An Attempt to Keep Flaps Alive with Artificial Perfusion in Rabbits

Objective: In free flap surgery, the condition of recipient vessels may not be appropriate for anastomosis because of anatomical factors or acquired features such as tumoral invasion, surgical treatment, or radiotherapy. Furthermore, free flap surgery is time-consuming, expensive, demanding, and more prone to complications. The aim of this study was to test the hypothesis that maintaining free flap perfusion with a temporary artificial system without microanastomosis until revascularization is adequate for flap vitality.Materials and Methods: We studied a total of 14 rabbits, which were placed into two groups: control and experimental. A 5×5 cm free skin island flap was elevated on the caudolateral scapular region. In the experimental group, the artery and vein of the flaps were cannulated and a 5 cc/h plasma infusion was artificially started prior to flap fixation. In the control group, the flaps were designed and sutured to the recipient area without perfusion.Results: The animals did not live long enough for us to analyze the maintenance of the clinical flap vitality. However, it was found that flap tissues in the experimental group were vital during the first 6 days after surgery, while composite graft tissues in the control group resulted in necrosis on day 3 in histopathological examination. Conclusion: Our experimental model proves that the artificial flap perfusion model with plasma perfusion extends the duration of tissue viability compared with that with non-perfusion (control group). This result could be improved with further investigations and may lead to the development of many future innovations.


Hansen SL, Young DM, Lang P, Sbitany H. Flap classification and applica- tions. In; Neligan PC (Chief editor), Gurtner GC (volume editor). Plastic Surgery 3rd ed. Volume 1, London: Elsevier Saunders, 2013.p.511-572.

Halle M, Ekström M, Farnebo F, Tornvall P. Endothelial activation with prothrombotic response in irradiated microvascular recipient veins. J Plast Reconstr Aesthet Surg 2010;63(11): 1910-6. [CrossRef]

Fosnot J, Fischer JP, Smartt JM Jr, Low DW, Kovach SJ 3rd, Wu LC, et al. Does previous chest wall irradiation increase vascular complica- tions in free autologous breast reconstruction? Plast Reconstr Surg 2011; 127(2): 496-504. [CrossRef]

Gürlek A, Miller MJ, Amin AA, Evans GR, Reece GP, Baldwin BJ, et al. Reconstruction of complex radiation-induced injuries using free-tis- sue transfer. J Reconstr Microsurg. 1998; 14(5): 337-40. [CrossRef]

Guelinckx PJ, Boeckx WD, Fossion E, Gruwez JA. Scanning electron microscopy of irradiated recipient blood vessels in head and neck free flaps. Plast Reconstr Surg 1984; 74(2): 217-26. [CrossRef]

Krag C, Holck S, DeRose G, Lyczakowski T, Freeman CR. Healing of microvascular anastomoses. A comparative study using normal and irradiated recipient vessels for experimental free flaps in rabbits. Scand J Plast Reconstr Surg 1982; 16(3): 267-74. [CrossRef]

Cigna E, Lo Torto F, Parisi P, Felli A, Ribuffo D. Management of microanastomosis in patients affected by vessel diseases. Eur Rev Med Pharmacol Sci 2014; 18(22): 3399-405.

Takamatsu A, Harashina T, Inoue T. Selection of appropriate recipi- ent vessels in difficult, microsurgical head and neck reconstruction. J Reconstr Microsur 1996; 12(8): 499-507. [CrossRef]

Angel MF, Khazanchi RK, O'Brien BM. The anatomy of the subscapu- lar artery and its effects on flap design in the rabbit. Ann Plast Surg 1990; 24(2): 152-5. [CrossRef]

Maeda M, Fukui A, Tamai S, Mii Y, Miura S. Extracorporeal circula- tion for tissue transplantation (in the case of venous flaps). Plast Re- constr Surg 1993; 91(1): 113-24. [CrossRef]

Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98(7): 1230-3. [CrossRef]

Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, In- gram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102(3): 711-21. [CrossRef]

Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E. Free flaps: out- comes and complications in head and neck reconstructions. J Cranio- maxillofac Surg 2009; 37(8): 438-42. [CrossRef]

Janz BA, Thomas PR, Fanua SP, Dunn RE, Wilgis EF, Means KR Jr. Pre- vention of anastomotic thrombosis by botulinum toxin B after acute injury in a rat model. J Hand Surg Am 2011; 36(10): 1585-91. [CrossRef]

Fathi M, Fathi H, Mazloumi M, Khalilzadeh O, Amanpour S, Meysa- mie A, et al. Preventive effect of botulinum toxin A in microanas- tomotic thrombosis: a rabbit model. J Plast Reconstr Aesthet Surg 2010; 63(10): e720-4. [CrossRef]

Eom JS, Koh KS, Al-Hilal TA, Park JW, Jeon OC, Moon HT, et al. Antithrombotic efficacy of an oral low molecular weight heparin con- jugated with deoxycholic asset on microsurgical anastomosis in rats. Thromb Res 2010; 126(3): e220-4. [CrossRef]

