Clinical Significance of Hyperhomocysteinemia in Free Flap Failure: A Case Report

Abstract

Failure of a microvascular free flap remains rare, yet multiple failures can occur, particularly in the presence of hypercoagulable conditions. This case series highlights our experience with a rare hypercoagulable state: hyperhomocysteinemia. We present two cases of patients with hyperhomocysteinemia in this report. High-dose heparinization was administered to both patients, resulting in successful salvage of one flap and failure of the other. Notably, one patient had a history of prior free flap failures. However, after correcting hyperhomocysteinemia, subsequent free flaps were successful. In cases of detected complications, a coagulability study is warranted, and adjustments to anticoagulation treatment may be necessary. Furthermore, when a history of flap failures is evident, screening for hyperhomocysteinemia may be warranted, with correction made prior to reconstruction.

Keywords: free flap failure; hypercoagulability; hyperhomocysteinemia.

Fig. 1

. ( A ) Initial photography of the case report during the initial evaluation at our center. ( B ) Conventional angiography of the case report. ( C ) Postop second-week picture of the case report after failed SCIP free flap. ( D ) Postop second-month picture of the case report following MSAP free flap. MSAP, medial sural artery perforator; SCIP, superficial circumflex iliac artery perforator.

Fig. 2.

( A ) Initial photograph of the patient presenting a skin defect with exposed bone due to chronic osteomyelitis. ( B ) Bone (left) and WBC (right) SPECT/CT imaging of the patient demonstrates a nonunion in the left distal tibia, characterized by diffusely increased tracer uptake, sclerotic changes, and WBC accumulation around a comminuted fracture with a dislodged screw, suggestive of probable osteomyelitis. ( C ) Photograph taken on the fifth postoperative day after gracilis muscle flap reconstruction in the patient with chronic osteomyelitis and a history of free flap failure. ( D ) The application of a skin graft following stabilization of the free flap.