Summary: Coagulopathies affect 3% of free flap patients and are among the leading causes of free flap failure. This report describes the case of a head and neck cancer patient that experienced two remote free flap failures before successful autologous mandibular reconstruction. Following identification of an unrecognized thrombophilic state, a focused anticoagulation strategy was executed, including an intraoperative heparin drip, stringent postoperative maintenance of Factor Xa levels between 0.3 and 0.5 IU per mL, and transition to an outpatient enoxaparin regimen of 1 mg per kg twice daily for 1.5 months following surgery. Here, we demonstrate that free tissue transfer following multiple previous failed attempts in the setting of hypercoagulability remains a viable reconstructive option with close interdisciplinary collaboration, close clinical monitoring, and patient-specific antithrombotic protocols.

Summary: Autologous reconstruction accounts for nearly one-quarter of all breast reconstruction cases in the United States, with the abdomen functioning as the most popular donor site. This case describes a 62-year-old woman who presented to our clinic with a remote history of estrogen receptor+/progesterone+ breast cancer and bilateral implant-based reconstruction. After grade IV capsular contracture of her left breast, she presented for autologous reconstruction. Due to her body habitus and prior belt lipectomy, deep inferior epigastric perforator flap reconstruction was contra-indicated. The thoracodorsal artery perforator (TDAP) flap is well described in the literature, and was chosen as an alternative salvage procedure to avoid latissimus harvest and the need for implants. The TDAP flap is often limited in volume and prone to distal tip necrosis, limiting its use in breast reconstruction. We have previously demonstrated the utility of the surgical delay phenomenon in improving the reliability of superficial inferior epigastric artery free flap breast reconstruction. In this case, we demonstrate the surgically delayed TDAP flap as a viable alternative to the latissimus flap with implants for bilateral total autologous breast reconstruction.

Summary: Patients with a history of massive weight loss who are undergoing autologous breast reconstruction after mastectomy represent a unique surgical challenge. Although these patients often have an abundance of excess skin, it may be difficult to acquire sufficient tissue volume for adequate reconstruction of bilateral breasts using single flap techniques due to the paucity of subcutaneous fat. Stacked flap techniques have emerged as an effective method in thinner patients with suboptimal fat distribution who desire autologous breast reconstruction. This can serve as an ideal strategy, specifically in this patient population, when it serves the dual function of providing adequate volume for bilateral breast reconstruction and the secondary benefit of removing the excess skin present after massive weight loss. In this article, we discuss surgical techniques used during two cases of bilateral stacked flap breast reconstruction in cancer patients subsequent to massive weight loss.

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Supplement, 100th Annual Meeting Display EPosters amputated in a period ranging from 265 to 4680 days due to chronic rejection or poor function. Two deaths occurredone on POD 1. At present a least 70 uterus transplants have performed, and 20 healthy infants delivered. Teams from Europe, North America, South America, and Asia have reported live births. Transplants are from living or deceased donors. Two cases of pediatric VCA have been reported. A total laryngeal transplant in child and bilateral transplant in a child and regained excellent function. Challenges remain regarding ideal immunosuppression, chronic rejection, standardization of outcomes and funding. All VCAs are not lifesaving procedures and the balance risks/benefits must be carefully evaluated. VCA represents the highest rung on the microsurgical reconstructive ladder. Restorative surgery continues to evolve.