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Differential cutaneous and muscular survival of a free myocutaneous latissimus dorsi flap following targeted pedicle embolisation in sacral reconstruction
Poster
Talk Description

Institution: Princess Alexandra Hospital - Queensland, Australia

Background Free flaps are traditionally considered dependent on an intact vascular pedicle in the early postoperative period, with flap compromise regarded as a surgical emergency. Emerging evidence suggests that neovascularisation may permit a degree of pedicle independence. This case demonstrates partial flap survival following deliberate pedicle embolisation to control a bleeding pseudoaneurysm. Case A 69-year-old man underwent radical excision of a sacral chordoma with abdominoperineal resection, posterior pelvic exenteration, and sacrospinal disarticulation. A free myocutaneous latissimus dorsi flap anastomosed to the residual superior gluteal vessels was used to reconstruct the large composite defect. 20 days postoperatively, a spontaneous, rapidly enlarging haematoma developed secondary to a pseudoaneurysm arising from the deep branch stump of the superior gluteal artery adjacent to the arterial anastomosis. Urgent endovascular embolisation was required and necessitated occlusion of the flap’s main vascular pedicle, with small collateral vessels noted angiographically. Following embolisation, the postoperative course was complicated by patchy deep muscle necrosis requiring conservative debridement and, ultimately, sinus tract formation. However, the cutaneous component of the flap was viable, with an intact inset, preserved capillary refill, and bleeding observed at initial debridement. This provided durable soft-tissue coverage over underlying metalwork, mesh, and bone allograft. Conclusion This case demonstrates tissue-specific survival of a free myocutaneous flap following deliberate, delayed pedicle embolisation. These findings support existing clinical and experimental evidence that neovascularisation within highly vascular recipient beds, with collateral inflow, may permit sustained flap viability once pedicle autonomy is established. This highlights the importance of judicious surgical decision-making in the uncommon scenario of delayed pedicle compromise.
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Dr Gayathri Nair - , Dr Tyler Ferdinands - , Dr Matthew Cheng - , Dr Luke Watson - , Dr Tavis Read -

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