Abstract
Breast reconstruction is one of the largest components of plastic and reconstructive surgery. Autologous free flap breast reconstruction continues to grow due to exceptionally high flap success rates. It provides patients with a durable and natural reconstruction with high patient satisfaction. A patent microvascular anastomosis is a key component to a successful autologous free flap breast reconstruction. Thrombus within the vascular anastomosis or the distal flap microcirculation is the most common cause of flap failure. This review aims to discuss microsurgical techniques including atraumatic handling of vessels, appropriate magnification, suture styles, anastomotic techniques, recipient vessel selection, the role of anticoagulation and antiplatelet therapy used to minimize the risk of thrombotic events. When microvascular thrombus occurs, early reoperation and reperfusion is imperative to flap survival. This review will discuss specific maneuvers and intraoperative interventions to maximize flap salvage.