike pills and injections, the placement of a penile implant is covered by Medicare. Bottom line, penis surgery cost is a common concern and question. And the answer is that there are solutions to covering the cost of penile implant surgery.
Because Medicare sets the standards for healthcare coverage in the U.S., some private insurers follow suit and provide insurance coverage for penile implants.
Insurance coverage for erectile dysfunction treatments
ED pills and injections are not covered by Medicare. Does Medicare pay for penile implants? Yes. For individuals who have Medicare benefits, the cost of oral or injectable medications will usually run between $400 to $500 per month. The costs of other treatment options for ED depend upon frequency of use and the dose needed. While these treatments need to be re-dosed with each episode of sexual activity, the penile implant is a one-time treatment with no associated fees for Medicare recipients. Because Medicare sets the standards for healthcare coverage in the U.S., some private insurers follow suit and provide insurance coverage for penile implants. However, many insurers do not provide coverage for penile implants, or they assess co-pay fees that are cost-prohibitive, leaving their subscribers with uncertainty about how to pay for the most effective treatment for erectile dysfunction.
Paying for penile implant surgery
For men without insurance coverage for penile prosthesis procedures or are not of the age where their ED pumps are covered by Medicare, several options should be considered:
- Some penile prosthetic surgeons offer “package pricing.” This is a low-cost option for penile implant surgery that bills the cost of surgery, facility fees and any penile implant directly to the patient. The “package price” is heavily discounted. Penile implant cost with package pricing typically runs between $16,000 and $19,000 and includes all associated fees. Penile implant cost will vary slightly, but package priced treatment is particularly attractive for men who are not eligible for Medicare or who are unable to change their current insurance for any reason.
Inquire if the penile implant manufacturer offers a co-pay assistance program or other financial assistance.
- Some penile implant manufacturers offer help to navigate insurance coverage with providers. Inquire if the manufacturer of your device offers a co-pay assistance program or other financial assistance program in the form of a loan for those who qualify. Such programs may be beneficial to individuals for whom the out-of-pocket expense of penile implant surgery has made moving forward impossible. Penile implant costs are not insignificant, but financial assistance programs may be a viable option for men considering this surgery for erectile function restoration.
- Consider switching to Medicare once eligible or investigating other plans that may offer more inclusive erectile restoration benefits. When looking at plan options, you can research whether the insurance covers penile implants or not.
This physician is a Boston Scientific consultant but was not compensated for the creation of this article.
Penile Revascularization | Penile Revascularization Surgery for ED
Penile arterial revascularization surgery for erectile dysfunction is an operation to improve arterial blood flow to the penis. An artery located in the lower abdomen called the inferior epigastric artery is mobilized and then connected (the connection is called an anastomosis) to an artery at the base of the top of the penis (proximal dorsal penis) called the dorsal artery. This surgery is also called penile microvascular arterial bypass surgery.
Penile revascularization is a concept that appeals to many men with erectile dysfunction (ED) and we are often contacted by men with ED wanting to know the cost of the surgery and when it could be scheduled. It makes sense that many men who have not been appropriately counselled would feel that penile revascularization surgery could cure their erectile dysfunction. Since the penis is not filling with enough blood to cause a firm erection, it would seem that if more blood could enter the penis by an increase in artery inflow, this would be an erectile dysfunction cure.
However, penile arterial revascularization surgery will generally not cure or effectively treat ED, and this surgery is not indicated for the vast majority of men with erectile dysfunction. Men with erectile dysfunction related to diabetes, hypertension, and atherosclerosis and other conditions generally have diffuse vascular disease and would not benefit from this surgery. In many cases, vascular ED is related to venous leak (a vein problem) and this is not effectively treated with penile revascularization surgery. Moreover, ED related to nerve injury (eg. after prostate removal for prostate cancer) will not be effectively treated with a penile microvascular arterial bypass surgery.
Penile revascularization is most appropriate for certain men who sustain pelvic fracture trauma and suffer associated vascular injuries that reduce blood flow to his otherwise normal penis. This surgery is performed at our Center by Dr. Gelman and Dr. Mark Kobayashi, a microvascular surgeon at UC, Irvine Medical Center.
In penile microvascular arterial bypass surgery, the epigastric artery is connected to the dorsal artery of the penis, increasing blood flow to the penis.
When penile revascularization surgery is performed, an incision is made above the penis, and the dorsal arteries that course along the top of the penis under the skin are exposed and isolated. A second incision is made along the abdomen and an artery called the inferior epigastric artery is isolated. This is an artery that gives blood supply to the abs (rectus abdominus muscle). Fortunately, the abs can function normally without this artery as other blood vessels also supply this muscle. These 2 arteries are then connected under an operating microscope. Penile revascularization is accomplished because blood from the epigastric artery (with good blood flow) brings increased blood flow to the dorsal artery of the penis (that has poor blood flow).
When men break their pelvis (pelvic fracture) from motor vehicle accidents or crush injuries, these injuries can be associated with arterial injuries (but also nerve injuries) that cause ED. A certain percentage of these men also have damage to their urethra where it is severed just under the prostate, and this is called a pelvic fracture urethral injury, or PFUI. The treatment of PFUI is called a posterior urethroplasty, an operation to remove the scar tissue between the severed ends of the urethra, and the reattachment of the 2 ends of the urethra back together. We evaluate patients with pelvic fracture urethral injuries and ED with testing, and if there is severe artery damage, this may be associated with poor blood flow to the urethra. In certain cases, penile revascularization is indicated prior to posterior urethroplasty to insure there is good blood flow for healing. As a bonus, this may help treat the associated erectile dysfunction. However, even in cases of PFUI, penile revascularization is rarely indicated.
Book Appointment | Urology of Virginia
Erectile dysfunction (ED) refers to the inability to achieve and/or sustain an erection that is hard enough to have sex. It’s not a normal part of aging, but it is extremely common because it is often a side effect of common medical problems that occur with aging. Fortunately, there are safe and effective treatments that we can offer to you.
Causes & Symptoms
You need emotional input, normal nerves and blood flow to the penis, and testosterone to achieve an erection. One or more of these functions are disturbed with aging. The most common reason for ED is impaired blood flow. You have doubtless heard of the use of coronary stents or coronary bypass for clogged arteries to the heart. The penile arteries are even smaller than the coronary arteries, so it comes as no surprise that ED is related to atherosclerosis (hardening of the arteries), high blood pressure, and high cholesterol.
Some other causes include:
- Diabetes is a very common cause of ED because it will affect both the nerves and the blood flow to the penis.
- Neurological problems such as stroke, Parkinson’s disease, multiple sclerosis and spinal cord trauma may cause ED.
- If the blood trapped in the penis during an erection leaks out too quickly, this is called “Venous leak” or cavernosal dysfunction.
- Genital or pelvic trauma, including the trauma of surgery (radical prostatectomy or extensive rectal surgery for cancer) can affect blood flow and nerves to the penis and lead to ED.
- Low testosterone can contribute to ED.
- Peyronie’s disease – calcific plaque in the penis that prevents symmetrical filling of the penis with blood during arousal. This condition can cause either penile curvature with erection, an hourglass deformity of the penis during erection or very weak erections.
- Other sources of ED include anxiety, abuse of alcohol or narcotics, smoking, and certain medications (for high blood pressure, depression, antihistamines, ulcer medications).
A good history and physical examination is essential for diagnosing ED, with particular attention to blood pressure, signs of blood flow problems to other areas of the body, signs of low testosterone (small testicles, breast enlargement) or presence of hard plaques in the penis.
If not already done by your primary care doctor, we may order blood tests, including a lipid panel, a fasting blood sugar or Hemoglobin A1c (tests for Diabetes), a testosterone level.
Additional tests may be selectively ordered depending upon your circumstance. Occasionally, we do vascular studies of the penile arteries or veins; but in most cases, poor arterial inflow or venous leak problems cannot be corrected with vascular surgery.
