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Page 2 of 6 Arkudas et al. Plast Aesthet Res 2018;5:38 I http://dx.doi.org/10.20517/2347-9264.2018.44

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Figure 1. Forty-one-year-old male patient with an unstable scar and fistula in the trochanter major region (arrow)

groin and hip region local random pattern flaps such as rotational flaps can be used. Also pedicled flaps such
as the anterior lateral thigh (ALT) flap or vertical rectus abdominis myocutaneous (VRAM) flap can achieve
[3-5]
stable healing of these defects . When local flaps are not available due to previous operations or did not
lead to the required result, free flaps are the last therapeutical option. Free flaps are raised at a distant body
[6]
part also known as donor site and are microsurgically anastomosed to recipient vessels at the defect area .
Typical free flaps are the latissimus dorsi flap, the parascapular flap or perforator flaps such as the deep
inferior epigastric perforator (DIEP) or the ALT flap. When local recipient vessels are missing, e.g., in cases
of trauma or infection, an arteriovenous (AV) loop from a main vascular axis can be used to enable local
[7,8]
microsurgical anastomoses for free flap transfer .
Here we present a patient with NF and multiple operations including local and free flaps who was referred to
our hospital with ongoing fistulas in the trochanter major region. After radical debridement defect coverage
was achieved using an arteriovenous loop with subsequent free latissimus dorsi flap transplantation.

CASE REPORT
A 41-year-old male patient suffered from back pain since he was 16 years old. He received multiple
treatments including a spondylodesis of L4 and L5 using an anterior approach. In the further course the
patient developed a wound dehiscence of the abdominal incision which was treated conservatively. Also
the spondylodesis was extended to S1 . Due to persistent back pain a spinal cord stimulation (SCS) device
was implanted leading to a NF of the left flank. Therefore the SCS devise was explanted and in the further
course a split skin graft transplantation of the left flank was performed. Also a rotational flap was made in
the left groin. Due to an unstable scar in the left iliac crest region defect coverage was attempted using a
groin flap. Afterwards again a NF occurred in the left hip region resulting in multiple fistulas after several
debridements. In the further course a pedicled DIEP flap was attempted and a free parascapular flap
anastomosed to the circumflexa iliaca profunda vessels and a pedicled ALT flap were performed in order to
achieve a stable healing of this region.

Unfortunately, the patient still suffered from an ongoing fistula and an unstable scar in the left trochanter