Patient With Facial Damage Undergoes Tissue Transplant
A man with cold agglutinin disease (CAD) successfully underwent microvascular free tissue transfer — a tissue and blood vessel transplant — to repair extensive damage to his face, a case study reported.
Authors noted that due to the lack of precedence in the literature, this report provides guidance on this procedure in CAD patients who have an increased risk of blood vessel blockage.
The case study, “Microvascular free tissue transfer in the setting of cold agglutinin disease,” was published in the journal Microsurgery.
In CAD, self-reactive antibodies called cold agglutinins bind and destroy red blood cells at low temperatures in a process known as hemolysis. This can cause the damaged cells to clump together and block small blood vessels, which is referred to as microvascular occlusion.
Microvascular free tissue transfer is a surgical technique applied following extensive tissue damage, in which tissues containing small blood vessels are transferred from one site of the body to the site of injury to promote healing.
Although blood vessel transfer in people with CAD may pose problems due to a higher risk of blood vessel blockage, there is a lack of published guidance on the procedure in CAD patients.
In this report, clinicians at the Galway University Hospital in Ireland described the case of microvascular free tissue transfer in a 61-year-old man with CAD who had sustained a self-inflicted gunshot wound to his lower face.
“We wish to highlight the previously unreported management of microvascular free tissue transfer in the setting of cold agglutinin disease,” the team wrote.
The man previously had been diagnosed with secondary CAD associated with a rare white blood cell cancer called Waldenström macroglobulinemia (WM). His symptoms included hemolysis and acrocyanosis — bluish color of the skin.
He successfully underwent surgery to repair his lower jaw bone using a rigid metal plate, but there was significant loss of the lower lip and plate exposure.
Two days later, the man was scheduled for microvascular free tissue transfer, in which a portion of skin tissue from his lower forearm would be transplanted onto his neck. Because of his CAD, the team members consulted with their colleagues in hematology who specialize in blood diseases.
Before the transfer surgery, his level of hemoglobin — the protein that carries oxygen in red blood cells — was slightly below the normal range at 8.8 grams per deciliter of blood. While his platelet count was within the normal range, his plasma viscosity, or blood thickness, was elevated.
Without any symptoms of high blood viscosity or worsening of hemolysis, no preoperative therapy was prescribed. Instead, the team monitored the patient closely and avoided cold temperatures.
The surgery took place in a heated surgical suite, where the man was given warmed fluids and warming blankets. To prevent red blood cell clumping in the arm and the tissue flap, no tourniquet was applied to his upper arm to reduce blood flow.
Before removing a flap of arm tissue, blood vessels in the neck were prepared in advance to be connected to the new blood vessels. After the flap was removed, it was flushed with a solution containing the anticoagulant heparin to prevent blood clotting (thrombosis) and kept warm with saline “to prevent cold-induced red cell agglutination.”
One artery and two veins were connected end-to-end onto the lower face. During and after surgery, he received daily doses of anticoagulants. Routine postoperative monitoring showed the procedure was successful with complete skin lap survival.
“This report gives guidance in the management of microvascular free tissue transfer in CAD,” the authors wrote. “It is highly relevant in microsurgery as antibody activation can lead to hemolysis, microvascular occlusion and thrombosis, and ultimate flap failure.”