Foot ischemia after a free fibula flap harvest: immediate salvage with an interpositional sapheneous vein graft.

The most dreaded major donor-site complication of free fibula flap is a foot ischemia, which is fortunately rare. Various authors have discussed the efficacy of the use of preoperative imaging methods including color Doppler, magnetic resonance angiography, and conventional angiography. A 25-year-old man presented with a 10-cm mandibular defect after a facial gunshot injury. Lower extremity color Doppler revealed triphasic peroneal, tibialis anterior, and posterior artery flows. A fibula osteocutaneous flap was harvested, and the mandible was reconstructed. However, the suture sites at the donor site began to demonstrate signs of necrosis, abscess formation, and widespread cellulitis beginning from postoperative day 9. Angiogram of the lower extremity on the 13th day demonstrated no flow in the right posterior tibial artery distal to the popliteal artery, whereas the anterior tibial artery had weak flow with collateral filling distally. An emergency bypass with a saphenous vein graft between the popliteal artery and the distal posterior tibial artery was performed. Repeated debridements, local wound care, and vacuum-assisted closure were applied. A skin graft was placed eventually. The extremity healed without severe functional disability. In conclusion, although the arterial anatomy is completely normal in preoperative evaluation, vascular complications may still ocur at the donor fibula free flap site. In addition, emergency cardiovascular bypass surgery, as we experienced, may be necessary for limb perfusion.