Hypercoagulability in microvascular breast reconstruction: an algorithmic approach for an underestimated situation.

Despite appropriate surgical technique and follow-up, flap failures can be encountered for which no valid reason is evident. Current literature states that these unpredictable flap failures can be caused by unknown patient factors, such as undiagnosed hypercoagulability. Our approach and experience utilizing an algorithm to minimize unpredictable failures in microvascular breast reconstruction by predetermining hypercoagulation risk factors in preoperative patients is presented. A prospective assessment of microsurgical breast reconstruction candidates between October 2007 and December 2010 was conducted. Patients were questioned about their tendency toward hypercoagulation. A thrombophilia panel was requested for patients confirming any risk factors. Appropriate surgical planning was conducted according to results of the panel. Of the 60 patients thoroughly questioned about hypercoagulation tendency, 21 (35%) confirmed having prothrombotic tendency and were referred to the thrombophilia testing. The results indicated hypercoagulation in 9 (15%) patients. The primary reconstruction plan of utilizing free flaps was abandoned for these patients and pedicled flaps or implants were preferred for reconstruction. These percentages emphasize the value of questioning risk factors and testing for hypercoagulation in patients seeking microsurgical breast reconstruction. We believe that detailed preoperative questioning of risk factors and appropriate testing according to prothrombotic tendency is beneficial in minimizing unpredictable flap failures and increasing rates of success.