Background
Arteriovenous (AV) looping prior to the lower extremity free flap reconstruction enables better venous drainage in flap circulation, leading to less flap complications and better survival. A two-staged reconstruction including free tissue transfer after AV looping ensures a robust venous drainage of the flap. Arterialization of the AV loop results in less venous problems after the free flap reconstruction. However, major problems of this staged operation include AV loop kinking, heavy compression and loop exposure, leading to AV graft failure and interruption of surgical planning.

Aim & Objective
We established the use of a venous flap for AV looping during the first stage of reconstruction to avoid AV loop kinking, heavy compression and loop exposure.

Cases Presentation
Three patients received the 2-staged lower limb reconstruction in our medical center from 2004 to 2006. All of them were indicated after debridement of their feet due to trauma or infection.During AV loop creation, the attached skin paddle was transferred along with the vein graft. In this manner, more space was reserved for the AV loop to prevent vein graft kinking and heavy compression. Additionally, the skin flap also provides good coverage over the AV graft to prevent exposure and rupture.

Results
All patients received vein graft transfer together with an attached skin paddle for AV looping first and a scheduled free flap transfer after a few days. All flaps survived well at 1 year follow-up visit after the reconstruction.