In patients with sickle cell disease (SCD) with complex defects, the use of reconstruction with free tissue transfer can prove successful with medical and surgical optimization, according to findings from a case report and systematic literature review published in Archives of Plastic Surgery.

SCD is an inherited blood disorder and is associated with the presence of abnormal hemoglobin S (HbS) protein. HbS polymerization is related to changes in the structure and function of erythrocytes, such as deformation into a sickle shape, development of increased stiffness, and the presence of elevated adhesion.

Historically, the use of free tissue transfer is contraindicated in patients with SCD because tissue hypoxia and obligate transient flap ischemia may trigger sickling and microvascular thrombosis. Further, individuals with SCD are known to be hypercoagulable and at elevated risk for peri- and postoperative complications, such as venous thromboembolism, pulmonary embolism, acute chest syndrome, vaso-occlusive crisis, cerebrovascular stroke, and acute kidney injury.

With this publication, the authors sought to accomplish the following:

  • Present a case report that describes the successful use of free tissue transfer in a patient with SCD.
  • Conduct a systematic literature review in an effort to identify prior cases involving free tissue transfer in patients with SCD, thus establishing rates of success and complications, as well as evaluating preoperative, intraoperative, and postoperative management strategies.

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The patient described in the case report was a 29-year-old African American male with SCD who presented to the emergency department with swelling of his right lower extremity, along with a large, infected wound over the right side of his face and scalp. He underwent free tissue transfer for soft tissue coverage of this large craniofacial defect—the result of a 2-month-old accident in which he sustained an electrical burn to his face and scalp after being pushed onto a subway live rail. The patient’s wound closure involved the use of a free anterolateral thigh flap reconstruction.

Key management considerations for this patient were:

  • Red blood cell transfusion to keep his HbS level at less than 30% and his Hb level at great than 10 g/dL.
  • Maintenance of hydration, normothermia, sufficient analgesia, and postoperative anticoagulation.

According to the systematic literature review, 7 articles were identified that described 13 cases of free tissue transfer that occurred in 10 patients with SCD. The patients ranged in age from 19 to 38 years (average age, 30.7 years). Overall, 5 cases were in males and 5 were in females.

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All of the patients received preoperative exchange transfusions. The target HbS level was less than 30%, except in 1 case in which it was 33.8% and another case in which it was not reported. In all of the cases, the Hb transfusion goal was greater than 10 g/dL; the goal was not reported in 4 of the cases. Of the 13 free flaps performed, success was reported in 10 of them.

“Free tissue transfer can be successfully performed in patients with SCD,”  the researchers explained. “However, evidence on the optimal management of this unique patient population in the perioperative period after free tissue transfer is limited to case reports in the literature,” they concluded.


Huang A, Patel RA, Gottlieb LJ. Free tissue transfer in sickle cell disease: a case report and systematic review. Arch Plast Surg. Published online May 29, 2023. doi:10.1055/s-0043-1763260