title: Free flap transplantation using an extracorporeal perfusion device: First three cases.
abstract: BACKGROUND
  Free flap transplantation may not be feasible in patients with inadequate or absent recipient vessels. We report successful mandibular composite reconstructions without anastomosis in three consecutive patients with vessel-depleted neck. Based on clinical reports describing early neovascularisation, temporary extracorporeal perfusion of flaps was maintained until the flaps had become independent from the extracorporeal blood supply.
  
  
  METHODS
  A blood transfusion bag filled with the patients' arterialised blood was connected to the flap artery and set under rhythmic compression to ensure continuous blood supply to the flap. The returning venous blood was collected but not reinfused. Extracorporeal circulation was sustained for 10-13 days until flaps had become independent from the external blood supply. Flap viability was assessed every 2 h using combined laser Doppler flowmetry and remission spectroscopy.
  
  
  RESULTS
  Successful bony reconstructions were achieved in all three consecutive patients substantiated by MRI-, CT-scan or bone scintigraphy. Neovascularisation occurred within the soft tissues of all flaps with the exception of one skin paddle, which later developed necrosis. Systemic transfusion of 12-25 units of packed red cells was necessary to compensate for the blood loss.
  
  
  CONCLUSIONS
  With this technique, transplantation of composite free flaps becomes feasible even in the absence of recipient vessels, opening up new treatment options to a broad range of complex surgical problems. Blood reinfusion should be pursued in the future to avoid excessive blood transfusions. The trial is registered with ClinicalTrials.gov, number NCT02449525.
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Klaus-Dietrich
authors.initials: KD
authors.lastname: Wolff
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mücke
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Achim
authors.initials: A
authors.lastname: von Bomhard
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Lucas M
authors.initials: LM
authors.lastname: Ritschl
authors.affiliation: Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Schneider
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Humbs
authors.affiliation: Department of Oral and Cranio-Maxillofacial Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, D-81675 Munich, Germany. Electronic address: andreas.fichter@tum.de.
authors.forename: Andreas M
authors.initials: AM
authors.lastname: Fichter
mesh_terms: D001158:Arteries; D015199:Extracorporeal Membrane Oxygenation / Q000295:instrumentation / Q000379:methods*; D058752:Free Tissue Flaps / Q000098:blood supply* / Q000601:surgery / Q000637:transplantation*; D006801:Humans; D017078:Laser-Doppler Flowmetry; D063175:Mandibular Reconstruction / Q000379:methods*; D008833:Microcirculation; D009333:Neck; D019651:Plastic Surgery Procedures / Q000379:methods; D013524:Surgical Flaps
keywords: Extracorporeal perfusion; Microvascular free flap; Reconstructive surgery; Vessel-depleted neck