If it appears that anxiety, stress, depression, emotional problem, or marital problems are related, we may ask for the help of a sexual counselor, psychologist or psychiatrist.
ED can be an early sign of generalized blood flow problems, so we may ask your primary care doctor or cardiologist to consider cardiac stress testing.
We would suggest starting with some behavioral changes – things like stopping smoking or drinking a lot of alcohol, losing weight, exercising, and eating a healthier. You may need to confer with your primary care doctor or other specialist if we feel that medications may need to be stopped or changed because they cause ED. You may also need to see a sexual counselor if there are marital problems or emotional issues that affect sexual function.
Medication – Oral Viagra (generic is Sildenafil), Cialis (generic is Tadalafil), and Levitra (generic is Vardenafil) are popular examples of drugs called phosphodiesterase inhibitors. These drugs increase blood flow to the penis during sexual stimulation. If the ED is not severe, these drugs often work well. Occasional side effects include headache, facial flushing, nasal congestion, but rarely cause visual disturbance. You urologist can review the differences between these drugs. You should not use these drugs if you have a history of angina (chest pain with exercise) and/or use nitrates (drugs related to nitroglycerin).
Testosterone replacement is an option for men with low levels. Testosterone will improve libido (sex drive) but it may not fully correct ED if there is poor blood flow. Often we need to use additional medication like the ones listed above.
Vacuum erection device – This is a kit that you can purchase that includes a plastic tube placed over the penis. A hand held pump is applied that creates a vacuum in the tube. This will cause blood to enter the penis. An elastic band is placed at the base of the penis to maintain the erection, then the tube is removed to permit sexual activity. Some men don’t like the “interruption” needed to apply the tube and get ready. Some men find the devices too hard to operate, but they are very safe and reuseable.
Intraurethral suppositories – We teach you how to place a small applicator into the opening of the penis that delivers a tiny pellet of drug (Prostaglandin). The drug causes increased blood flow to the penis. You get an erection within 10-20 minutes. Some men are unwilling to use it complain of urethral burning or penile aching. The urethral suppositories can be expensive.
Intracorporeal injections – We can teach you how to inject a medication into the side of the penis (Prostaglandin, sometimes mixed with Papaverine and Phentolamine). The drug will cause increased blood flow to the penis within 10 minutes. The dose of drug is adjusted so that the erection will not last too long. The needle is very small, so the injection is not very painful. Rarely the injection can cause a prolonged erection that becomes painful, and may require an urgent visit to your urologist or the emergency room.
Penile Prosthetic Surgery – We usually reserve penile implants for cases that don’t respond to other measures or men who do not wish to pursue those other measures. The penile implant is a great choice, but you cannot return to the use of a vacuum pump or penile injections once you have had this surgery.
The penis has two side by side corporal bodies into which we can implant a malleable penile prosthesis or an inflatable penile prosthesis. In the case of a malleable implant, there are two plastic cylinders with a steel core down the middle of each cylinder. Once implanted, the penis has fixed length and girth, but it can be concealed by bending both cylinders down. When you want to have sex, you simply bend both cylinders up. The inflatable implant uses cylinders that fill with water when activated by a pump placed in the scrotum. After you have sex, the cylinders can be emptied into a reservoir placed under the belly muscle. The inflatable implant is sometimes called a “three piece implant” because there are cylinders, a pump, and a reservoir.
The inflatable implant looks more natural than a malleable device. The inflatable cylinders are flaccid when it is not being used. The inflatable cylinders get a little larger than the malleable device when it is activated. The inflatable device has more working components, so there is more possibility for mechanical malfunction and re-operative surgery. Another risk of any type of prosthetic surgery is infection. This may require removal and replacement of the device.
Penile prosthetic devices provide total spontaneity when you desire sexual activity. Unlike any other treatment listed, there is no waiting to get ready!
Injection of a penile plaque /Removal of the plaque with grafting/Plication of the penis – these are procedures offered specifically for Peyronie’s disease with bothersome penile curvature. Severe cases of Peyronie’s disease may require placement of an inflatable penile prosthesis.
Glossary of Terms
A phosphodiesterase inhibitor that improves blood flow to the penis during stimulation. It can be taken with or without food. It can be taken on demand (only when you plan to have sex) or it can be taken on a daily basis at a lower dosage. Daily dosing of Cialis may also help urinary symptoms caused by an enlarged prostate.
Inability to achieve and/or sustain an erection sufficient for sex.
A needle is placed into the side of penis to inject a drug that causes increased blood flow and induces an erection.
An applicator is placed into the urethra, then a pellet of Prostaglandin is released and dissolves in the urethra to produce and erection.
A phosphodiesterase inhibitor, a drug that increases blood flow to the penis when stimulated. It must be taken on an empty stomach for better absorption. It may cause headache or facial flushing. It is an “on demand” drug – you take it only when you want to have sex.
Not so much a disease as it is a condition in which a calcific plaque builds up in the penile corporal bodies. The plaque prevents full expansion of the penis when achieving an erection. There may be curvature to the erection or very weak erections from restricted blood flow.
Penile prosthesis or implant
A device that allows for a hard erection – two cylinders are placed into the two penile corporal bodies. Implants may be malleable (they simply bend down or up) or inflatable (cylinders fill with water when activated, but they can be emptied when not in use).
Blood can enter the penis, but the blood is not trapped in the penis long enough to sustain an erection because the penile veins are leaky.
A phosphodiesterase inhibitor, a drug that increases blood flow to the penis when stimulated. It must be taken on an empty stomach for better absorption. It may cause headache or facial flushing. It is an “on demand” drug – you take it only when you want to have sex.
Frequently Asked Questions
I ejaculate within minutes of having intercourse. I have no interest in having sex. I cannot reach orgasm. Is this ED?
No! These problems are not ED and they are not treated in the same way. You could be experiencing one of the following:
- Premature ejaculation – reaching a climax sooner than desired – this leads to detumescence (erection goes away), but it is not erectile dysfunction. The treatment could involve sexual therapy, possibly the use of drugs that will slow down the time when you ejaculate.
- Loss of libido or sex drive – sometimes seen with erectile dysfunction, but not the same. We would check your testosterone and perhaps other hormone levels. We would also explore whether there are psychosocial issues that might be related.
- Anorgasmia – inability to reach orgasm – can be caused by medical problems, pelvic surgery, genital trauma, psychological issues – but it is not ED.
If I keep my diabetes in the best control possible, will my ED go away?
Probably not, since the ED is probably related to neurovascular disease already caused by the diabetes. Nevertheless, it’s important to manage your diabetes carefully to prevent other serious vascular events like a stroke or heart attack.
I get a headache when I use Viagra or Levitra or Cialis. What can I do about it?
If the headache is mild, ignore it. If it is annoying, take Tylenol when you take the drug for ED to pre-treat for possible headache.
I get a good erection if I inject my penis with Papaverine (common trade names, EDEX or Caverject). So can I give myself a big dose to last even longer?
Your urologist will help you find the dose that gives you an erection that lasts 30-60 minutes. Injecting even more drug may cause a prolonged erection that will become painful. If the erection does not come down, you will have to see your urologist or an emergency room doctor to have another penile injection of saline or phenylephrine, a drug that reverses the one that caused the erection. Prolonged erections lead to scarring within the penis. Future efforts to inject the penis may be less effective.
Is sensation and ejaculation the same when I have a penile implant placed?
Yes – the surgery does not affect nerves that go to the penis, so penile sensation and ejaculation are unchanged. Men who have had prostate surgery have either limited or no ejaculation, but this is not improved or made worse by placing a penile implant.
I had a penile implant and my erection is not as large as I am used to! Is this expected?
Your urologist should tell you that a penile implant provides rigidity to the shaft of the penis, but the head of the penis remain soft even when you are using the penile prosthesis to have sex. The erection won’t be as large as you had at age 18, but the erection is quite serviceable!
If I don’t like my penile prosthesis, can I go back to the other therapies?
