Clinical Case Handling and Experience Sharing for Venous Congestion Following Free Flap Graft.

Background: Venous congestion is a common complication following free flap transplantation, yet its natural progression and optimal management strategies remain poorly understood. Early-stage venous congestion is often misdiagnosed as venous crisis, leading to unnecessary flap removal. This study aims to elucidate the clinical course and treatment outcomes of venous congestion in anterolateral thigh (ALT) perforator flaps.

Methods: Two cases of squamous cell carcinoma (SCC) patients who underwent ALT flap reconstruction after tumor resection were retrospectively analyzed. Postoperatively, both flaps exhibited venous congestion despite patent arterial and venous anastomoses. Bloodletting therapy using low-molecular-weight heparin (LMWH) was instituted to alleviate congestion. Clinical progression, treatment protocols, and flap outcomes were meticulously documented.

Results: Following LMWH-based bloodletting therapy, venous congestion significantly improved in both cases. New microcirculation was established within the flaps, evidenced by gradual resolution of purple discoloration, reduced swelling, and formation of granulation tissue. Full flap survival was achieved in both patients by postoperative day 42, with no secondary surgeries required.

Conclusions: Conservative management with LMWH bloodletting therapy effectively resolves venous congestion in ALT flaps, promotes microcirculatory regeneration, and prevents flap necrosis. This approach offers a viable alternative to surgical re-exploration, reducing patient morbidity. Our findings underscore the importance of early recognition and targeted intervention for venous congestion, providing valuable insights for optimizing flap salvage protocols.