Brands MT, van den Bosch SC, Dieleman FJ, Bergé SJ, Merkx MA. Prevention of thrombosis after microvascular tissue transfer in the head and neck. A review of the literature and the state of affairs in Dutch Head and Neck Cancer Centers. Int J Oral Maxillofac Surg 2010; 39(2): 101-6. [CrossRef]

Hanasono MM, Butler CE. Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg 2008; 24(5): 305-14. [CrossRef]

Lewis CM, Deschler DG. Desirudin reduces the rate of microvenous thrombosis in a rat model. Laryngoscope 2008; 118(7): 1149-52. [CrossRef]

Nayak VK, Deschler DG. Clopidogrel use for reducing the rate of thrombosis in a rat model of microarterial anastomosis. Arch Otolar- yngol Head Neck Surg 2005; 131(9): 800-3. [CrossRef]

Lee KS, Suh JD, Han SB, Yoo JC, Lee SJ, Cho SJ. The effect of aspirin and prostaglandin E(1) on the patency of microvascular anas- tomosis in the rats. Hand Surg 2001; 6(2): 177-85. [CrossRef]

Lewis CM, Deschler DG. Desirudin reduces the rate of microvenous thrombosis in a rat model. Laryngoscope 2008; 118(7): 1149-52. [CrossRef]

Miyamoto S, Okazaki M, Ohura N, Shiraishi T, Takushima A, Ha- rii K. Comparative study of different combinations of microvascular anastomoses in a rat model: end-to-end, end-to-side, and flow-through anastomosis. Plast Reconstr Surg 2008; 122(2): 449-55. [CrossRef]

Klöppel M, Tudor C, Kovacs L, Papadopulos NA, Höhnke C, Himsl I, et al. Comparison of experimental microvascular end-to-end anasto- mosis via VCS-Clips versus conventional suture technique in an animal model. J Reconstr Microsurg 2007; 23(1): 45-9. [CrossRef]

Stewart RB, Bass LS, Thompson JK, Nikoi ND, Becker G, Kung RT. Improved microvessel repair: laser welding with an anti-thrombotic solder. Lasers Surg Med 2002; 31(1): 36-40. [CrossRef]

Ichikawa M, Muneshige H, Ikuta Y. Comparison of tensile strength and thrombus formation between mechanical microvascular anasto- moses using a biodegradable ring device and sutured anastomoses. J Reconstr Microsurg 2002; 18(2): 131-6. [CrossRef]

Pikoulis E, Burris D, Rhee P, Nishibe T, Leppäniemi A, Wherry D, et al. Rapid arterial anastomosis with titanium clips. Am J Surg 1998; 175(6): 494-6. [CrossRef]

Zhong C, Tang NX, Zheng CF, Xu YW, Wang TD. Experimental study on microvascular anastomosis using a dissolvable stent support in the lumen. Microsurgery 1991; 12(2): 67-71. [CrossRef]

Nakayama Y, Soeda S, Iino T, Uchida A. Is the sleeve anastomosis a risky technique? Br J Plast Surg 1987; 40(3): 288-94. [CrossRef]

Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, et al. Choice of flap and incidence of free flap success. Plast Re- constr Surg 1996; 98(3): 459-63. [CrossRef]

Bulletti C, Jasonni VM, Martinelli G, Govoni E, Tabanelli S, Ciotti PM, et al. A 48-hour preservation of an isolated human uterus: endometrial responses to sex steroids. Fertil Steril 1987; 47(1): 122-9. [CrossRef]

Kamada N, Calne RY, Wight DG, Lines JG. Orthotopic rat liver trans- plantation after long-term preservation by continuous perfusion with fluorocarbon emulsion. Transplantation 1980; 30(1): 43-8. [CrossRef]

Sloviter HA, Kamimoto T. Erythrocyte substitute for perfusion of brain. Nature 1967; 216(5114): 458-60. [CrossRef]

Constantinescu MA, Knall E, Xu X, Kiermeir DM, Jenni H, Gygax E, et al. Preservation of amputated extremities by extracorporeal blood perfusion; a feasibility study in a porcine model. J Surg Res 2011; 171(1): 291-9. [CrossRef]

Usui M, Ishii S, Muramatsu I. An experimental study on the effect of fluorocarbon on the preservation of free skin flaps in the rabbit. Clin Orthop Relat Res 1983; 175: 273-9.

Daniel RK, Kerrigan CL. Principles and physiology of skin flap sur- gery. In: Mc Carthy Plastic Surgery, Ed McCarthy JG, Plastic Surgery, Vol I, 1990, Philadelphia: WB Sounders Co. p. 275-328.

Fisher J, Gingrass MK. Basic principles of skin flaps. In: Georgiade GS, Georgiade NG, Riefkohn R, Barwick WJ Eds. Text book of Plastic Maxillofacial and Reconstructive Surgery, 3rd ed. Baltimore: Williams and Wilkins, 1997, p.19-29.

Black MJM, Chait L, O'Brien BMC, Sykes PJ, Sharzer LA, et al. How soon may the axial vessels of a surviving free flap be safely ligated? A study in pigs. Br J Plast Surg 1978; 31: 295-9. [CrossRef]

Roux FA, Saï P, Deschamps JY. Xenotransfusions, past and present. Xenotransplantation 2007; 14(3): 208-16. [CrossRef]

Kaynak Göster