Not easily. Applying a vacuum pump or doing penile injections may damage the cylinders or cause an infection. If the cylinders are removed, there may be scarring that prevents the other therapies from improving any blood flow to the penis. It’s best to try any of the other therapies before choosing to have surgery to place a penile prosthesis.
Department of Vascular Surgery
- Clinic of Surgery
- Department of Vascular Surgery
Head of Department
Cardiovascular Surgeon of the Highest Qualification Category,
Chief External Transplant Specialist …
Head of department: 8 (351) 749-37-15
Resident office: 8 (351) 749-38-61
Doctor on duty: 8 (351) 232-80-16
The department of vascular surgery provides specialized, incl.h. high-tech, medical care for patients with vascular diseases on the basis of the Chelyabinsk Regional Clinical Hospital since 1972
Consultation at the clinic is carried out by 2 angiosurgeons. Advisory and methodological assistance is provided by the head of the regional Center for Heart and Vascular Surgery, Professor, Doctor of Medical Sciences, Honored Doctor of the Russian Federation – A.A. Fokine.
The department has 55 beds, has 7 – 5, 2 – 4, 3 – 3, 2 – 2 and 3 single wards with improved conditions, one of them – increased comfort of stay.2 recovery rooms are equipped with oxygen supply and functional beds. In them, patients are observed for 1-2 days after transfer from the intensive care unit.
The department employs one doctor of medical sciences, one candidate of medical sciences.
Among 8 angiosurgeons who treat and operate on patients, 6 have the highest qualification category. All of them were trained in leading Russian and foreign clinics. Given the particular complexity of patients, the department staff includes a cardiologist and a neurologist with experience in treating vascular patients, which significantly improves the quality of diagnosis and treatment.
Treatment in the department using modern methods will help prevent severe complications of vascular diseases such as cerebral stroke, gangrene of the lower extremities, ruptured aneurysm of the abdominal aorta, pulmonary embolism and many others.
The following diseases are diagnosed and treated:
- atherosclerosis of the aorta and lower extremities
- aneurysm of the abdominal aorta
- atherosclerosis of the branches of the aortic arch
- Raynaud’s syndrome
- varicose veins of the lower extremities
- varicose veins of the lower extremities
- thromboembolism of the pulmonary arteries
- ltmphostasis of the extremities
- end-stage chronic renal failure
thrombosis of various localizations
Methods for the diagnosis of vascular diseases
- duplex and triplex scanning of the main vessels with the use of computerized contrast instruments 9000 amplification
- magnetic resonance nuclear tomography with contrast enhancement
- direct angio and aortography 9000 4
- radioisotope scintigraphy
Methods of treatment of vascular diseases
- prosthetics (shunting) of the aorta and main arteries of the extremities
- prosthetics of the abdominal aorta in case of aneurysm
- endoprosthetics aneurysm stenosis 9000 aorta and great arteries
- reconstructive operations on the branches of the aortic arch
- hybrid operations for atherosclerosis of the arteries of the extremities
- balloon angioplasty and stenting of the carotid arteries
- operations for congenital anomalies of the vascular system
- thrombolysis in venous and arterial thrombosis
- formation of vascular access for hemodialysis
- kidney transplantation
from the main arteries and veins
Purulent-necrotic lesions of the neuroischemic form of diabetic foot syndrome.New Opportunities for Complex Surgical Treatment |
1. International Working Group on the Diabetic Foot. International Agreement on the Diabetic Foot. Moscow: “Coast”, 2000.
2. Ragnerson-Tennvall G., Apelqvist J. Cost effective management of diabetic foot ulcers. Pharmacoeconomics, 1997 Jul .; 12 (1): p. 42-53.
3. Dedov I.I., Suntsov Yu.I., Kudryakova S.V. Economic problems of diabetes mellitus in Russia. Diabetes mellitus, 2000; (3): 56-58.
4. Melissa F. Green, Zarrintaj Aliabadi, Bryan T. Green Diabetic foot: Evaluation and management. South Med. J., 2002; 95 (1): p. 95-101.
5.Boulton A. J. M. (Ed.) The foot in diabetes. Mosby, 1991.
6. Edmonds M., Foster A., Fraser S. Are the foot arteries spared in the diabetic ischaemic limb? Materials of the 2nd EASD Diabetic Foot Study Group Meeting (Crieff, Great Britain, Sept. 2001): p. A20.
7. Pokrovsky A.V., Dan V.N., Chupin A.V. Ischemic diabetic foot.In the book. Diabetic foot syndrome / Ed. I.I. Dedova, M.B. Antsiferova, G.R. Galstyan, A. Yu. Tokmakova / Moscow, 1998.
8. American Diabetes Association. Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts. Diabetes Care 1999; Vol. 22: p. 1354-1360.
9. Semitko S.P., Yaroshchuk A.S., Tsigelnikov S.A., Arabadzhyan I.S., Kostyanov I.Yu., Ioseliani D.G. Combination of endovascular and surgical correction of multifocal atherosclerosis manifestations in an elderly patient. Angiology and Vascular Surgery, 2004; T.10 No. 3: p. 125-128.
10. Graziani L. Pacilli P. Extensive use of angioplasty revascularization techniques in the treatment of ischemic diabetic foot ulcers: a multicentric study. Materials of the 2nd EASD Diabetic Foot Study Group Meeting (Crieff, Great Britain, Sept.2001): p. A30.
11. Bommayya I., Edmonds M. The importance of infra-inguinal angioplasty in savage of diabetic foot. Materials of the 3 th EASD Diabetic Foot Study Group Meeting (Hungary, 2002): p. A25.
12. Faglia E., Graziani L. Extensive infrapopliteal angioplasty in diabetic subjects with foot ulcer. Materials of the 1st EASD Diabetic Foot Study Group Meeting (Fuigi, Italy, Sept.2000): p. A10.
13. Olshansky M.S., Esipenko V.V., Ivanov A.A., Moshurov I.P., Kazansky D.V. Endovascular correction of multi-storey arterial lesions in critical ischemia of the lower limb in an elderly patient. Angiology and Vascular Surgery, 2007; T.13 No. 2: p. 42-44.
