The British Association of Plastic Surgeons (2004) 57, 769–772

The influence of sildenafil on random skin flap

survival in rats: an experimental study
Nedim Sarifakioglu*, Serdar Gokrem, Levent Ates, Unzile B. Akbuga,
Gürcan Aslan

Ankara Training and Research Hospital, Department of Plastic and Reconstructive Surgery, Cebeci, Ankara,
Turkey

Received 22 July 2003; accepted 20 April 2004

KEYWORDS
Sildenafil; Skin flap; Flap
survival; PDE-inhibitors
Summary Sildenafil (Viagraw), a selective and specific inhibitor of cyclic guanosine
monophosphate (cGMP) phosphodiesterases (PDEs), is currently marketed for the
treatment of erectile dysfunction. Sildenafil is a potent and highly selective PDE-V
inhibitor and enhances smooth muscle relaxation in human. Systemic arterial and
venous smooth muscle cells contain PDE-V and nitric oxide (NO) which is a major
mediator of relaxation of the smooth muscle cell.
The aim of the present study is to investigate, in a rat model, the potential effect of
sildenafil on survival of random pattern skin flaps. For this purpose, 32 Sprague-Dawley
rats were used and a McFarlane-type caudally based skin flap was designed on the
dorsum of the rat (2.5 £ 8 cm). Rats were divided into four groups: One control (Group
D), and three treatment groups (Groups A, B, C). Sildenafil was administered orally to
the experiment groups; Group A: 3 mg/kg/single dose a day, Group B: 10 mg/kg/single
dose a day and Group C: 10 mg/kg/twice dose a day. The areas of flap necrosis were
measured in each group. The extent of viable flap areas were expressed as a
percentage of total flap area, and differences were studied by Completely Randomised
Experimental design.
The areas of necrosis of skin flaps decreased depending on sildenafil dose, but
viability of the flaps treated with 3 mg/kg/day was not different than the control
group. The flaps receiving 2 £ 10 mg/kg/day sildenafil gave the highest ðP , 0:01Þ
survival rate. As a conclusion, sildenafil may have a dose dependent effect to increase
flap survival in random skin flaps.
Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights
reserved.

Sildenafil is a PDE inhibitor. PDE inhibitors are
not new to clinical practice. Nonspecific PDE
inhibitors, such as theophylline and papaverine,
cause smooth muscle relaxation by increasing
levels of both cAMP and cGMP. However, the
*Corresponding author. Angora evleri, F-6 Blok, No. 40
Beysakent, 06800, Ankara, Turkey. Tel.: þ90-312-2126262.
E-mail address: nsarifakioglu@yahoo.com
availability of subtype-specific PDE inhibitors is a
recent advance. There are 11 subtypes of PDE,
each with its own tissue distribution and
substrate specificity.1 For example, amrinone
and milrinone are cardiac inotropes that inhibit
PDE-III and possibly PDE-I; they have a largely
selective effect on cardiac inotropy because
they elevate cAMP preferentially in cardiac
cells.2

