Fibula Free Flap Survival after Early Arterial Avulsion

Abstract

Objectives: 1) Recognize factors that influence free flap survival. 2) Describe early neovascularization in free tissue transfer. Methods: Retrospective case report. Results: A 58-year-old male patient underwent composite resection with fibula osteocutanous free flap reconstruction for a floor of mouth squamous cell carcinoma involving the anterior mandible. On postoperative day 10, the patient was found to have a rapidly expanding neck hematoma and intraoperatively was found to have complete arterial avulsion of the pedicle. No revision microanastomosis was performed due to the lack of an available microsurgeon. Although arterial inflow to the vascular pedicle was lost, the flap showed 100% survival at 4 weeks post-op. This rare outcome suggests early neovascularization in this free tissue transfer. The exact timing of neovascularization in free flaps is not clearly delineated. Experimental animal models have suggested neovascularization as early as postoperative day 7. Review of the literature shows that successful neovascularization is dependent on many factors, especially previous radiation treatment, quality of the recipient site, infection, and vascular ischemia. Conclusions: This and other rare case reports of maintained flap viability despite loss of the vascular pedicle suggest early neovascularization. This report stresses the importance of flap surveillance in order to avoid premature flap revision in cases of early neovascularization.