Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hematol. Nov 6, 2016; 5(4): 94-98
Published online Nov 6, 2016. doi: 10.5315/wjh.v5.i4.94
Successful lower leg microsurgical reconstruction in homozygous sickle cell disease: Case report
Carolina Posso, Francisco Cuéllar-Ambrosi
Carolina Posso, Plastic and Reconstructive Surgery Service, University of Antioquia, Antioquia, Medellín 050010238, Colombia
Francisco Cuéllar-Ambrosi, Hematology Service, León XII Clinic, IPS Universitaria, Antioquia, Medellín 050010204, Colombia
Author contributions: Posso C and Cuéllar-Ambrosi F contributed to the acquisition of data and writing of the manuscript.
Institutional review board statement: This case report was reviewed by and adhered to the standards set forth by the Institutional Review Board of the Clinic León XIII Ips University of Antioquia, Colombia.
Informed consent statement: The anonymity of the identity of the patient involved in this study was not compromised in the case report. The patient provided written informed consent for publication of these data.
Conflict-of-interest statement: Both authors declare no conflicts of interests in relation to this study or its publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Carolina Posso, MD, Plastic Surgeon-Microsurgeon, Plastic and Reconstructive Surgery Service, University of Antioquia, Antioquia, Medellín 050010238, Colombia.
Telephone: +57-4-3861283
Received: May 21, 2016
Peer-review started: May 23, 2016
First decision: July 27, 2016
Revised: October 12, 2016
Accepted: October 25, 2016
Article in press: October 27, 2016
Published online: November 6, 2016

We present an 18-year-old female with sickle cell disease, who presented with an extensive lower leg ulcer over a 12-year course of the disease. Definitive reconstruction was made using a free latissimus dorsi flap and split-skin grafts. One week before the surgery, the plasmapheresis protocol and blood transfusion were administered, in order to achieve a hemoglobin S level of ≤ 30%. Intraoperatively, the flap pedicle was rinsed with plasminogen activator inhibitor-1 until the thrombolytic agent was obtained from the comitant vein; after the arterial flow had been released, an intravenous bolus dose of heparin (2000 U) was administrated. No vascular complications occurred. Postoperatively, the patient received a 10-d course of hemodilution and a 14-d course of full-dose anticoagulation. After 8 mo postoperatively, the patient was able to walk and run, and showed complete wound healing. This case indicates that sickle cell disease is not a contraindication to free tissue transfer; however, the complications, their rate and overall outcomes for these cases are not yet clear. Herein, we provide an algorithm based on our clinical experience in this type of case and treatment, including several recommendations that may help to reduce thrombosis risk and systemic complications.

Keywords: Sickle cell disease, Free flaps, Success rate, Microsurgical reconstruction, Ulcer

Core tip: This is a case report of a successful microsurgical reconstruction in a patient with sickle cell disease who presented with an extensive lower leg ulcer during a 12-year course of the disease. We provide several recommendations for plasmapheresis and blood transfusions before the surgical reconstruction, and the anticoagulation protocol during the procedure and the postoperative period. This case description is intended to increase our colleagues’ motivation to perform microsurgical reconstruction with a safer approach in the presence of hematologic diseases with elevated risk of thrombosis.