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

available, neither random pattern nor pedicled flaps. For free flap transplantation, also no recipient vessels
such as the circumflexa femoris lateralis vessels (previously used for the ALT flap), the circumflexa iliaca
profunda vessels (used for the free parascapular flap), the circumflexa iliaca superficialis vessels (used for
the pedicled groin flap) or the deep inferior epigastric vessels (used for the DIEP attempt) were available.
Furthermore, the femoral vessels were too distant to the defect. Therefore AV loop was created from the
femoral vessels using a great saphenous vein graft [14,15] . These kinds of AV loops have a relatively high
[16]
thrombose rate compared to short subclavian loops for example . Therefore we recommend a two-step
procedure with first implantation of the AV loop and in a second procedure free flap transplantation. Using
this protocol, flap loss due to an AV loop thromboses can be minimized. Patency was checked preoperatively
using a Doppler ultrasound. For defect reconstruction we used a myocutaneous latissimus dorsi flap. This
flap possesses a long vascular pedicle with adequate vessel diameter for microsurgical anastomoses to
the great saphenous vein of the AV loop legs and it is known for its low flow resistance and therefore low
complication rate when combined with an AV loop. Also, the latissimus dorsi flap provides enough muscle
tissue for sealing the defect down to the trochanter major. Using the skin island a defect reconstruction
without split skin grafting was possible.

[17]
Gawaziuk et al. also previously reported on a case series of free flap transfer after NF and was able
[18]
to show no flap failures and a minimal complication rate. Beier et al. were also able to demonstrate a
thoracic reconstruction using a bilateral free pre-expanded tensor fascia latae (TFL) flap in an 8-year-old
[19]
child. Also Barbosa et al. showed a chest wall reconstruction using a free latissimus dorsi flap after NF.
The special feature of the presented case are the multiple previously performed operations including local
pedicled and random pattern flaps as well as a free flap, making any local flap impossible and further free
flaps significantly more difficult. Therefore we had to perform a combined approach using AV loop and
subsequent free latissimus dorsi transfer.

Tissue defects after NF often require an adequate defect reconstruction. Mostly this can be performed using
split skin grafts or in regions with exposed structures such as bone or vessels, local or free flaps can achieve
long-term stable results. Here we present a case of a NF in the trochanter major region after spondylodesis
and SCS device implantation and multiple preoperations including local and free flaps. Therefore we
performed a complex microsurgical reconstruction using AV loop and free latissimus dorsi transfer. This can
be considered as the final stage of any reconstruction latter due to its high complexity.

DECLARATIONS
Authors’ contributions
Manuscript preparation: Arkudas A, Regus S, Meyer A, Lang W, Schmitz M, Horch RE
Operative procedure: Meyer A, Lang W, Schmitz M

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.