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We present the case of a 40-year-old patient with sickle cell trait who underwent bilateral breast reconstruction with microvascular TRAM flap transfer. Intraoperatively, the patient developed arterial anastomotic thrombosis of the right breast flap. The left breast flap had already been harvested and was placed on ice. Both anastomoses were then successfully completed. Postoperatively, the patient developed a pulmonary embolism and heparin-induced thrombocytopenia. On postoperative day 12, the left cutaneous Doppler signals were lost, and exploration revealed a thrombosed pedicle and nonviable left breast flap. Pathologic specimen evaluation revealed sickled cells within the flap microvasculature. We believe that prolonged ischemia time and hypothermia precipitated erythrocyte sickling within the flap, causing intra-flap thrombosis that propagated to the pedicle. While sickle cell diseases are not a contraindication to free tissue transfer, we believe that flap cooling should be utilized with caution in this circumstance.

The anterolateral thigh flaps allows for a large amount of vascularized skin and subcutaneous tissue for transfer as a locoregional flap or for microvascular free tissue transfer. In the settings of a large flap, primary closure of the donor site can be difficult. Multiple techniques, including the use of tissue expansion, can be used to assist with donor site closure. The DermaClose external tissue expander can be employed in such situations. We describe two cases with a unique use of the DermaClose system and postoperative complications.

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