In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation

Wolff, Klaus‐Dietrich; Ritschl, Lucas M.; Bomhard, Achim von; Braun, Christian; Wolff, Constantin T.; Fichter, Andreas M.

doi:10.1016/j.jcms.2019.12.005

Cited by 12 publications

(7 citation statements)

References 42 publications

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“…We also aimed to focus on early autonomization that could lead to a change in current practice. Moreover, we included cases described by Wolff et al [19,102,104], which were novel since they consisted of intermittently perfused flaps with an extracorporeal system. This is the first clinical in vivo description of flap autonomization enhancement through intermittent ischemic preconditioning.…”

Section: Discussionmentioning

confidence: 99%

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

Berkane,

Kostyra,

Chrelias

et al. 2023

Bioengineering

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Autonomization is a physiological process allowing a flap to develop neo-vascularization from the reconstructed wound bed. This phenomenon has been used since the early application of flap surgeries but still remains poorly understood. Reconstructive strategies have greatly evolved since, and fasciocutaneous flaps have progressively replaced muscle-based reconstructions, ensuring better functional outcomes with great reliability. However, plastic surgeons still encounter challenges in complex cases where conventional flap reconstruction reaches its limitations. Furthermore, emerging bioengineering applications, such as decellularized scaffolds allowing a complex extracellular matrix to be repopulated with autologous cells, also face the complexity of revascularization. The objective of this article is to gather evidence of autonomization phenomena. A systematic review of flap autonomization is then performed to document the minimum delay allowing this process. Finally, past and potential applications in bio- and tissue-engineering approaches are discussed, highlighting the potential for in vivo revascularization of acellular scaffolds.

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Section: Discussionmentioning

confidence: 99%

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

Berkane,

Kostyra,

Chrelias

et al. 2023

Bioengineering

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“…In contrast to a decade ago, indications for ex-vivo machine perfusion have expanded and have been employed in humans to either salvage free flaps or prolong tissue preservation. With the former indication, Wolff et al [15] described the use of an extracorporeal system to salvage free flaps in five patients whose recipient vessels were severely compromised due to irradiation or atherosclerosis. As the microvasculature anastomosis would be challenging and impractical, free flaps were instead sutured into the recipient site and perfused extracorporeally for several days until revascularization occurred.…”

Section: Machine Perfusionmentioning

confidence: 99%

Current opinion: advances in machine perfusion and preservation of vascularized composite allografts – will time still matter?

Muss,

Loftin,

et al. 2023

Current Opinion in Organ Transplantation

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Purpose of review A major hurdle hindering more widespread application of reconstructive transplantation is the very limited cold ischemia time (CIT) of vascularized composite allografts (VCAs). In this review, we discuss cutting edge machine perfusion protocols and preservation strategies to overcome this limitation. Recent findings Several preclinical machine perfusion studies have demonstrated the multifactorial utility of this technology to extend preservation windows, assess graft viability prior to transplantation and salvage damaged tissue, yet there are currently no clinically approved machine perfusion protocols for reconstructive transplantation. Thus, machine perfusion remains an open challenge in VCA due to the complexity of the various tissue types. In addition, multiple other promising avenues to prolong preservation of composite allografts have emerged. These include cryopreservation, high subzero preservation, vitrification and nanowarming. Despite several studies demonstrating extended preservation windows, there are several limitations that must be overcome prior to clinical translation. As both machine perfusion and subzero preservation protocols have rapidly advanced in the past few years, special consideration should be given to their potential complementary utilization. Summary Current and emerging machine perfusion and preservation technologies in VCA have great promise to transform the field of reconstructive transplantation, as every extra hour of CIT helps ease the complexities of the peri-transplant workflow. Amongst the many advantages, longer preservation windows may allow for elective procedures, improved matching, establishment of novel immunomodulatory protocols and global transport of grafts, ultimately enabling us the ability to offer this life changing procedure to more patients.

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“…One solution to circumvent these obstacles would be to master extracorporeal perfusion processes, thereby providing an exogenous supply of oxygen and nutrients to the flap and bridging the period necessary to reach flap autonomization/neo-vascularization and avoiding a vascularized transfer. Mastering a multi-day perfusion protocol [24] could be used for microsurgery-free flap reconstruction, as described by Wolff et al [16,25,26]. Until now, they have been the first and only team to describe a clinical series of free fasciocutaneous flap reconstruction using exclusive extracorporeal perfusion.…”

Section: Introductionmentioning

confidence: 99%

“…Their innovative technique used anterolateral thigh, soleus, medial sural, radial forearm, and fibular vascularized fasciocutaneous paddles placed on the recipient site for 4 to 12 days until autonomization. However, their innovative approach will require important optimization to overcome the current limitations and lower the current complication rate of 67% observed in their series on partial flap loss [16,25,26]. On the other hand, Brouwers and Kruit have explored machine perfusion-based approaches in muscle flaps to study ex vivo thrombolysis in flap salvage [27], as well as for extended preservation as a relevant model for vascularized composite allotransplantation (VCA) [18,28].…”

Section: Introductionmentioning

confidence: 99%

Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study

Berkane,

Lellouch,

Goudot

et al. 2023

Bioengineering

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Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.

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In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation

Cited by 12 publications

References 42 publications

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

Current opinion: advances in machine perfusion and preservation of vascularized composite allografts – will time still matter?

Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study

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