Autologous Mandible Reconstruction in a Hypercoagulable Patient following Multiple Failed Free Flaps

Abstract

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.

Use of Flow-through Free Flaps in Head and Neck Reconstruction

“… 4 , 9 To improve operative time and flap design, the primary surgeon may also consider the use of virtual surgical planning and patient specific titanium plates when bony flaps are involved. 8 , 22 The ultimate goal of these cases is to improve speech articulation, respiration, deglutition, mastication, and facial aesthetics by reducing an exposed oral cavity.…”

“…2,4 The neck that is previously irradiated or operated on does not preclude the use of recipient vasculature from the ipsilateral side. 2,8 However, recipient sites away from the zone of injury/radiation, as with the case of the transverse cervical vessels, may decrease the risk of vascular complications. 9 In our series, free flaps were harvested in a standard fashion.…”

“…An exception to this is when patients have a documented history of hypercoagulability, and further interventions to prevent postoperative thromboembolism are taken. 8 , 15 In addition, we perform flap checks every 1 hour the first 24 hours postoperatively, every 2 hours between 24 and 48 hours postoperatively, and every 4 hours for the remainder of the hospital admission.…”

Survival and infection rates of microvascular free flaps in pediatric mandibular reconstruction: A systematic review and meta‐analysis

“…Moreover, the reporting of anticoagulation protocols was not clearly reported in most of our included studies. This raises significant concerns considering the approximate 3% incidence of coagulopathies within patients undergoing free flap surgery and the consequential severe ramifications as a predominant etiology of flap failure (Maier et al, 2022). Our collected data encompassed two instances of flap failure ascribable to venous thrombosis, each emanating from separate studies (Santamaría et al, 2008; Santamaría et al, 2021).…”