Free Tissue Transfer in Patients with Hematologic Malignancies: A Case Series

Azmi Ritana, Dewi Aisiyah Mukarramah, Muhammad Irsyad Kiat, Kasih Rahardjo Djarot, Irena Sakura Rini, Resti Mulyasari, Oskar Ady Widarta


Introduction: Free tissue transfer performed in patients with hematologic malignancies has several considerable challenges. Studies that report the challenges and outcomes related to these patients have been rather limited. This study presents the outcome of free tissue transfer as the reconstructive option for patients with hematologic malignancies. This study reports our experience regarding the perioperative evaluation, management, and outcomes of five patients with hematological malignancies that underwent free tissue transfer at Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia.

Case Presentation: Five patients with hematologic malignancies, aged 26 to 60 years, who underwent free tissue transfer at Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia from January 2017 to February 2020 were included. The outcomes such as flap survival, complications, and mortality were reviewed. There were three patients with NonHodgkin lymphoma (NHL), one patient with peripheral T-cell lymphoma, and one patient with acute myeloid leukemia (AML). All patients received free tissue transfer with flap modalities such as radial free forearm flap and anterolateral thigh. One patient had a postoperative complication of vein compromise and was treated with negative pressure wound therapy (NPWT), which resulted in partial flap necrosis. Dehiscence was also found in one patient, and the patient underwent reoperation. Then, a myocutaneous trapezius flap was applied. There was no total flap loss, no donor site morbidity, and no mortality.

Conclusions: This study has shown that free tissue transfer was a reliable reconstructive option for patients with hematologic malignancies. Flap survival and minimal complications can be achieved by optimizing the patient’s condition preoperatively, performing the meticulous nontraumatic surgical technique, closely monitoring potential post-operative complications, and implementing a multidisciplinary approach with the hematooncologists.


free tissue transfer, hematologic malignancies, leukemia, lymphoma

Full Text: View | Download

DOI: 10.33371/ijoc.v16i4.913

Article Metrics

Abstract View: 237,
PDF Download: 165


Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1999;125(3):295–9.

Ungaro R, Mikulska M. The skin and soft tissue infections in hematological patients. Curr Opin Infect Dis. 2020;33(2):101–9.

Weledji EP, Orock GE. Surgery for non-Hodgkin’s lymphoma. Oncol Rev. 2015;9(1):274.

Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute. Microsurgery. 2014;34(5):339-44.

Basheer MH, Wilson SM, Lewis H, Herbert K. Microvascular free tissue transfer in reconstruction of the lower limb. J Plast Reconstr Aesthetic Surg. 2008;61(5):525–8.

Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofacial Surg. 2003;31(4):197–201.

Suh JM, Chung CH, Chang YJ. Head and neck reconstruction using free flaps: a 30-year medical record review. Arch Craniofac Surg. 2021;22(1):38–44.

Pohlenz P, Blessmann M, Heiland M, et al. Postoperative complications in 202 cases of microvascular head and neck reconstruction. J Craniomaxillofacial Surg. 2007;35(6–7):311

Fukuiwa T, Nishimoto K, Hayashi T, Kurono Y. Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction. Auris Nasus Larynx. 2008;35(3):390–6.

Özkan Ö, Chen HC, Mardini S, et al. Microvascular free tissue transfer in patients with hematological disorders. Plast Reconstr Surg. 2006;118(4):936–44.

Lin PY, Carbera R, Chew KY, Kuo YR. The outcome of free tissue transfers in patients with hematological diseases: 20-year experiences in single microsurgical center. Microsurgery. 2014;34(7):505–10.

Ishak A, Zaharil A, Saad M, et al. Anterior chest wall reconstruction for cutaneous involvement of Hodgkin’ s lymphoma. J Surg Med. 2019;3(12):888–90.

Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia. 2002;4(6):465–73.

Verhoef J. Prevention of infections in the neutropenic patient. Clin Infect Dis. 1993;17 Suppl 2:S359–67.

Negaard HFS, Iversen PO, Østenstad B, et al. Hypercoagulability in patients with haematological neoplasia: No apparent initiation by tissue factor. Thromb Haemost. 2008;99(6):1040–8.

