Free flap engraftment despite early pedicle thrombosis due to antithrombin deficiency

Early pedicle occlusion following microvascular flap transfer is the major cause for flap loss, which is most often surgery-associated and occurs usually within the first 48 h postoperatively. In unusual postoperative courses, patient-associated factors (e.g. thrombophilic disposition) have to be investigated. We present a case of posttraumatic reconstruction of a full-thickness skin defect of the foot in a healthy young man with a microvascular flap. At day 4 after surgery, a complete pedicle occlusion of the flap occurred resulting in a removal of the flap. Six days after transfer of another flap, a complete pedicle occlusion occurred as well in the second flap. The second flap survived due to engraftment through neovascularization. Retrospectively, antithrombin deficiency was detected. This case presents flap survival resulting from early engraftment after total pedicle occlusion, indicating the importance of a thorough and focused medical history and specific preoperative investigation if patient history is suspect for coagulopathy.