90,000 Long-term results of reconstructive operations without endarterectomy in diffuse coronary atherosclerosis | Belash
1.Soylu E, Harling L, Ashrafian H, Casula R, Kokotsakis J, Athanasiou T. Adjunct coronary endarterectomy increases myocardial infarction and early mortality after coronary artery bypass grafting: a meta-analysis. Interact Cardiovasc Thorac Surg. 2014; 19: 462–73. PMID: 24893867.https: //doi.org/10.1093/icvts/ivu157
2. Ghatanatti R, Teli A. Coronary endarterectomy: recent trends. J Clin Diagn Res. 2017; 11: PE01–4. PMID: 28969206.PMCID: PMC5620847. https://doi.org/10.7860/JCDR/2017/27036.10339
3. Wang Ch, Chen J, Gu Ch, Li J. Analysis of survival after coronary endarterectomy combined with coronary artery bypass grafting compared with isolated coronary artery bypass grafting: a meta-analysis. Interact Cardiovasc Thorac Surg. 2019; 29: 393-401. PMID: 31180487.https: //doi.org/10.1093/icvts/ivz125
4.Aoki J, Ong AT, Rodriguez Granillo GA, et al. “Full metal jacket” (stented length ≥64 mm) using drug-eluting stents for de novo coronary artery lesions. Am Heart J. 2005; 150: 994-9. PMID: 16290984.https: //doi.org/10.1016/j.ahj.2005.01.050
5. Tsagalou E, Chieffo A, Iakovou I, et al. Multiple overlapping drug-eluting stents to treat diffuse disease of the left anterior descending coronary artery. J Am Coll Cardiol.2005; 45: 1570–3. PMID: 15893168.https: //doi.org/10.1016/j.jacc.2005.01.049
6. Fukui T, Tabata M, Taguri M, Manabe S, Morita S, Takanashi Sh. Extensive reconstruction of the left anterior descending coronary artery with an internal thoracic artery graft. Ann Thorac Surg. 2011; 91: 445-51. PMID: 21256288.https: //doi.org/10.1016/j.athoracsur.2010.10.002
7.Rocha AS, Dassa NP, Pittella FJ, et al. High mortality associated with precluded coronary artery bypass surgery caused by severe distal coronary artery disease. Circulation. 2005; 112: I328–31. PMID: 16159841.https: //doi.org/10.1161/CIRCULATIONAHA.104.525717
8. Lozano I, Capin E, de la Hera E-M, Llosa JC, Carro A, López-Palop R. Diffuse coronary artery disease not amenable to revascularization: long-term prognosis.Rev Esp Cardiol (Engl Ed). 2015; 68: 629-40. PMID: 25936615.https: //doi.org/10.1016/j.rec.2015.02.013
9. Baranauskas A, Peace A, Kibarskis A, et al. FFR result post PCI is suboptimal in long diffuse coronary artery disease. EuroIntervention. 2016; 12: 1473–80. PMID: 27998839.https: //doi.org/10.4244/EIJ-D-15-00514 12
10. Brown RA, Shantsila E, Varma Ch, Lip GY.Epidemiology and pathogenesis of diffuse obstructive coronary artery disease: the role of arterial stiffness, shear stress, monocyte subsets and circulating microparticles. Ann Med. 2016; 48: 444–55. PMID: 27282244.https: //doi.org/10.1080/07853890.2016.1190861
11. Fukui T, Takanashi Sh, Hosoda Ya. Long segmental reconstruction of diffusely diseased left anterior descending coronary artery with left internal thoracic artery with or without endarterectomy.Ann Thorac Surg. 2005; 80: 2098-105. PMID: 16305852.https: //doi.org/10.1016/j.athoracsur.2005.06.047
12. Kato Ya, Shibata T, Takanashi Sh, Fukui T, Ito A, Shimizu Yo. Results of long segmental reconstruction of left anterior descending artery using left internal thoracic artery. Ann Thorac Surg. 2012; 93: 1195-200. PMID: 22381445. https://doi.org/10.1016/j.athoracsur.2011.12.059
13.Belash S.A., Barbukhatti K.O., Porkhanov V.A. Comparative analysis of immediate results of reconstructive procedures on coronary arteries with or without endarterectomy in diffuse coronary atherosclerosis. Breast and cardiovascular surgery. 2019; 61 (1): 45–54. https://doi.org/10.24022/0236-2791-2019-61-1-45-54
14. Zimarino M, Ricci F, Romanello M, Di Nicola M, Corazzini A, De Caterina R. Complete myocardial revascularization confers a larger clinical benefit when performed with state-of-the-art techniques in high-risk patients with multivessel coronary artery disease: a meta-analysis of randomized and observational studies.Catheter Cardiovasc Interv. 2016; 87: 3-12. PMID: 25846673.https: //doi.org/10.1002/ccd.25923
15. Garcia S, Sandoval Ya, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol. 2013; 62: 1421–31. PMID: 23747787.https: // doi.org / 10.1016 / j.jacc.2013.05.033
16. Akchurin R.S., Salichkin D.V., Emelyanov A.V., Galyautdinov D.V., Vasiliev V.P., Shiryaev A.A. Coronary artery bypass grafting for diffuse and distal lesions of the coronary arteries. Cardiological Bulletin. 2015; X (4): 50-5.
17. Akchurin R.S., Shiryaev A.A., Vasiliev V.P., Galyautdinov D.M., Vlasova E.E. Current trends in coronary surgery.Circulatory pathology and cardiac surgery. 2017; 21 (3s): 34–44. https://doi.org/10.21688/1681-3472-2017-3S-34-44
18. Akchurin R.S., Shiryaev A.A., Vasiliev V.P. et al. Early and long-term results of coronary artery bypass grafting in patients with a history of coronary stenting. Cardiology and Cardiovascular Surgery. 2016; 9 (4): 11-16. https://doi.org/10.17116/kardio20169411-16
19.Alekyan B.G., Zakaryan N.V., Staferov A.V., Sargsyan A.Z., Kadyrov B.A. Immediate results of endovascular treatment of patients who were refused surgical myocardial revascularization due to coronary artery bypass graft. Breast and cardiovascular surgery. 2013; 3: 14–8.
20. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC / AHA / AATS / PCNA / SCAI / STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2014; 130: 1749–67. PMID: 25070666.https: //doi.org/10.1161/CIR.0000000000000095
21. Graham MH, Chambers RJ, Davies RF. Angiographic quantification of diffuse coronary artery disease: reliability and prognostic value for bypass operations. J Thorac Cardiovasc Surg. 1999; 118: 618-27. PMID: 10504625. https://doi.org/10.1016/s0022-5223(99)70006-1
22.Kleisli T, Cheng W, Jacobs MJ, et al. In the current era, complete revascularization improves survival after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2005; 129: 1283–91. PMID: 15942568.https: //doi.org/10.1016/j.jtcvs.2004.12.034
23. Stavrou A, Gkiousias V, Kyprianou K, Dimitrakaki IA, Challoumas D, Dimitrakakis G. Coronary endarterectomy: the current state of knowledge. Atherosclerosis. 2016; 249: 88–98.PMID: 27085158. https://doi.org/10.1016/j.atherosclerosis.2016.03.036
24. Bezon E. Coronary artery reconstruction: optimal technique of coronary endarterectomy. Ann Thorac Surg. 2006; 82: 2341-2. https://doi.org/10.1016/j.athoracsur.2006.04.006
25. Takahashi M, Gohil S, Tong B, Lento P, Filsoufi F, Reddy RC. Early and mid-term results of off-pump endarterectomy of the left anterior descending artery.Interact Cardiovasc Thorac Surg. 2013; 16: 301-5. PMID: 23190620. PMCID: PMC3568806. https://doi.org/10.1093/icvts/ivs482
26. Wang J, Gu Ch, Yu W, Gao M, Yu Ya. Short- and long-term patient outcomes from combined coronary endarterectomy and coronary artery bypass grafting: a meta-analysis of 63,730 patients (PRISMA). Medicine (Baltimore). 2015; 94: e1781. PMID: 26469920. PMCID: PMC4616783. https://doi.org/10.1097/MD.0000000000001781
27. Bitan O, Pirundini PA, Leshem E, et al. Coronary endarterectomy or patch angioplasty for diffuse left anterior descending artery disease. Thorac Cardiovasc Surg. 2018; 66: 491-7. PMID: 28315286.https: //doi.org/10.1055/s-0037-1600918
28. Costa M, Betero AL, Okamoto J, Schafranski M, Reis E, Gomes RZ. Coronary endarterectomy: a case control study and evaluation of early patency rate of endarterectomized arteries.Braz J Cardiovasc Surg. 2020; 35: 9-15. PMID: 32270954. PMCID: PMC7089746. https://doi.org/10.21470/1678-9741-2018-0402
29. Li D, Guo P, Chen L, Wu Y, Wang G, Xiao C. Outcomes of surgical patch angioplasty of the coronary artery for diffuse coronary artery disease. Braz J Cardiovasc Surg. 2020. Epub April 22. [published online ahead of print]. https://doi.org/10.21470/1678-9741-2019-0390
30.Ogus TN, Basaran M, Selimoglu O, et al. Long-term results of the left anterior descending coronary artery reconstruction with left internal thoracic artery. Ann Thorac Surg. 2007; 83: 496-501. PMID: 17257976.https: //doi.org/10.1016/j.athoracsur.2006.09.073
31. Caparrelli DJ, Ghazoul M, Diethrich EB. Indications for coronary artery bypass grafting in 2009: what is left to surgery. J Cardiovasc Surg. (Torino). 2009; 50: 19-28.PMID: 19179987.