S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2004.04.014
770
Sildenafil, a potent and selective PDE-V inhibi-
tor, was first studied as an antianginal medication.
It was realised that erection was a common side
effect, which could be explained by decreasing the
breakdown of cGMP and thus prolonging the
vasodilatory effects on the penile circulation
induced by NO in response to sexual stimulation.2
Since the vascular smooth muscle is under the
control of endothelial NO, whose main action is to
activate the soluble guanylyl cyclase. Sildenafil
will, therefore enhance the physiological relaxation
and amplify the pharmacological activity of any
drug that leads to activation of guanylyl cyclase in
the vascular system.2
The vasodilatory properties of sildenafil are
largely responsible for unwanted effects. The
most common adverse effects of sildenafil are
mainly symptoms of vasodilatation; such as head-
ache, flushing, and nasal congestion.3 – 6 Addition-
ally, because platelets contain PDE-V, sildenafil
might affect the function of these cells. So
sildenafil may change the platelet aggregation and
can cause peptic ulceration.7 But no effects on
bleeding times or microcirculatory disturbances
have been reported so far in the literature.2,7
Considering its pharmacological adverse effects
and actions as mentioned above, we hypothesise
that sildenafil may lead to a improvement in skin
flap survival as a result of its unavoidable side
effects on the vascular smooth muscle and on the
microcirculatory hemodynamics related to platelet
functions. We therefore investigated its effects on
the survival of random skin flaps in an experimental
model.
Material and method
The Institutional Animal Care and Use Committee at
Ministry of Health, Ankara Training and Research
Hospital, approved this study.
Experimental protocol
Thirty-two male Sprague-Dawley rats weighing 270 –
300 g were used in this study. Animals were housed
in separate rat cages at 22 8C and were fed with
rodent food and tap water ad libitum. Animals were
anaesthetised with an intraperitoneal injection of a
combination of ketamine (100 mg/ml) and xylazine
(20 mg/ml) at a total dose of 0.2 ml per 100 g of
body weight. Dorsal hair was removed with an
electric shaver, and all surgical procedures were
performed under sterile conditions. A McFarlane-
type caudally based skin flap was designed on the
N. Sarifakioglu et al.
dorsum of the rat (2.5 £ 8 cm) using the iliac crest
as a constant anatomic landmark to ensure posi-
tioning. The flap was elevated beneath the panni-
culus carnosus (which is equivalent to the
subcutaneous fat in humans) and each flap was
then sutured back to its donor site immediately
with continuous 4/0 silk sutures. When perforating
vessels were found in the base of flaps, they were
electrically cauterised to make flaps with a com-
pletely random vascular pattern.
Administration of the drug
Sildenafil (Viagraw, Phizer Labs, New York, NY)
tablets (25 mg) was obtained from commercially
available sources and dissolved with tap water to
obtain homogen drug solution. The first drug
solution was administered to the animals 2 h after
the surgical procedure and the drug administered to
the animals using mouth gag and feeding tube.
Animals were divided into four groups. Group A ðn ¼
8Þ; received 3 mg/kg sildenafil, single dose a day
during 7 days, Group B ðn ¼ 8Þ; received 10 mg/kg,
the sildenafil single dose a day during 7 days, Group
C ðn ¼ 8Þ; received 10 mg/kg/twice dose a day
during 7 days (totally: 20 mg/day), and Group D
ðn ¼ 8Þ was control group and received only tap
water during the experiment (Table 1). Group A
received total 33.6 mg sildenafil with 52.64 ml
tampon solution (resolving tap water solution)
during the treatment procedure, in the mean
time, Group B received 112 mg sildenafil with
44.8 ml tampon solution, and group C received
224 mg sildenafil with 33.6 ml tampon solution
during the experiment procedure.
Flaps were photographed and were observed for
7 days. One week after the preparation of flaps, the
survival area of flaps was measured using a
planemeter.
Statistical method
In the study for assessing the results, Completely
Randomised Experimental design was used.8
Results
No animal died from the drug treatment or the
surgical procedure. All experimental flaps exhibited
sharp demarcations between viable and necrotic
areas that were easily measured by planemeter.
The mean percentage of survival of flaps were as
follows: Group A: 73%, Group B: 77.4%, Group C:
83.3%, and 71.6 in the control group. The mean
The influence of sildenafil on random skin flap survival in rats: an experimental study 771

Table 1 According to groups, total sildenafil concentration, treatment dose and its contents regarding tampon and stock solutions
during the study

Groups n Day Sildenafil dose mg/ml Total sildenafil dose Stock suspension volume Tampon solution Total volume
(mg/kg/day) (mg) (ml) (tap water) volume (ml)
(ml)

Group A 8 7 3 0.6 33.6 3.36 52.64 56

Group B 8 7 10 2 112 11.2 44.8 56
Group C 8 7 20 4 224 22.4 33.6 56
Group D 8 7 0 0 0 0 56 56

