Advances in microsurgical tools and techniques enable reconstructive surgeons to perform complex tissue reconstructions following oncological resection or trauma.
Prolonged replant ischaemia time due to delayed patient transfer and lack of recipient vessels present true obstacles in reconstructive microsurgery. Extracorporeal perfusion (EP), a concept derived from extracorporeal cardiopulmonary support, has recently been trialed for these challenges.
A comprehensive literature review of clinical experiences utilizing EP in free flap reconstructions and extremity replantations following trauma was undertaken to examine its indications, pitfalls, and gaps. Eleven papers met the search criteria and were included in this review. Over the past 19 years, 21 patients received EP as part of their free flap reconstruction, and four patients had amputated limbs receiving EP prior to replantation. In both patient groups, EP was utilized when prolonged tissue ischemic time was anticipated. Additionally, EP was also utilized in free flap head and neck reconstructions in patients with vessel depleted neck.
The intricacies of EP – perfusate, temperature, duration, rate, and pressure – varied between research groups and patients. Outcomes were more favourable with EP utilized for free flaps when compared to the utilization of EP for amputations. This could be attributable to the traumatic nature and a longer ischemic time before establishing EP in amputations. Being an innovative and complex system, EP, as an adjunct for free flaps and replantations, is challenged by limited information to establish a replicable protocol and reliable algorithm for predictable outcomes.
While EP has thus far only been applied to selected reconstructive cases, it has the potential to serve as a valuable repertoire for surgeons to undertake more complex reconstructions and replantations. Furthermore, EP will drastically change the practice of vascularize composite allotransplantations of face and extremities with hope to improve the tissue storage capacity with lessened ischaemia induced cellular damage.