32. Taşdemir O, Kiziltepe U, Karagöz HY, Yamak B, Korkmaz S, Bayazit K. Long-term results of reconstructions of the left anterior descending coronary artery in diffuse atherosclerotic lesions. J Thorac Cardiovasc Surg. 1996; 112: 745–54. PMID: 8800164. https://doi.org/10.1016/s0022-5223(96)70061-2
33. Shehada Sh-E, Mourad F, Balaj I, et al.Long-term outcomes of coronary endarterectomy in patients with complete imaging follow-up. Semin Thorac Cardiovasc Surg. 2019; Apr 22; S1043-0679 (19) 30095-4. [published online ahead of print]. PMID: 31022447.https: //doi.org/10.1053/j.semtcvs.2019.04.008
EVOLUTION OF TECHNOLOGY FOR CLOSING EXTENSIVE AND DEEP SOFT TISSUE DEFECTS OF THE HUMAN BODY
The work is devoted to the study of the evolution of the technology of closing extensive and deep soft tissue defects of the human body on the basis of the vascular anatomy of the plastic material used.Local plastic surgeries (Burow, V-Y-plasty, rotational and displaced flaps, rhomboid according to Limberg) were initially based on the integrity of the subpapillary or subpapillary + deep dermal vascular plexus. These operations have serious limitations of their application if the correct choice of the ratio of the length and width of the plastic material (1: 1) is not observed. Increasing the area of plastic material by spreading the skin-fatty tubular “jumping” Filatov-Gillies flap, formed on the basis of compensatory increased blood flow along the subpapillary and deep dermal vascular plexuses, is an extremely long and unreliable method.This is caused by random blood flow in the wall of the tubular flap. The method of forming a tubular “jumping” skin-fat flap around the axis of the saphenous artery and its accompanying vein, namely, the formation of a reliable (well-supplied) plastic material of a larger area, could give great opportunities. However, due to limited mobility, a tubular flap with an axial type of blood supply has not found wide application in practice. The extremely mobile axial non-free Pontaine saphenous-cutaneous-fascial flap has expanded the possibilities of plastic surgery for large wounds, mainly on the extremities.The greatest opportunities for closing soft tissue defects of the human body are today perforating flaps and their modification – propeller and “boomerang” based on direct and indirect skin perforators.
EVOLUTION OF TECHNOLOGIES FOR CLOSURE OF VAST AND DEEP SOFT-TISSUE DEFECTS OF HUMAN BODY.pdf INTRODUCTION Trauma has always haunted and will continue to haunt humanity. Trauma is usually understood as a one-stage sudden mechanical effect of an external factor on the body, which causes anatomical and functional disorders in tissues and organs with local and general changes .In the practice of specialists in the field of reconstructive and plastic microsurgery, there are frequent cases of extensive deep wounds of various origins: mechanical, gunshot, thermal, vascular-necrotic, etc. algorithm for helping patients, for example, with extensive and deep soft tissue defects of the body. Purpose of the study: to analyze numerous technologies for closing large and deep soft tissue defects based on modern data on the blood supply to the integumentary tissues of the human body and the experience of the clinic of the Institute of Microsurgery (Tomsk).ANALYSIS METHODOLOGY Analysis of various types of plastic material used to close a soft tissue defect in the human body was based primarily on anatomical data on the blood supply of integumentary tissues and its reliability. The latter, in turn, were based on classical data on the anatomy of the vascular plexuses in the skin and subcutaneous tissue obtained by G.C. Cormack and B.G.H. Lamberty  (Fig. 1). The used plastic material – flaps – depending on the sources of blood supply and in accordance with classification I.A. McGregor and G. Morgan , was divided into random (random, non-axial blood supply) and axial (axial blood supply) flaps. To assess this or that technology UDC 616-018.6-001-089.844: 615.462 doi 10.17223 / 1814147/64/01 for closing a soft tissue defect, we used the “six C” method proposed by G.C. Cormack and B.G.H. Lamberty [4, 5]: circulation – CI (blood supply – a factor of paramount importance), constituents – CII (selectivity – the choice of tissue composition), construction – CIII (type of flap stem and the possibility of its transposition), conformation – CIV (geometric configuration) , contiguity – CV (diligence – location in relation to the wound), conditioning – CVI (transplant conditions – one-stage or after delay maneuvers).Rice. 1. Vascular plexuses of integumentary tissues (skin, subcutaneous tissue) according to G.C. Cormack, B.G.H. Lamberty  ANALYSIS RESULTS Large wounds in general surgery mean wounds with an area of more than 50 cm2 that do not heal on their own and require surgical plastic interventions to restore the skin. These wounds can be a source of severe intoxication of the body with the products of tissue decay and the vital activity of microbes, and contribute to significant losses of fluid, proteins and electrolytes .Deep wounds of soft tissues of the human body, for example, extremities, are understood as those when, along with the skin, deep tissues are damaged: from one’s own fascia to bones or including them . № 1 (64) March ‘2018 Issues of reconstructive and plastic surgery Plastic surgery Nowadays, not only general surgeons, but also dermatologists know that even extensive skin injuries, but without damage to the basement membrane, i.e. within the epidermis (thermal burns of 1-2 degrees) do not require surgical treatment.The healing of such damaged skin (2nd degree burn with preservation of the exfoliated epidermis as a biological film) is accompanied by epithelialization of the wound without the formation of a skin scar. If the skin lesion extends beyond the basement membrane, healing proceeds with the formation of a scar, and the closure of an extensive skin defect may even require the use of a “split skin autograft” (skingraft). In this case, the success of the surgical intervention will be due to the state of the subpapillary vascular plexus, i.e.That is, the preservation of the papillary layer of the dermis of the recipient zone. Development of a scientifically based technology for the closure of large and deep wounds, i.e. wounds with an area of more than 50 cm2 with damage, including skin, subcutaneous tissue, own fascia and even deeper tissues, for example, muscles, bones on the limbs, took a relatively short period of time. Until the beginning of the XX century. surgeons who practiced the closure of large wounds were not professionals, i.e. plastic surgeons in the modern sense of “doctor – plastic surgeon”, although the term “plastic surgery” was proposed by E.Zeis back in 1838 By trial and error, surgeons came to understand the importance of adhering to the principle of the correct choice of the ratio of the length and width of the transferred plastic material (1: 1 or 1: 1.5) in local plastic operations. It is these ratios that made it possible to displace tissues within the skin-fat layer without a particular danger of necrosis in it. In this case, the blood supply to the displaced tissues was provided by the vessels of the subpapillary or subpapillary and deep dermal vascular plexuses (depending on the thickness of the displaced tissues).According to the G.C. Cormack and B.G.H. Lamberty [4, 5], a transferable plastic material for local plastic surgery, could have a maximum of two (circulation, conditioning) out of six Cs. According to the type of blood supply of the transported plastic material, this material was random. Of course, with the help of local plastic surgery technologies (Burow, V-Y-plastic, rotary and displaced flaps, rhomboid according to Limberg, etc.), it is impossible to close large wounds. Other technologies were needed for obtaining a well-perfused plastic material for closing wounds with an area of more than 50 cm2.A huge stimulus for the development of plastic surgery for soft tissue defects, especially of the face, was the large number of wounded during the First World War. Harold Gillies (England), who received the unofficial title of “father of plastic surgery” among the surgeons of that time, was especially successful in this area of plastic surgery. Harold Gillies (1882-1960) – military surgeon, “the father of plastic surgery” He often spoke about the clinical dilemma that could not be ignored, namely, “tissue transfer is a constant battle between blood supply and beauty.”He cut out his “tubed pedicle” flaps without taking into account the anatomy of blood vessels in the skin and subcutaneous tissue, without having the appropriate knowledge about the role of deeper cutaneous and perforating vessels, which are important in the blood supply to the skin and subcutaneous tissue of the corresponding region. And, nevertheless, it was on the basis of intact subpapillary and deep dermal vascular plexuses in random blood flow