International Agency for Research on Cancer, World Health Organization. Estimated number of incident cases and deaths worldwide, both sexes, all ages [Internet]. Globocan; 2020 [Cited 2021 Dec 30]. Available from:

Cancer Registry in Dharmais Cancer Hospital-National Cancer Center. Most common cancer based on ICD-10 in 2013-2017. Dharmais Cancer Hospital-National Cancer Center; 2020 [Cited 2022 Mar 20]. Available from:

Herrera FA, Lee CK, Kryger G, et al. Microsurgery in the hypercoagulable patient: review of the literature. J Reconstr Microsurg. 2012;28(25):305–12.

Jokuszies A, Herold C, Niederbichler AD, Vogt PM. Anticoagulative strategies in reconstructive surgery – clinical significance and applicability. Ger Med Sci. 2012;10:Doc01.

Wu K, Lei JS, Mao YY, et al. Prediction of flap compromise by preoperative coagulation parameters in head and neck cancer patients. J Oral Maxillofac Surg. 2018; 76(11):2453.e1-7.

Biben JA, Atmodiwirjo P. Free flap thrombosis in patients with hypercoagulability: a systematic review. Arch Plast Surg. 2019;46(6):572-9.

Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist’s perspective. Plast Reconstr Surg. 2015;136(4):545e-52e.

Hanasono MM. Reconstructive surgery for head and neck cancer patients. Adv Med. 2014;2014:795483.

Yazar S. Selection of recipient vessels in microsurgical free tissue reconstruction of head and neck defects. Microsurgery. 2007;27(7):588–94.

Lee KT, Mun GH. The efficacy of postoperative antithrombotics in free flap surgery: a systematic review and meta-analysis. Plast Reconstr Surg. 2015;135(4):1124–39.

Askari M, Fisher C, Weniger FG, et al. Anticoagulation therapy in microsurgery: a review. 2006;31(5):836–46.

Barton BM, Riley CA, Fitzpatrick JC, et al. Postoperative anticoagulation after free flap reconstruction for head and neck cancer: a systematic review. Laryngoscope. 2018;128(2):412-21.

Breccia M, Avvisati G, Latagliata R, et al. Occurrence of thrombotic events in acute promyelocytic leukemia correlates with consistent immunophenotypic and molecular features. Leukemia. 2007;21(2):79–83.

Wu YY, Tang L, Wang MH. Leukemia and risk of venous thromboembolism: a meta- analysis and systematic review of 144 studies comprising 162,125 patients. Sci Rep. 2017 26;7(1):1167.

Froemel D, Fitzsimons SJ, Frank J, et al. A review of thrombosis and antithrombotic therapy in microvascular surgery. Eur Surg Res. 2013;50(1):32–43.

van Gijn DR, D’Souza JD, King W, Bater M. Free flap head and neck reconstruction with an emphasis on postoperative care. Facial Plast Surg. 2018;34(6):597-604.

Wong CH, Wei FC. Microsugical free flap in head and neck reconstruction. Head Neck. 2010;32(9):1236-45.

Kucur C, Durmus K, Uysal IO, et al. Management of complications and compromised free flaps following major head and neck surgery. Eur Arch Otolrhinolaryngol. 2016;273(1):209-13.

Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and wound healing. Int Wound J. 2005;2(2):112–27.

Denham JW, Hauer-Jensen M. The radiotherapeutic injury – a complex ‘wound’. Radiother Oncol. 2002;63(2):129–45.

Wang J, Boerma M, Fu Q, Hauer-Jensen M. Radiation responses in skin and connective tissues: effect on wound healing and surgical outcome. Hernia. 2006;10(6):502–6.

Wei FC, Demirkan F, Chen HC, et al. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder? Plast Reconstr Surg. 2001.;108(5):1154-60;discussion 1161-2.

Qiu SS, Hsu CC, Hanna SA, et al. Negative pressure wound therapy for the management of flaps with venous congestion. Microsurgery. 2016;36(6):467–73.

Hjortdal VE, Sinclair T, Kerrigan CL, et al. Venous ischemia in skin flaps: microcirculatory intravascular thrombosis. Plast Reconstr Surg. 1994;93(2):366–74.


  • There are currently no refbacks.

Copyright (c) 2022 Indonesian Journal of Cancer

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.