Fibula free flaps are standard in facial reconstructions after head and neck cancer resection and typically have short flap ischemia times, often under 2 hours. Methods for short-term flap ischemia are characterized, but methods for extremely prolonged flap ischemia have not been well-described. We describe a 72-year-old patient who underwent composite floor of mouth and mandible resection with fibula free flap reconstruction. Patient intraoperative instability forced flap ischemia of over 10 hours with arterial insufficiency and venous thrombosis. Despite complicated and extremely prolonged ischemia, aggressive local and systemic anticoagulants with intraoperative leach therapy were still effective in flap salvage. The flap ultimately survived without necrosis. This case describes a method to guide surgeons faced with situations of forced, prolonged flap ischemia. Traditionally indicated in short-term ischemia, anticoagulation and leach methods can be effective for intraoperative treatment of extremely prolonged flap ischemia, arterial insufficiency, and venous thrombosis. Address correspondence and reprint requests to Kalpesh T. Vakharia, MD, MS, University of Maryland School of Medicine, 419 W. Redwood Street, Suite #370, Baltimore, MD 21201; E-mail: kvakharia@som.umaryland.edu Received 13 November, 2020 Accepted 30 November, 2020 Disclosures: No outside sources of support to report. The authors report no conflicts of interest. © 2021 by Mutaz B. Habal, MD.
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