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The effect of controlled carbon dioxide insufflation on the viability of ischemic random skin flaps in rats



Despite the indications of carboxitherapy in situations of ischemia and necrosis, there is still no scientific evidence to support its clinical applicability. The purpose of this study was to investigate the effect of controlled carbon dioxide insufflation on the viability of dorsal ischemic random skin flaps in rats.


A randomized, single-blind, experimental study was conducted. Thirty-six Wistar-EPM rats were randomly distributed into three groups: group 1 (control using ischemic random skin flap procedure without gas insufflation); group 2 (flap procedure with controlled carbon dioxide insufflation); and group 3 (flap procedure with controlled inert gas insufflation). In groups 2 and 3, gas was insufflated intradermally in rats for 5 s (150 ml/min) using a 0.2-mm needle inserted at a 90° angle to the skin at two points (one located 2.5 cm from the cranial base of the flap and the other 7.5 cm from the midline of the flap). This procedure was repeated for 7 consecutive days. Macroscopic analysis (necrotic area) was performed using the paper-template method proposed by Sasaki and Pang. Microscopic analysis of the vascularization process was performed using hematoxylin and eosin staining.


No statistically significant differences were found for the parameter vascularization, inflammatory infiltrate, and percentage of necrotic area.


Controlled carbon dioxide insufflation did not have a significant impact on the viability of ischemic random skin flaps.

Level of evidence: Not ratable.

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No funding was received for conducting this study.

Author information




Mariana Merida Carrillo Negrao participated in study conception and design, data collection, analysis, and interpretation, the technical and surgical procedures, and in writing this manuscript.

Bernardo Sérgio Hochman Rzeszetkowski participated in study conception and design.

Luiz José Muaccad Gama participated in data collection, analysis, and interpretation and in the technical procedures.

José da Conceição Carvalho Júnior participated in critical revision and final approval of this manuscript.

Lydia Masako Ferreira participated in study conception and design and in the critical revision and final approval of this manuscript.

Corresponding author

Correspondence to Lydia Masako Ferreira.

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Ethical approval

This study was approved by the Research Ethics Committee and the Animal Use Ethics Committee of Federal University of São Paulo under number 0359/12. All use of animals was in agreement with the policies described in the Guide for the Care and Use of Laboratory Animals.

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Upon submission, all authors consent to the publication of the manuscript in the European Journal of Plastic Surgery.

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Conflict of interest

Mariana Merida Carrillo Negrao, Bernardo Sérgio Hochman Rzeszetkowski, Luiz José Muaccad Gama, José da Conceição Carvalho Júnior, and Lydia Masako Ferreira declare no competing interests.

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This work is dedicated to the memory of Bernardo Sérgio Hochman Rzeszetkowski.

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Negrao, M.M.C., Rzeszetkowski, B.S.H., Gama, L.J.M. et al. The effect of controlled carbon dioxide insufflation on the viability of ischemic random skin flaps in rats. Eur J Plast Surg 44, 569–576 (2021).

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  • Carbon dioxide
  • Insufflation
  • Skin
  • Surgical flaps
  • Rats