Conservative Management of Presumptive Free Flap Pedicle Compromise on Postoperative Day 6: Report of Two Cases and Literature Review

ABSTRACT Pedicle compromise after free tissue transfer typically mandates urgent surgical re‐exploration, as flap viability is considered entirely dependent on an intact vascular supply before inosculation is achieved. Whether selective conservative management can be considered in selected cases remains an open question. We report two cases of lower extremity free flap reconstruction in which presumptive late pedicle compromise—occurring on postoperative day 6 in both patients—was managed conservatively with full flap survival. Case 1 was a 71‐year‐old non‐smoking woman with hypertension who underwent coverage of a traumatic pretibial bone‐exposing defect (measuring approximately 9 × 5 cm) with a free superficial circumflex iliac artery perforator (SCIP) flap (approximately 10 × 6 cm) anastomosed to the posterior tibial perforator and a deep vein. Case 2 was a 33‐year‐old moderate smoker who underwent deep inferior epigastric perforator (DIEP) flap reconstruction (approximately 15 × 9 cm) for tibial plate exposure following a fracture fixation and wound dehiscence, anastomosed to the posterior tibial perforator and deep vein. In both cases, loss of Doppler signal and clinical ischemia on postoperative day 6 were accompanied by bedside indocyanine green (ICG) imaging demonstrating peripheral perfusion originating from the flap margins distant from the anastomosis, consistent with early neovascularization. Re‐exploration was deferred in both cases. Both flaps developed minor marginal epidermal loss without full‐thickness necrosis, and achieved complete healing within 6 weeks. Follow‐up was 6 months in both cases. These cases suggest that, in carefully selected patients with multimodal evidence of peripheral flap perfusion, conservative management of presumptive late pedicle compromise may be considered. The accompanying literature review is subject to publication bias, as only cases with successful outcomes are systematically reported; the true failure rate of conservative management cannot be estimated from available evidence. These findings are hypothesis‐generating and should not be interpreted as a new standard of care; prospective validation is required before definitive recommendations can be made.