Salvage of a free osteocutaneous fibula flap by creating a distal arteriovenous fistula in facial reconstruction

The case of a 25-year-old male with a facial gunshot wound is reported. A free fibula flap was performed for facial reconstruction. At 48 h after the operation, a thrombotic event was observed in the anastomosis. A distal arteriovenous (AV) fistula was performed to regulate the blood flow in the flap, and a combination of flaps (forehead flap and internal mammary artery perforator (IMAP) flap) was used for the skin defects. After creating the distal AV fistula, the blood flow was regulated and the free flap salvaged. No bone healing problem was observed in the free fibula flap and there were no complications related to the forehead and IMAP flaps. The fistula was patent at 2 years postoperative. Although all high-resistance flap conditions cannot be corrected with a distal AV fistula, the method presented in this case could be used as a last resort procedure for free flap salvage.