Incidental Total Necrosis of a Successful Flap Due to a Secondary Operation after One Year

Developments in microsurgical techniques and instruments have enabled the high success rate of microvascular tissue transfers. Initially, the survival of a free flap is dependent on its vascular pedicle, and the failure of flaps generally occurs within seven days of surgery. Several experimental studies have shown that pedicles can be ligated 5 to 10 days after the operation. Hence, at that time, the flap can be safely divided, and its survival can be ensured [1]. In addition, clinical studies have recommended that flaps can be safely divided between 7 and 21 days after surgery [2]. In this article, we report a case of the total loss of a flap after a secondary operation that was performed one year after successful reconstruction using a latissimus dorsi muscle flap. A 68-year-old male presented with a chronic wound on his left leg. The patient had suffered an open fracture of his left tibia 15 years previously due to a fall. Radiologic findings revealed non-union of the tibia, and osteomyelitis was suspected. The orthopedic surgeon debrided the osteomyelitic bone, and we performed a reconstruction using a latissimus dorsi muscle free flap, which was 10 cm × 8 cm in size, and a split thickness skin graft to cover the wound. The pedicle was located in the middle of the flap, and a posterior tibial vessel was used as the recipient vessel. The reconstruction was successful without complications such as partial necrosis, color change, or congestion (Fig. 1). Eighteen months later, the debrided bone with the bone defect seemed to be unstable, and the orthopedic surgeon planned an open reduction and internal fixation with a plate and free bone graft. A skin incision was made at the lateral margin of the flap, and the operation was conducted with a tourniquet applied. The location of the pedicle was marked using a hand Doppler before the operation, and no injury was found in the pedicle during dissection. There was no evidence that the main pedicle was bleeding after the tourniquet was removed. Immediately after the operation, the flap displayed a partial change of skin color (Fig. 2), and after three weeks, it became totally necrotic. We decided to discard the flap (Fig. 3) and reconstructed the defect with an anterolateral thigh flap, which was 12 cm × 9 cm in size, by using the posterior tibial artery as the recipient vessel (Fig. 4). Three weeks later, the orthopedic surgeon removed the plate and the screws. A skin incision was made at the lateral margin of the flap. The method by which the perforator of the flap was marked was the same as Incidental Total Necrosis of a Successful Flap Due to a Secondary Operation after One Year