that H. Gillies made a real technological breakthrough in obtaining a significant area of plastic material on the side wall of the chest or abdomen for the subsequent closure of extensive soft tissue defects in the facial region. heads.This plastic material was called “tubular flap”, while patients called it “suitcase handle” or “jumping flap”. H. Gillies performed the first operation to close the face defect after a massive burn in October 1917 . The operation diagram is shown in Fig. 2. Then hundreds of similar interventions were performed, which the author described in his famous book “Plastic Surgery Of The Face”  (Fig. 3, 4). Apparently, he was not familiar with the book of the famous Russian surgeon from Kiev Yu.K. Shimanovsky “Operative surgery, part 2: Surface operations Issues of reconstructive and plastic surgery № 1 (64) March’2018 Baitinger V.F., Selyaninov K.V., Kurochkina O.S. and others of the human body ”(1865), who described another type of blood supply to the skin – from the subcutaneous arteries. This knowledge could be useful for H. Gillies in terms of reducing the number of necrotic complications. Rice. 2. Scheme of the first in Europe surgery for the formation of tubular flaps (October 1917). Completed by H.D. Gillies Fig.3. The title page of the first book in the world literature on facial plastic surgery based on the experience of the First World War (Gillies H.D., 1920) Fig. 4. Clinical case of the use of tubular flaps (from the book HD Gillies, 1920) Yuliy Karlovich Shimanovsky (1829-1868) – professor of operative and military surgery at the University of St. Vladimir (Kiev) In fairness, it must be said that the “tubular flap” is based on the skin-fat layer, blood supplied mainly by the vessels of the subpapillary and deep dermal vascular plexuses, was first described by the Soviet ophthalmologist from Odessa V.P. Filatov and was called in the medical environment “Filatov stem”. The first operation of using a round stem to close the defect of the lower eyelid by V.P. Filatov performed on September 9, 1916, and the results were published in 1917 . The Filatov stem in the classic author’s technological version (the formation of a stalk flap, training, transfer of the stem to the boundaries of the defect, spreading the stem at the site of the defect) was widely used by Soviet military surgeons during the Great Patriotic War (1941-1945).Technically, this is a difficult operation, since the formation of the so-called tubed pedicle flap requires a very precise preparation in the subcutaneous tissue in order not to damage the deep dermal and subpapillary vascular plexuses along its entire length. In this case, it is possible № 1 (64) March ‘2018 Issues of reconstructive and plastic surgery Plastic surgery already observe a different principle of the ratio of the length and thickness of the stem (3: 1). The multistage and long duration of preparation for the transfer of this tubular flap to the recipient zone has always been a big problem for patients.And nevertheless, this flap was in the arsenal of surgical technologies for a very long time – until the 70s. XX century, when foreign surgeons loudly announced the end of the era of H. Gillies tubular flap. Professor Vladimir Petrovich Filatov (USSR, Odessa). For the first time in the world he developed the technology of a round skin and fat flap for closing a defect in the lower eyelid (September 9, 1916) According to the classification of G.C. Cormack and B.G.H. Lamberty, a tubular flap moved from the side of the abdomen to the facial region of the head, could recruit a maximum of four (circulation, construction, contiguity, conditioning) out of six C’s.According to the type of blood supply to the transported material, the tubular flap remained random (random). In 1917, the Danish military surgeon J.F. Esser was the first to draw attention to the fact that cutting out a skin-fat flap along the axis of the saphenous artery and its accompanying vein, allows you to get a reliable and well-supplied plastic material. According to the G.C. Cormack and B.G.H. Lamberty, a transferable plastic material for local plastic surgery, could recruit four (circulation, construction, contiguity, conditionning) out of six Cs.In terms of the intensity of blood supply, this flap significantly surpassed Filatov-Gillies tubular flaps, combining axial and random type of blood supply. In other words, for J.F. Esser, which he called “arterialized”, the principle of observing the ratio of length and width became completely unimportant . Dr. J.F. Esser (1887-1946) – Danish military surgeon, a prominent specialist in the field of reconstructive surgery of gunshot wounds to the face It took another 52 years until the English surgeon S.H. Milton confirmed J.F. Esser . The only drawback of the Esser-Milton tubular “arterialized” flap was its limited mobility. The advantages of the flap were significant, the main one being the axial blood supply. It is known that blood flow through any arterial vessel is directly proportional to the 4th power of its radius. For example, a vessel with a diameter of 1.6 mm will pass 256 times more blood than a vessel with a diameter of 0.4 mm. With an increase in its lumen by another 0.4 mm, i.e. up to 2 mm, the blood flow will be 625 times greater than through a vessel with a diameter of 0.4 mm.In 1979, B. Ponten announced that he had developed a “superflap” for closing a soft tissue defect on the lower limb, calling it “fasciocutaneous flap”. The composition of this arterialized flap included skin, subcutaneous tissue, and its own (deep) fascia. The base of the flap was sharply narrowed by the intersection of all soft tissues with the exception of its axial vessels. The fascial skin flap, even in a non-free version, received greater mobility. It is extremely reliable, since it included its own fascia, which facilitated not only the lifting of the flap, but also guaranteed the preservation of the axial vascular bundle and, accordingly, good blood flow through the subcutaneous vessels, through the subpapillary and deep dermal vascular plexuses.In addition, the ratio of the length and width of the plastic material was dramatically increased (up to 3: 1). This circumstance has become an important factor for the development of surgery for extensive soft tissue defects, in particular, on the lower limbs. According to the G.C. Cormack and B.G.H. Lamberty, B. Ponten’s axial superflap could have four (circulation, construction, contiguity, conditioning) out of six Cs, since it is non-composite (not for deep wounds) with disabilities Reconstructive and Plastic Surgery Issues # 1 (64) March ‘2018 10 Baitinger W.F., Selyaninov K.V., Kurochkina O.S. and others. Cutting out various geometrical confi-This technology was very popular before the guration. According to the type of blood supply to the material being transported, the “superflap” is axial. Thus, the development of technology for the transplantation of non-free fascial skin flaps on the vascular pedicle (axial vessels) proceeded in an evolutionary way. After their introduction into clinical practice, plastic surgeons clarified the indications for the closure of extensive and deep soft tissue defects. The line between superficial and deep defects was the intrinsic fascia: with its integrity, local plastic operations and free skin autografts were performed; in case of damage to its own fascia – non-free skin-fascial flaps.Plastic surgeons were well aware that in case of extensive and, especially, deep wounds, it is desirable to have composite axial flaps of different geometry, which would include not only skin, subcutaneous tissue, its own fascia, but also muscles and bones. It is known that musculocutaneous flaps were first developed long before the tubular “jumping” flaps of Filatov-Gillies appeared. Even earlier, the Italian surgeon I. Tanzini began to use a musculocutaneous flap based on the latissimus dorsi muscle to close an extensive cutaneous wound of the chest wall after radical mastectomy .1920 Then a new marking appeared, which made it possible to close the wound after mastectomy with one’s own tissues (skin). At the beginning of the twentieth century. in France, a musculocutaneous flap based on m. platysma specifically for head and neck reconstructive surgery . In 1964 V.Y. Bakamjian and M. Littlewood  began to include m. platysma and received a well-perfused plastic material to eliminate tissue defect after removal of oropharyngeal tumors. The main problem of moving these flaps is low mobility due to the wide base in the area of their reversal.It soon became clear that using the main advantage of the thoracodorsal musculocutaneous flap – the presence of always large thoracodorsal vessels (arteries and veins) accompanying the latissimus dorsi muscle – can be made extremely mobile. It became possible to unfold the thoracodorsal flap on the neurovascular bundle (both after crossing the latissimus dorsi tendon and without crossing it) onto the upper limb, shoulder girdle, chest wall, and the back of the neck. We present our clinical observation of the elimination of a large defect in the soft tissues of the shoulder girdle and deltoid muscle in patient A., 33 years old (work injury) (Fig. 5). a b Fig. 5. Extensive defect in the area of the left shoulder girdle and shoulder: a – the border of the defect; b – lifting a non-free thoracodorsal flap to close the defect; c – the final result in # 1 (64) March ‘2018 Issues of reconstructive and plastic surgery Plastic surgery 11 In a person with a similar vascular world, he performed microsurgical transplantation with anatomy a little (m. latissimus dorsi, m. pectoralismajor). Most often, muscles have a more complex vascular anatomy, which could be systematized only in 1981.