Free Flap Reconstruction and Its Management in Sickle Cell Trait: Lessons Learned from a Case

Mehta, Rupa; Rao, Karthik Nagaraja; Nagarkar, Nitin M.; Aggarwal, Aakash

doi:10.1007/s13193-021-01447-w

Cited by 3 publications

(9 citation statements)

References 24 publications

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“…While some case studies performed on SCT patients argue that the genetic disease should be considered a relative contraindication similar to smoking (Mehta et al), others argue that the risks of ischemia and hypothermia can be localized to the flap itself and that SCT does not represent a systemic contraindication. 2 5 McAnneny et al performed a bilateral DIEP flap on a patient with SCD and had a unilateral flap failure due to thrombosis postoperatively. They argued that flap hypothermia when cooling the left flap during harvest was the cause for failure in the context of the patient's SCT.…”

Section: Discussionmentioning

confidence: 99%

“…Optimized measures to prevent complications in SCT patients taken in other studies include doubling the dose of low molecular weight heparin after surgery (Young-Afat et al 6 ), exchange transfusion to keep the HbS level lower than 25% 4 6 application of active heating to prevent hypothermia, 7 supplemental oxygen, aspirin, verapamil, nitroglycerin paste, phosphodiesterase inhibitors, 7 hypotonic fluids, and the use of a pedicled flap versus free flap when HbS is greater than 30%. 5 However, there is no consensus as to whether these measures should be universally adopted by all surgeons. Future studies regarding preoperative optimization of HbS content through the use of medications such as voxelotor (hemoglobin polymerization inhibitor) 8 and hydroxyurea (increased production of fetal hemoglobin) 9 could also prove fruitful.…”

Section: Discussionmentioning

confidence: 99%

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Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Webster

Araya

Bartolacci

et al. 2023

J Reconstr Microsurg Open

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Background While sickle cell disease has long been considered a contraindication to breast free flap reconstruction, there have been less definitive decisions about the impact of sickle cell trait on these procedures. We sought to analyze the patients with sickle cell trait who underwent free deep inferior epigastric perforator (DIEP) flap and pedicled latissimus dorsi (LD) flap at a single institution to determine the reconstructive outcomes. Methods Patients with sickle cell trait who underwent breast free DIEP and pedicled LD reconstruction from 2007 to 2021 at a single institution by the lead surgeon were analyzed for demographics and surgical outcomes. Results Four patients were identified as having sickle cell trait and having undergone a breast flap reconstruction. The average age of the patients was 54 years, median body mass index was 25, and past medical history was notable for one patient being a current smoker, and one patient having hypertension. Two patients received a unilateral free DIEP flap, one received a bilateral free DIEP flap, and one received a unilateral pedicled LD flap for a total of five flaps in four patients. Three of the patients received prior hormone therapy, one received prior radiation therapy, and one received prior chemotherapy. There were no instances of flap failure, vessel thrombosis, pulmonary embolism, or deep venous thrombosis. One patient experienced wound dehiscence. Conclusion In this case series we present four patients with sickle cell trait who successfully underwent breast flap reconstruction without any instances of flap or systemic thrombosis. More work is needed to determine how to pre- and postoperatively optimize patients with sickle cell trait for favorable breast flap reconstruction outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Webster

Araya

Bartolacci

et al. 2023

J Reconstr Microsurg Open

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“…However, there are few case reports describing uncomplicated flap incorporation when such precautions were followed. 4,5 One case of successful flap incorporation was described in a patient with 23.3% HbS who underwent oral cavity composite resection and reconstruction with a fibular free flap. Nitrous oxide was avoided intraoperatively to prevent sickling crisis, and hemodynamics were controlled with esmolol and dexmedetomidine infusion.…”

Section: Discussionmentioning

confidence: 99%

“…Sickle-shaped erythrocytes increase blood viscosity within the microvasculature, which can lead to microcirculatory collapse and, in free-tissue transfer patients, partial flap necrosis. [3][4][5] Erythrocytes in heterozygous carriers contain 30%-40% HbS; so polymerization occurs less frequently, and the chance of microcirculatory collapse is reduced.…”

mentioning

confidence: 99%

Microsurgery in the Sickle Cell Trait Population: Can it Be Safely and Successfully Performed?

