Hereditary Coagulopathies: Practical Diagnosis and Management for the Plastic Surgeon

Abstract

Background: Venous thromboembolism is a devastating complication representing one of the major causes of postoperative death in plastic surgery. Within the scope of plastic surgery, body-contouring procedures are often considered to carry a higher risk of venous thromboembolism. Hereditary thrombophilias comprise a group of conditions defined by a genetic predisposition to thrombosis development. Collectively, hereditary thrombophilias are present in at least 15 percent of Western populations and underlie approximately half of thromboembolic events. Although the topic of venous thromboembolism is discussed widely throughout the literature, there is little published on the diagnosis and management of hereditary thrombophilias in the plastic surgery literature. The goals of this study were to present a review of the major inherited thrombophilias, to delineate the risk of these disorders, and to recommend a practical algorithm for patient screening and management before major plastic surgery. Methods: A MEDLINE search was performed from 1965 to the present to review the literature on inherited thrombophilia disorders. Results: Based on the English language literature and clinical experience, the authors suggest practical guidelines for screening and management of hereditary thrombophilias. A thorough medical history and preoperative evaluation are key to reducing venous thromboembolism complications. Conclusions: Hereditary thrombophilias are present in a significant number of thromboembolic events. Preoperative vigilance on the part of the plastic surgeon may help to identify patients with undiagnosed hereditary thrombophilias and thereby decrease the incidence of venous thromboembolism. (Plast. Reconstr. Surg. 125: 1544, 2010

Free Tissue Transfer in the Hypercoagulable Patient

“…Friedman et al have outlined questions to ask patients to identify any coagulopathies. 36 If there is a positive history, referral to a hematologist should be considered with discussion of perioperative anticoagulation management. Patients need to have full informed consent and be counseled about their higher risk of microvascular complications and flap loss.…”

Postoperative Enoxaparin Prevents Symptomatic Venous Thromboembolism in High-Risk Plastic Surgery Patients

“…We observed multiple breakthrough events in the VTEPS enoxaparin group, although the distinct causes of these events remains unclear. Unrecognized hypercoagulability has been identified as a major contributor to VTE risk 33–36 . VTEPS data supports that prior personal history of VTE is an important risk factor as well (Table 3).…”

Microsurgery and the Hypercoagulable State

“…If negative, the patient proceeds with standard surgical evaluation. 60 We disagree with the approach proposed by Friedman and colleagues, particularly as it relates to the microsurgical population, because of the primacy it places on thrombophilia testing. As discussed above, a pathophysiologic link between hereditary thrombophilia and flap thrombosis has not been established, and the presence of hereditary thrombophilia without a personal history of thrombosis was not associated with adverse flap outcomes in a retrospective cohort study.…”