[fifteen]. A very important event remained almost unnoticed in the professional surgical community – the execution of N.H. Antia and V.I. Buch in 1971, the first in the world surgical practice of successful free autologous transplantation of an epigastric skin and fat flap to close a soft tissue defect on the face after removal of ameloblastoma . This became a precedent not only in terms of the originality of the use of this method in oncology, but also in terms of performing microvascular anastomoses without the aid of an operating microscope.The ophthalmic operating microscope and eye instruments for performing microvascular sutures were first introduced into the technology of free (microvascular) grafting by B. O’Brien and K. Harii, who opened the way for revolutionary microsurgical technologies that dramatically expand the possibilities of plastic surgery . The term “free flap” was coined by G.I. Taylor and R.K. Daniel . In fairness, it should be admitted that the founder of the technology of transferring tissues with an axial type of blood supply from one area to another with the immediate inclusion of the transferred tissues into the bloodstream of the new recipient zone was J.R. Cobbett. In 1968 he was the first in the big toe on the stump of the amputated big toe . After that, he became the generally recognized leader of a completely new direction in reconstructive microsurgery – free transplantation of tissue complexes with an axial type of blood supply to another anatomical region with the fastest possible inclusion in the blood flow of recipient vessels. Microvascular autotransplantation of tissue complexes began to be called a revolutionary surgical technology, which opened the way to transplanting various kinds of complex-compound flaps for the simultaneous elimination of very complex deep defects, where, for various reasons, not only soft tissue surface structures are absent, but also muscles, bones, joints, etc.Currently, plastic surgeons divide indications for transplantation of tissue complexes on microvascular anastomoses into absolute and relative. Absolute – these are clinical situations in which plastic elimination of the defect by any other methods is impossible or so long and multistage that the treatment itself can invalidate the patient; the method of free transplantation of a complex of tissues on microvascular anastomoses is technically the most difficult method in plastic surgery.However, the results achieved with its help are sometimes incomparable and even inaccessible when using other techniques (Fig. 6) . a b c Fig. 6. Traumatic amputation of the penis and its reconstruction with a free reinnervated thoracodorsal flap: a – type of defect and marking of donor vessels and motor branch of the obturator nerve; b – neophallus 6 months after surgery; c – formation of the head of the neophallus (Institute of Microsurgery, Tomsk, 2016) Issues of reconstructive and plastic surgery № 1 (64) March’2018 12 Baitinger V.F., Selyaninov K.V., Kurochkina O.S. and others. According to the classification of G.C. Cormack and the experience of breast reconstruction by large free B.G.H. Lamberty, a composite plastic material with an axial type of blood supply of various geometrical configurations, without any restrictions on mobility, corresponds to all six “C” (circulation, constituents, construction, conformation, contiguity, conditioning). In this regard, the technology of free transplantation of tissue complexes on microvascular anastomoses has found the greatest application (in 90% of cases) in oncology (head and neck tumors), maxillofacial surgery and reconstructive andrology.This colossal advantage of axial flaps should have finally excluded from the arsenal of plastic surgeons the time-consuming technologies of forming random flaps by V.P. Filatov and H. Gillies. However, this did not happen in Russia (Fig. 7). Rice. 7. The use of Filatov stem to close the midface of a patient after a gunshot wound (Tomsk, 2016) Anatomical data concerning the third source of blood supply to human skin (direct and indirect cutaneous perforators) have long been known [21, 22].And only in 1989 I. Koshima and S. Soeda  presented the first clinical fatty skin flap of the anterior abdominal wall (DIEAP) based on direct perforators of the deep branch of the inferior epigastric artery. It turned out to be so successful that it now claims to be the gold standard in breast reconstruction. Free perforating flaps are most often used in oncological practice to close extensive head and neck defects after the stage of tumor removal. The most popular of all free perforating flaps used in oncology (head and neck) is ALT-flap (anterolateral thigh flap).Perforating flaps in a non-free version, as well as their modification in the form of propeller flaps, are currently the main plastic material for closing soft tissue defects of the lower extremities. In recent years, a large number of non-free perforating flaps have also been developed, which can successfully close any extensive superficial wounds of the human body [24, 25]. CONCLUSIONS 1. The development of technologies for obtaining plastic material for the closure of extensive and deep wounds has become possible on the basis of new applied anatomical data concerning the vascular anatomy of the integumentary tissues of the human body.2. The prospect of expanding the indications for effective and low-budget local plastic technologies for the closure of extensive superficial wounds of the human body is possible provided that non-free axial perforating flaps are introduced into the practice of plastic surgery. 3. At the present stage of development of plastic surgery in Russia, there are no indications for the use of Filatov-Gillies technologies. 4. The high cost of this technology and frequent complications (up to 12%) in the form of total or marginal necrosis of the transplanted tissues prevent the widespread introduction of microvascular autotransplantation of tissue complexes into the practice of reconstructive plastic surgery of large and deep wounds of the human body.Conflict of interest. The authors declare no conflicts of interest.
Kazarezov M.V., Bauer I.V., Koroleva A.M. Traumatology, Orthopedics and Reconstructive Surgery. Novosibirsk: NGMA; 2001: 288 s.
Cormack G.C., Lamberty B.G.H. Cadaver studies of correlation between vessel size and anatomical territory of cutaneous supply. Brit. J. Plast. Surg. 1986; 39: 300-306.
McGregor I.A., Morgan G. Axial and random pattern flaps. Brit. J. Plast. Surg. 1973; 26: 202-213.
Cormack G.C., Lamberty B.G.H. A classification of fascio-cutaneous flaps according to their patterns of vascularization. Brit. J. Plast. Surg. 1984; 37: 80-87.
Cormack G.C., Lamberty B.G.H. The arterial anatomy of the skin flap. 2nd Ed., Edinburgh: Churchill Lavingstone; 1994: 538 p.
M. I. Kuzin, B. M. Kostyuchenok Wounds and wound infection. M .: Medicine; 1990: 571 s.
Gillies H.D. Plastic surgery of facial burns. Surg. Gynecol. Obstet. 1920; 30: 121-134.
Filatov V.P.Round stem plastic. Vestn. ophthalmology. 1917; 34 (4-5): 149-158.
Esser J.F.S. Schwerer Verschlusseiner Brustwand perforation. Berlin Clin. Wochenschr. 1918; 55: 1197.
Milton S.H. The tubed pedicle flap. Brit. J. Plast. Surg. 1969; 422: 22-53.
Tanzini I. Soprailmionuovo processo di amputazione della mammilla. Gazz. Med. Ital. 1906; 67: 141.
Morax V. L’autoplasticpalpebraleoufacialel’aide de lambeaupediculesempruntes a la region cervicale (procede de Snydacker) et de l’autoplastie en deux temps avec utilization pedicule.Annales Oculist. 1908; 4489: 4414.
Bakamjian V.Y., Littlewood M. Cervical skin flaps for intraoral and pharyngeal repair following cancer surgery. Brit. J. Plast. Surg. 1964; 17: 191-210.
Mathes S.J., Nahai F. Classification of the vascular anatomy of muscles: Experimental and clinical correlation. Plast. Reconstr. Surg. 1981; 67 .: 1177-1178.
Antia N.H., Buch V.I. Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. Brit. J. Plast. Surg.1971; 24: 15-19.
Daniel R.K., Williams H.B. The free transfer of skin flaps by microvascular anastomoses. An experimental study and reappraisal. Plast. Reconstr. Surg. 1973; 52: 16-31.
