Can a true perforator flap survive on venous blood? A case report of anterolateral thigh true perforator flap supplied by antegrade venous inflow.

In some cases of degloving injury, as a result of multiple venous anastomoses formed on the peripheral and proximal sides, the detached flap skin did survive, though with patchy necrosis. On the basis of this experience, the skin and soft-tissue defects after removing skin cancer were closed with an anterolateral thigh true perforator flap, measuring 4 × 5 cm in size, which is nourished by venous blood. The subcutaneous vein on the peripheral side of the defect was anastomosed to the perforator artery, and the veins on the proximal side of the defects were anastomosed to the concomitant veins of the perforator. After surgery, to ensure a sufficient blood flow to the flap, the affected limb was positioned lower than the heart for 1 week. To prevent microthrombus in the perforator branch and the flap, preventive anticoagulant therapy was performed. The transplanted flap had marked cyanosis for a few days, but turned pinkish on the sixth day after surgery. The flap survived completely. As opposed to venous flaps reported in the past, the physiologic direction of blood flow of the flap is from arteries to veins, and it is nourished exclusively by venous blood. If a flap is small, and there are no appropriate recipient vessels nearby, this method could serve as a favorable alternative.