Case 03 2026: Emergency limb salvage with combined free vastus lateralis and anterolateral thigh flap after post-traumatic brachial artery graft thrombosis in a 16-year-old patient
Dr. Ibrahim Güler1
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Dokuz Eylül University, Izmir, Turkey; Department of Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Magdeburg, Germany
Abstract
Keywords: Limb salvage, free flap, anterolateral thigh flap, vastus lateralis, brachial artery injury, Gustilo–Anderson IIIC, microsurgery, trauma reconstruction Authors: Dr. Ibrahim Güler, Prof. Dr. Cenk Demirdöver . Department of Plastic, Reconstructive and Aesthetic Surgery, Dokuz Eylül University, Izmir, Turkey; Department of Plastic, Aesthetic and Hand Surgery, Otto von Guericke University, Magdeburg, Germany Abstract A 16-year-old female sustained a crush injury of the left upper extremity, resulting in an open humeral fracture (Gustilo–Anderson IIIC), brachial artery injury, and extensive soft-tissue loss. Initial treatment by trauma and vascular surgery included external fixation and brachial artery reconstruction using a saphenous vein graft. Early graft thrombosis led to critical limb ischemia, and above-elbow amputation was proposed. An emergency limb salvage attempt was performed using a combined free vastus lateralis and anterolateral thigh flap. The limb was successfully salvaged, with a favorable contour and good long-term functional outcome after secondary debulking procedures. Patient medical history A 16-year-old previously healthy female sustained a crush injury to the left upper extremity, resulting in an open humeral fracture (Gustilo–Anderson IIIC), brachial artery injury, and extensive soft-tissue loss [1,2]. Initial management by the trauma and vascular surgery teams at the same hospital included external fixation to stabilize the humeral fracture and reconstruction of the brachial artery using a saphenous vein interposition graft. Early thrombosis of the vein graft led to critical limb ischemia, and above-elbow amputation was subsequently proposed. Before and After Patient examination On examination by the plastic surgery team, the left upper extremity showed extensive soft-tissue loss around the elbow and proximal forearm, with the humerus stabilized in an external fixator. Despite the thrombosis of the brachial artery interposition graft,
BeforeAfterA 16-year-old previously healthy female sustained a crush injury to the left upper extremity, resulting in an open humeral fracture (Gustilo–Anderson IIIC), brachial artery injury, and extensive soft-tissue loss [1,2]. Initial management by the trauma and vascular surgery teams at the same hospital included external fixation to stabilize the humeral fracture and reconstruction of the brachial artery using a saphenous vein interposition graft. Early thrombosis of the vein graft led to critical limb ischemia, and above-elbow amputation was subsequently proposed.
All necrotic tissue was excised until viable bleeding muscle and soft tissue were reached. The wound was converted into a clean, reconstructable defect measuring approximately 19 x 12 cm.
The thrombosed saphenous interposition graft was confirmed. Recipient arteries and veins suitable for microvascular anastomosis were identified proximally in the arm.
2
A free anterolateral thigh (ALT) flap incorporating a segment of the vastus lateralis (VL) muscle was harvested to provide sufficient tissue volume for reconstruction of the deep soft-tissue defect. After completion of flap harvest, the flap was transferred to the left upper extremity. The thrombosed saphenous vein graft was removed and the recipient vessels were irrigated with heparinized solution, after which a flow-through arterial anastomosis was created between the proximal and distal segments of the brachial artery, with two concomitant veins anastomosed for venous outflow. This was followed by insetting of the vastus lateralis muscle to fill the deep defect and positioning of the ALT skin paddle for definitive surface coverage. The remaining skin defect was covered with split-thickness skin graft harvested from the thigh region.
3
Despite the severity of the trauma, the flap demonstrated stable perfusion and progressive wound healing.
4
The limb was preserved with stable soft-tissue coverage and improving function.
5
These images demonstrate progressive thinning of the flap and restoration of a more natural forearm contour, including the ability to hold a pen and perform fine motor tasks.
6
These images demonstrate progressive thinning of the flap and restoration of a more natural forearm contour, including the ability to hold a pen and perform fine motor tasks.
7
These images demonstrate progressive thinning of the flap and restoration of a more natural forearm contour, including the ability to hold a pen and perform fine motor tasks.
8
These images demonstrate progressive thinning of the flap and restoration of a more natural forearm contour, including the ability to hold a pen and perform fine motor tasks.
9
Ten-year postoperative photographs demonstrate durable soft-tissue coverage, stable contour, and preserved function of the salvaged upper extremity. The transferred flap has maintained a proportional relationship to the surrounding tissues and adapted harmoniously to the patient’s somatic development over time, resulting in a balanced and natural overall silhouette.
10
Ten-year postoperative photographs demonstrate durable soft-tissue coverage, stable contour, and preserved function of the salvaged upper extremity. The transferred flap has maintained a proportional relationship to the surrounding tissues and adapted harmoniously to the patient’s somatic development over time, resulting in a balanced and natural overall silhouette.
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• Following emergency reconstruction, the patient underwent intensive clinical flap monitoring and general condition stabilization. Early referral to hand therapy and occupational therapy was initiated to preserve joint mobility and hand function.
• Given the initial volume of the transferred tissues, staged secondary debulking procedures were planned and performed at appropriate intervals to refine contour, improve range of motion, and optimize the silhouette of the reconstructed forearm. Secondary contour refinement is an integral part of successful limb reconstruction, not a complication.
• Long-term follow-up focused on functional recovery, scar management, and progressive rehabilitation, ultimately allowing the patient to return to daily activities and professional life with preserved use of her left hand.
How to cite this article
Dr. Ibrahim Güler. Case 03 2026: Emergency limb salvage with combined free vastus lateralis and anterolateral thigh flap after post-traumatic brachial artery graft thrombosis in a 16-year-old patient. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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