Late ischemic compromise of free flaps is a rare occurrence.1–3 Largo et al recently reported a series of presentations with vascular flap complications as outpatients. There were 17 such cases out of 7443 free flap reconstructions in their series (0.002% incidence) and all patients had complete or partial flap failure despite salvage attempts. Very low salvage rates of outpatient free flap ischemia have been reported by other authors.2,3 We present a case of delayed outpatient free flap ischemia due to an avulsed arterial pedicle and discuss the factors that allowed successful salvage in this scenario.

Case presentation

A 48-year-old woman with a history of multi-focal right breast cancer underwent right mastectomy and sentinel node biopsy with adjuvant chemotherapy and radiotherapy (50Gy in 25 fractions). Thirty-four months following completion of radiotherapy she underwent a right breast reconstruction with a free, deep inferior epigastric perforator (DIEP) flap utilising a single left medial row perforator. The flap weighed 1.10 kg after shaping.

The fourth costal cartilage was resected to access the internal mammary vessels. Anasotomoses were with a running 9-0 nylon for the vein and interrupted 9-0 nylon for the artery. There were no intraoperative vascular concerns and the vascular pedicle draped comfortably in a gentle arc inferolaterally from the anastomoses. The flap was inset with fascial and dermal suspension sutures peripherally and with subcutaneous skin closure. The patient recovered well with normal flap observations and was discharged home on postoperative day three.

On day 13 post-surgery the patient slipped backwards while walking, landing on her buttocks. She noted immediate painful swelling of the right chest, which increased rapidly over several minutes. She was pre-syncopal. An ambulance transferred her to the emergency department where she was assessed and the plastic surgical registrar called immediately. She had marked right chest swelling, was tachycardic and mildly hypotensive. The flap was noted to be cool and pale without an audible Doppler signal.

A haematoma with flap compromise was diagnosed. Resuscitation was begun with intravenous crystalloid, prior to an urgent transfer to the operating theatre. She arrived on the operating table two hours and thirty minutes post fall. Her haemoglobin was 60 g/L and she remained hypotensive until blood transfusion which was commenced at induction of anaesthetic. A full microsurgery set-up was organised for suspected pedicle rupture.

The flap was elevated off the chest wall and found to be ischaemic with no bleeding from the flap edge. A large haematoma (1.5–2L) was evacuated from the sub-flap space which was seen to be tracking to the pedicle. After removal of the haematoma, brisk arterial bleeding was encountered from the anastomotic region. Bleeding was controlled with digital pressure while the internal mammary artery (IMA) was definitively identified and controlled with a microvascular clamp. The arterial anastomosis had completely avulsed but the venous anastomosis remained intact and patent. The inferior end of the IMA was mobilised from the pleura to which it was densely adherent. One millimetre was trimmed from each end of the arterial pedicle and the quality of the vessel ends remained suitable for attempted re-anastomosis. The flap artery was flushed liberally with heparinised saline and there appeared to be no resistance to flow (suggesting no arterial thrombosis). Re-anastomosis was completed with interrupted 9–0 nylon. There was no tension on the pedicle. After releasing clamps, the flap colour became light pink with a two second capillary return time and bright red bleeding from the dermal edges. We examined the flap vein and there was good orthograde flow on Acland’s test.

Absorbable, haemostatic gelatin sponge was placed between the internal mammary vessels and pleura to prevent further adherence and the flap was re-inset over a 15 Blake drain. Monitoring was as per protocol for a new free flap.

There were no further surgical complications and the patient was discharged at day six following anastomosis and continues to do well with no signs of flap necrosis or ischaemia.


There are several features of this case which are unusual when discussing delayed flap ischemia. Firstly, it is rare for ischemic events to happen as an outpatient.1–3 Secondly, pedicle avulsion is typically described as an intraoperative phenomenon or an early postoperative complication.4,5 There are few reports in the literature of a DIEP flap pedicle avulsing in an outpatient.6 Thirdly, due to the acute nature of the circumstances, there was minimal delay in either transfer to hospital or transfer into the operating theatre for salvage. The flap had a total ischemic time of just over three hours which is tolerable for a fascio-cutaneous flap. Finally, because of a purely mechanical cause of flap ischemia, there was evidently no intra-flap thrombosis and perfusion was excellent immediately following re-anastomosis. This combination of features allowed a rare salvage of flap ischemia suffered in the community.

The critical nature of this complication should not be overlooked. The haematoma appeared to have tamponaded only after a considerable volume had entered the sub-flap space and the patient showed signs of shock. Expedient theatre for haemostasis outweighed the importance of flap salvage in this scenario but fortunately events transpired such that flap salvage was safely undertaken.

The use of adjuncts for safe pedicle positioning have been reported with nerve conduits and fat grafts in the literature.7,8 Absorbable haemostatic gelatin sponge is commonly utilised by the author in microvascular reconstruction as it provides some mechanical stability to pedicle positioning, softens when moistened and can be easily removed if re-exploration is required. In this case it was used to prevent the IMA from re-adhering to the pleura as it was felt that avulsion occurred as a weak point had developed between the adherent, immobile, irradiated internal mammary artery and the mobile pedicle artery.


Flap ischemia occurring in the community can occasionally be salvaged if expedient return to theatre is possible and the flap shows no signs of intra-flap compromise. Pedicle avulsion is a rare cause of flap ischemia and requires urgent surgical care.

Patients/guardians have given informed consent to the publication of images and/or data.

Conflict of interest

The authors have no conflicts of interest to disclose.


The authors received no financial support for the research, authorship and/or publication of this article.

Updated: June 23, 2021 AEST—new formatting, pagination