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Microvascular Free Flap Failure Caused by Unrecognized Hypercoagulability

Davison, Steven P. D.D.S., M.D.; Kessler, Craig M. M.D.; Al-Attar, Ali M.D., Ph.D.

Plastic and Reconstructive Surgery: August 2009 - Volume 124 - Issue 2 - p 490-495
doi: 10.1097/PRS.0b013e3181adcf35
Reconstructive: Head and Neck: Clinicopathological Conferences

Background: Microvascular free flap techniques have improved over the past two decades such that flap failure rates have dropped to under 3 percent in most large series of high-volume centers. However, despite technical and patient-selection advances, some components of free flap failure might be attributable to undiagnosed patient factors.

Methods: In this clinicopathologic conference article, the authors present four patients with major free flap microvascular complications who were later diagnosed with multiple risk factors for hypercoagulability and biochemical abnormalities, and present the characteristic associated findings.

Results: Previously undiagnosed hypercoagulability was present in four patients with major free flap microvascular complications. Hematologic consultation and laboratory investigation revealed the biochemical abnormalities.

Conclusions: In certain patients undergoing microvascular free flap reconstruction, undiagnosed hypercoagulability risk factors can be a source of free flap failure that is independent of patient selection or technical factors. Diagnosis, management, patient counseling, and initiation of deep venous thromboembolism prophylaxis measures are critical clinical components of care of these patients.

Washington, D.C.

From the Department of Plastic Surgery and the Division of Coagulation, Georgetown University Hospital.

Received for publication October 8, 2008; accepted February 27, 2009.

Disclosure: None of the authors has any financial conflicts of interest.

Steven P. Davison, D.D.S., M.D., Da Vinci Plastic Surgery, 3301 New Mexico Avenue, Suite 236, Washington, D.C. 20016,

©2009American Society of Plastic Surgeons