Taylor G.I., Daniel R.K. The free flap: composite tissue transfer by vascular anastomosis. Aust. N.Z. J. Surg. 1973; 43: 1-3.
Cobbett J.R. Free digital transfer. J. Bone Joint Surg. 1969; 51B: 677-679.
Trofimov E.I. Microsurgical autotransplantation of tissues – direction of reconstructive microsurgery: author.dis .. Dr. med. sciences. M .; 2001: 25 p.
Manchot C. Hautarterien des Menschlichen Korpers. Leipzig: FCW Vogel; 1889: 84 S.
Salmon M. Les arteres de la peau. Paris: Masson; 1936: 122 p.
Koshima I., Soeda S. Inferior epigastric artery skin flap without rectus abdominis muscle. Brit. J. Plast. Surg. 1989; 42: 645.
Slesarenko S.V., Badul P.A. The technique of spatial redistribution of integumentary tissues during plastic closure of deep and extensive wound defects.Reconstructive and plastic surgery issues. 2013; (4): 17-25.
Badiul P., Sliesarenko S., Sliesarenko K. The local perforator flaps for plastic closure of extensive military wounds. Chirurgia Plastycznai Oparzenia. 2015; 2: 59-60.
90,000 Article page: Klinicheskaya Meditsina
Fukushima S., Kobayashi J., Bando K. et al. Late outcomes after isolated coronary artery bypass grafting for ischemic mitral regurgitation. Jpn. J. Thorac. Cardiovasc. Surg. 2005; 53 (7): 354-60.
Borisov I.A. Plastic surgery on the mitral valve in patients with coronary heart disease. Clinical medicine. 2012; 90 (8): 19-23.
Grossi E. A., Goldberg J. D., LaPietra A. et al. Ischemic mitral valve reconstruction and replacement: Comparison of long-term survival and complications. J. Thorac. Cardiovasc. Surg. 2001; 122 (6): 1107-24.
McGee E.S. Jr., Gillino A.M., Blackstone E.H., Cosgrove D.M. et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.J. Thorac. Cardiovasc. Surg. 2004; 128: 916-24.
Crabtree T.D., Bailey M.S., Moon M.R. et al. Recurrent mitral regurgitation and risk factors for early and late mortality after mitral valve repair for functional ischemic mitral regurgitation. Ann. Thorac. Surg. 2008; 85: 1537-43.
Shikhverdiev N.N., Marchenko S.P. Fundamentals of reconstructive heart valve surgery / Ed. ed. N.N. Shikhverdiev. SPb .: Deaton; 2007.
Burakovsky V.I., Bockeria L.A., Bukharin V.A. Cardiovascular Surgery: A Guide.2nd ed. / Ed. prof. L.A. Boqueria. M .: Medicine; 1996.
Ostrovsky Yu.P. Heart surgery. M .: Medical literature; 2007.
Akchurin R.S., Burmistrova I.V., Vasiliev V.P. and other Topical issues of heart surgery in adults. In the book: Cardiovascular pathology. The current state of the problem: Collection of works dedicated to the 80th anniversary of E.I. Chazova. M .; 2009: 6-25.
Akchurin R.S., Dzemeshkevich S.L., Shiryaev A.A. et al. Combined surgery of coronary arteries and heart valves. Modern technologies of surgery of coronary heart disease: Collection of articles.M .; 2001: 13-5.
Akchurin R.S., Shiryaev A.A., Dzemeshkevich S.L. et al. Assessment of factors of hospital mortality in patients with coronary heart disease with high operational risk. Breast and cardiovascular surgery. 2005; 2: 14-20.
Horii T., Suma H., Isomura T. et al. Left ventricle volume affects the result of mitral valve surgery for idiopathic dilated cardiomyopathy to treat congestive heart failure. Ann. Thorac. Surg. 2006; 82: 1349-55.
Kuwahara E., Otsuji Y., Iguro Y., Ueno T., Zhu F., Mizukami N. et al. Mechanism of recurrent / persistent ischemic / functional mitral regurgitation in the chronic phase after surgical annuloplasty: Importance of augmented posterior leafl et tethering. Circulation. 2006; 114: I-529-I-34.
Braun J., Bax J.J., Versteegh M.I. et al. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation. Eur. J. Cardiothorac. Surg. 2005; 27 (5): 847-53.
De Bonis M., Torracca L, Maisano F. et al. Recurrence of mitral regurgitation parallels the absence of left ventricular reverse remodeling after mitral repair in advanced dilated cardiomyopathy. Ann. Thorac. Surg. 2008; 85: 932-9.
Akchurin R.S., Shiryaev A.A., Dzemeshkevich S.L. et al. Assessment of factors of hospital mortality in patients with coronary heart disease with high operational risk. Breast and cardiovascular surgery. 2005; 2: 14-20.
Ashikhmina E.A. Left ventricular remodeling after early surgical correction of mitral insufficiency: maintaining a constant stroke volume.Russian journal of cardiology. 2015; 1: 43-9.
N.A. Belokon, V.P. Podzolkov Congenital heart defects. M .: Medicine; 1991.
Diseases of the heart and blood vessels: A guide for physicians / Ed. E.I. Chazova. M .: Medicine; 1992; T. 2.
Dzemeshkevich S., Korolev S., Frolova J. et al. Isolated replacement of the mitral leaflets and “Mercedes” plastics of the giant LA: surgery for patients with LV dysfunction and LA enlargement. J. Cardiovasc. Surg. 2001; 42 (4): 505-8.
Dzemeshkevich S., Korolev S., Frolova J. et al. Isolated replacement of the mitral leaflets – new technique of preservation the subvalvular apparatus. Coron. Europaeum. 1999; 8 (1): 189.
Dzemeshkevich S.L., Stevenson L.W. Myocardial dysfunction and cardiac surgery. M .: GEOTAR-Media; 2009.
Karaskov A.M., Porkhanov V.A., Kosmacheva E.D., Mironenko S.P. Ischemic mitral valve dysfunction. Krasnodar; 2006.
Mironenko V.A. Reconstructive surgery for ischemic mitral insufficiency in combination with coronary artery bypass grafting.Breast and cardiovascular surgery. 2001; 5: 19-24.
Skopin I.I. Multicomponent mitral valve reconstruction and coronary artery bypass grafting is a hybrid operation. Breast and cardiovascular surgery. 2009; 3: 65-7.
Skopin I.I., Mironenko V.A., Perepelitsa A.A. Rapprochement of papillary muscles in valvular heart disease and left ventricular dysfunction / All-Russian Congress of Cardiovascular Surgeons. Bulletin of the N.N. A.N. Bakuleva RAMS “Cardiovascular diseases”.2008; 9 (6): 35.
Sukhanov S.G. Ischemic mitral regurgitation and myocardial revascularization: is there a relationship? Breast and cardiovascular surgery. 2006; 4: 18-22.
Timofeeva I.V. Dynamics of mitral regurgitation in patients with coronary artery disease after coronary artery bypass grafting. Perm Medical Journal. 2006; 23 (4): 47-56.
Dominik J., Zacek P. Heart Valve Surgery. Berlin; Heidelberg: Springer-Verlag; 2010.
Baumgartner F.J. Cardiothoracic Surgery. 3-rd Ed.Landes Bioscience; 2003.
Hochman J.S., Choo H. Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage. Circulation. 1987; 75 (1): 299-306.
Hung J., Papakostas L., Tahta S.A., Hardy B.G, Bollen B.A., Duran C.M. et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation. 2004; 110 (11 Suppl. 1): 85-90.
Moon M.R., Ingels N.B. Jr., Daughters G.T. 2d et al.Alterations in left ventricular twist mechanics with inotropic stimulation and volume loading in human subjects. Circulation. 1994; 89 (1): 142-50.
Wakasa S., Kubota S., Shinqu Y. et al. The extent of papillary muscle approximation affects mortality and durability of mitral valve repair for ischemic mitral regurgitation. J. Cardiothorac. Surg. 2014; 9: 98.