Eliseo,

Berlin,

Mansour

et al. 2023

Plastic and Reconstructive Surgery - Global Open

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Summary: Free-tissue transfer reconstruction in patients with sickle cell anemia risks failure due to polymerization of sickle hemoglobin within the flap microcirculation. However, outcomes vary, as the amount of polymerization is dependent on factors such as disease phenotype/diagnosis, degree of hypoxia, and intracellular dehydration. Most of the literature focuses on patients with sickle cell disease, which produces higher concentrations of sickle hemoglobin and, therefore, is a contraindication to microvascular reconstruction. Fewer reports describe microsurgery in patients with sickle cell trait (SCT) who carry the heterozygous phenotype. Here, we present a case in which a patient with SCT underwent microsurgical breast reconstruction with deep inferior epigastric perforator free-tissue transfer. The 52-year-old woman had previously experienced a failed alloplastic-based reconstruction after radiation therapy for breast cancer. In our case, clinical and Doppler examinations demonstrated that arterial and venous anastomoses had remained patent; so the patient was discharged on postoperative day 4. Blistering developed on postoperative day 8, and by day 15 there was partial necrosis of the inferior-lateral aspect of the deep inferior epigastric perforator flap. Debridement and closure resolved the issue, and at 5 months postprocedure, the flap remained well-perfused and well-incorporated. This case, presented here with patient consent, reports a successful outcome of microsurgical reconstruction in a patient with SCT. It expands the limited evidence to support the safety and feasibility of autologous surgical interventions for patients with the heterozygous phenotype of sickle cell anemia.

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“…Seven articles describing free tissue transfer in SCT were excluded from analysis but reviewed in the "Discussion" section. [13][14][15][16][17][18][19] Fig. 3 (A Patient ages ranged from 19 to 38 years old (average 30.7 years), with five males and five females.…”

Section: Systematic Reviewmentioning

confidence: 99%

Free Tissue Transfer in Sickle Cell Disease: A Case Report and Systematic Review

2023

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Hemoglobinopathies such as sickle cell disease (SCD) are traditionally considered a relative contraindication to free tissue transfer, due to concerns that erythrocyte sickling will increase the risk of microvascular thrombosis and flap failure. This article describes a case report with the successful use of free tissue transfer in a patient with SCD and provides a systematic literature review on free tissue transfer in SCD. A retrospective chart review was performed of a patient with SCD who underwent free tissue transfer at the authors' institution. A systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using the keywords “free tissue transfer,” “free flap,” or “microsurgery” and “sickle cell” on PubMed, Ovid/Medline, and Scopus. A 29-year-old male with delayed presentation of an electrical burn to the face and scalp underwent wound closure with a free anterolateral thigh flap. Key management principles included red blood cell transfusion to keep hemoglobin S under 30% and hemoglobin greater than 10 g/dL, maintenance of hydration, normothermia, adequate analgesia, and postoperative anticoagulation. Systematic literature review identified 7 articles describing 13 cases of free tissue transfer in 10 patients with SCD, with combined complete free flap success in 10 of the 13 flaps. Free tissue transfer can be successfully performed in patients with SCD. However, evidence on the optimal management of this unique patient population in the perioperative period after free tissue transfer is limited to case reports in the literature.

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Free Flap Reconstruction and Its Management in Sickle Cell Trait: Lessons Learned from a Case

Cited by 3 publications

References 24 publications

Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Should Sickle Cell Trait Be a Contraindication to Breast Reconstruction?—A Case Series Analysis

Microsurgery in the Sickle Cell Trait Population: Can it Be Safely and Successfully Performed?

Free Tissue Transfer in Sickle Cell Disease: A Case Report and Systematic Review

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