The anterolateral thigh (ALT) flap has become the workhorse flap for head and neck reconstruction. As a flap requiring meticulous dissection, inadvertent injuries of the perforator or pedicle could occur during the dissection. However, its occurrence and salvage experience is rarely reported.
A 50-year-old man was diagnosed with squamous cell carcinoma of the tongue and received an immediate ALT flap reconstruction after a hemiglossectomy. The ALT flap nourished by two musculocutaneous perforators was dissected and transferred as usually. However, the revascularized flap remained pale and showed no dermal bleeding. Vasospasm was impressed, and we waited for its spontaneous resolution. Along with the time, the atrial pulsation became stronger and stronger and could be easily palpated anywhere at the pedicle level. One hour passed, the flap still showed no sign of perfusion. Under microscopic examination, we traced along the pedicle in the direction from the anastomoses to the perforators and found out that the arterial pulsation and continuity were disrupted at the pedicle-perforator junction, where a nearby hemoclip used to clamped a muscular branch of the pedicle was also noted. The two concomitant veins were unremarkable. We confirmed the pedicle artery was trapped in the hemoclip and was transected but struggled in finding the distal transected end, nor did the distal runoff. We first tried to salvage the flap by anastomosing the transected pedicle artery to the smaller concomitant vein in a retrograde fashion, but it only showed transient reperfusion, evidenced by scanty dermal bleeding. The arterial inflow stopped at the pedicle-perforator junction then. As the last try, we performed microdissection retrogradely from the two perforators, and eventually found a vascular lumen shortly after the confluence of these two perforators. We then succeeded the pedicle-perforator arterial anastomosis by 10-0 Nylon. The flap resumed substantial perfusion dramatically. The postoperative course was uneventful afterward.
Inadvertent vascular pedicle or perforator injury does occur inevitably. Early detection of the injury may facilitate a prompt salvage managements. Here, we report an unnoticed arterial injury at the pedicle-perforator junction and share our experience in the salvage practice.