Salvage of fibular osteocutaneous flap with creation of arteriovenous fistula

In utilizing free-tissue transfers to reconstruct complex wounds, occasionally a mismatch exists between the donor-flap inflow and the recipient vessel outflow. This occurs more often with fasciocutaneous flaps as opposed to muscle flaps due to their higher resistance. The result of this may be microvascular thrombosis within the system and ultimately flap failure. The creation of an arteriovenous fistula at the distal aspect of the flap may improve the flow dynamics and ultimately salvage the flap. We submit a case of a free osteocutaneous fibular flap used for reconstruction of an ulnar forearm defect. Due to intraoperative thrombosis as a result of flow mismatch, we were able to salvage the flap using a distal arteriovenous fistula. This fistula improved the flow dynamics of the flap by bypassing the high intraflap resistance. An arteriovenous fistula should be kept in the repertoire of the microvascular surgeon as a potential option for flap salvage.