Reverse Flow Fibula Free Flap: Technique for Intraoperative Flap Salvage in a Case of Inadequate Antegrade Perfusion

The reverse flow technique describes flap revascularization via anastomoses at the distal pedicle. The technique has been described for various indications but rarely as a means of flap salvage. To our knowledge, there are no previously reported cases where the reverse flow concept was utilized as a means of salvage of an osteocutaneous fibula free flap with severe atherosclerosis of the proximal peroneal artery. We describe the use of reverse flow to salvage the case of a 71-year-old male with significant atherosclerosis of the proximal peroneal artery preventing adequate microvascular anastomosis and inflow, despite multiple attempts. We were able to establish arterial perfusion of the flap using a reverse flow technique, with perfusion through the distal peroneal artery via the contralateral facial artery. This case describes the first reported use of the reverse flow technique for salvage of an osteocutaneous fibula free flap when severe atherosclerosis prevented antegrade arterial inflow. The technique appears to be a viable option for free flap salvage in similar instances.