Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity.

BACKGROUND: Microvascular free-tissue transfer is a reliable pillar of reconstructive surgery, yet pedicle thrombosis remains a challenge. The authors examined the phenomenon of late venous thrombosis (after postoperative day 3) and detail a method of flap salvage that can be utilized following this microvascular insult.
METHODS: A retrospective review was performed of all free flap breast reconstructions performed by the senior author (J.M.S.) from 1991 to 2008, utilizing a prospectively maintained database. All cases of postoperative thromboses were evaluated. Late venous thrombosis was defined as a thrombosis occurring after postoperative day 3.
RESULTS: A total of 1277 free flap breast reconstructions were performed over the 17-year period. Nineteen flaps had venous thromboses (1.5 percent), and 10 of these occurred after postoperative day 3 (average, 5.67 days; range, 4 to 12 days). Operative exploration was employed in seven of 10 cases, with the remaining patients presenting too late or too advanced for operative intervention. Sixty percent of flaps were fully salvaged, and two were partially saved, with some subsequent volume loss. Earlier late venous thrombosis presentation led to better outcomes overall.
CONCLUSIONS: Late venous thrombosis is a rare phenomenon that, although occurring late in the postoperative course, is an acute event. Early recognition and urgent treatment are key to flap salvage, with clinical judgment dictating the treatment choice. In the absence of extenuating circumstances, the authors prefer urgent exploration in the operating room, as flap survival following late venous thrombosis is a race against time but with a high probability of salvage if the proper steps are taken. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.