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Figure 1. Algorithm for management after flap failure.

management of the patient and has the most influential impact on helping patients through this difficult
time.

HEMATOLOGICAL INVESTIGATION
A hematology workup should be considered if risk factors for clotting are identified during the preoperative
evaluation, or if unexplained clotting resulting in failure is encountered postoperatively. While free flap
transfer can be successfully performed in patients with underlying thrombophilias, hypercoagulability has
traditionally been described as a relative contraindication to free tissue transfer. A recent systematic review
performed by Kotamarti et al. found an 18.4% thrombosis rate with a pooled 12.2% flap failure rate in breast
reconstruction patients concerning patients with hypercoagulability . Many patients with hereditary or
[22]
[23]
acquired thrombophilia experience their first complication in the setting of surgery . Additionally, when
thrombosis is discovered postoperatively in these patients, the salvage rate is near zero [23,24] .

Thrombophilia is reported to have a prevalence rate of 5 to 27% of the population, with even higher
prevalence in oncologic patients and patients undergoing lower extremity reconstruction [22,25,26] .
Hypercoagubility disorders can be hereditary or acquired. Hereditary disorders include factor V Leiden,
prothrombin G20210A mutation, methylenetetrahydrofolate reductase (MTHFR) mutations, protein C
deficiency, protein S deficiency, antithrombin III deficiency, and elevated factor VIII. Acquired conditions