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Chen et al. Plast Aesthet Res 2023;10:24 https://dx.doi.org/10.20517/2347-9264.2022.136 Page 19 of 26

Flap alternatives
Much of the decision-making regarding the next steps following flap failure depends on what was found
following troubleshooting of the prior failed flap, anatomical limitations of the patient, and the patient’s
preferences. The decision to pursue another reconstruction should be made only after a thorough
reassessment of the patient’s medical and familial history for hypercoagulability and other potential risk
factors. Following their review of 14 patients who underwent tertiary breast reconstruction after a prior
failed reconstruction, Hamdi et al. recommend that, based on their experience, the latissimus dorsi flap and
the thoracodorsal artery perforator flap with or without an implant are associated with lower morbidity
compared to free flaps, and should be considered if the patient is at high risk of complications . At our
[161]
center, pedicled options such as the latissimus flap are essential for patients at high risk for microsurgical
thrombosis. If the patient displays a strong preference for a free flap and they are deemed a candidate for a
second attempt at free tissue transfer, preoperative planning should include CT and color Duplex imaging
to assess alternative donor sites and viable recipient vessels, hematologic consultation for assessment of
thromboembolism risk and application of thromboprophylaxis measures, and preparation of secondary
options in case the second free flap fails.

CONCLUSION
Microvascular thrombosis continues to pose challenges in autologous breast reconstruction. Reconstructive
surgeons should be mindful of obtaining relevant patient history, assessing risk factors, and consulting
anatomical imaging when necessary during preoperative planning, and vigilantly monitor signs of flap
compromise during the operative and postoperative phases. Cases of suspected thrombosis should be
approached systematically to ensure proper management, using algorithms such as the ones we have
presented in this review. Nevertheless, further investigation into individual techniques is necessary to
optimize the prevention and management of thrombotic complications in breast reconstruction.

DECLARATION
Author’s contributions
Made substantial contributions to manuscript conception, literature review, manuscript preparation, and
manuscript editing: Chen A, Garvey SR, Nanda A, Lee BT, Cauley RP

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
@ The Author(s) 2023.