percentage of skin flap necrosis was similar in Group
A between control group (Group D). Survival rates
between these groups showed no statistical
significant difference. The flaps receiving 2 £
10 mg/kg/day sildenafil gave the highest survival
rate (Fig. 1). The areas of necrosis of random skin
flaps decreased related to sildenafil dose. Groups B
and C gave significantly higher ðP , 0:01Þ survival
rate.
Discussion
Random skin flaps are widely used for reconstruc-
tion and wound coverage. Flap length is limited,
however, and therefore methods of extending flap
survival are needed. Tissue necrosis at the distal
aspects of random flaps is generally attributed to
deficient blood perfusion of this area.9 Sildenafil
would appear to be a good candidate for pharma-
cologic improvement of skin-flap viability because
of unique properties on the smooth muscle and
platelets.
The PDEs play a central role in regulating smooth
muscle tone, and control a wide variety of
Figure 1 Survival rate of the flaps in four groups of rats
treated with different concentrations of sildenafil.
Histograms with different letters are statistically differ-
ent at P , 0:001 level as measured with LDS mean range
test. The bars on histograms are standard deviations from
the mean survival rates. Randomised block experimental
design (Snedecor and Cochran, 1980).
physiologic processes and functions. They can be
subdivided into enzymes that are functionally and
structurally related, and so far 11 of these PDEs
have been identified.10 PDE-V receptors are dis-
tributed through the vascular smooth muscle,
intestine, heart, platelets, placenta, and chondro-
cytes.1 Specifically, PDE-V inhibitors inactivate
PDEs that normally metabolise the nucleotide
cGMP. The accumulation of cGMP allows for an
enhanced smooth muscle relaxation and increased
blood flow in target tissues.1,2 Thus, sildenafil has
been recognised as being effective for the treat-
ment of erectil dysfunction. However, there has
been no study on the pharmacological action of
sildenafil from the standpoint of the random skin
flap survival.
Two characteristics of sildenafil suggest that this
agent might enhance skin flap survival. First,
sildenafil changes and/or may decrease platelet
aggregation thus potentially reducing thrombosis
within cutaneous blood vessels.1,7 Second its most
commonly seen side effects related to its vasodila-
tory effect on the vascular smooth muscles. Plate-
lets are very well studied with respect to PDEs, and
the cGMP-dependent protein kinase plays an
important role in platelet inhibition by NO.7,11
Sildenafil is expected to potentiate platelet
inhibition.
There is a well-recognised and self-evident
relationship between sildenafil and its side effects
related to vasodilator properties.1,2,5 – 7 Most of
these side effects are caused by amplification and
prolongation of physiological activation of cGMP-
signaling pathways. For this reason, it is imperative
to emphasise that sildenafil must never be adminis-
tered to patients taking organic nitrates. Further-
more sildenafil has diminished selectivity for
cAMP-specific PDE isoform-3, which is involved in
cardiac contractility.7 In addition, potentially pre-
cipitous decreases in blood pressure, resulting from
the vasodilating properties of sildenafil.7,10,12,13
The most common side effects of the sildenafil
include headache (15.6%), facial flushing (10.4%),
nasal congestion, and dyspepsia are clearly due to
772
vasodilatory adverse effect.12 – 15 The results of this
study suggested that sildenafil might have also
peripheral vasodilatory effects on vascular smooth
muscle cells other than smooth muscle in the known
target tissues. The decreasing percentage of
necrosis on the flap model between group A and
group C may be related to total drug’s dose and/or
drug’s plasma concentration. The plasma clearance
of sildenafil in humans is 10 ml/min/kg; and the
terminal half life is around 4 h.1
There are few reports in the literature consider-
ing vasodilatory effects of PDE inhibitors. Three of
them are reported by Ichioka and co-authors.16 – 18
Amrinon (a selective PDE-III inhibitor) acts as a
potent vasodilator on the target organs and
improves microcirculatory hemodynamics. Another
study by Grossmann et al. compared the venodi-
lator potencies of the PDE-III inhibitors amrinone
and enoximone with the unspecific PDE inhibitors
theophylline and pentoxifylline in human hand veins
in vivo. In the light of their findings, enoximone and
amrinone have similar venodilatory potency which
is six times higher than that of theophylline.19
Maintaining the viability of flaps is one of the
major concern in plastic and reconstructive sur-
gery. Increasing distal perfusion in random flaps is
believed to be especially important for enhancing
flap survival.20 The McFarlane-type skin flap used in
this study has been confirmed to provide a well-
controlled and predictable model of acute flap
failure. Because of this properties of the flap, we
choose McFarlane flap as an experiment model.
In conclusion, these findings suggest that silde-
nafil can contribute to survival of random pattern
flaps in a dose dependent way. This effect may be
independent of the NO/cGMP pathway, and may be
related to improve microcirculatory hemody-
namics, but this remains to be elucidated. On the
basis of the available biochemical data from
previous studies and the physiological responses
from this study, further clinical and experimental
evaluation of sildenafil or other second generation
PDE-V inhibitors such as Vardenafil or Tadalafil as a
improvement of random skin flaps viability is
warranted.
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