Eur J Plast Surg (2003) 26:367–369
Thomas W. Collin · Paul Morris · Elaine Sassoon ·
Trevor J. O’Neill
Arteriovenous fistula in a free pectoralis minor flap
Received: 11 March 2003 / Accepted: 5 May 2003 / Published online: 6 November 2003
Abstract The acquired arteriovenous fistula, a rare
occurrence, usually results from an identifiable traumatic
insult. The precipitating event is often a penetrating
injury, although other factors such as blunt injury,
infection and changes in local haemodynamics can also
initiate changes leading to such vascular anomalies. The
subject of this report, a 42-year-old female, previously
had an acoustic neuroma excised in September 1991,
which left her with a dense right facial palsy. In an
attempt to reconstruct the nerve, a facial reanimation
procedure was performed. This was a two-stage procedure
that involved a cross facial nerve graft, followed a year
later by a free pectoralis minor flap. The aim was to
introduce innervated muscle into the cheek to restore
function and symmetry. The surgery was successfully
completed in June 1997. This case report describes the
appearance of an arteriovenous fistula following the use
of a pectoralis minor free flap in facial reanimation. There
are no published accounts of arteriovenous fistulae arising
in free flaps in head and neck surgery.
Keywords Arteriovenous fistula · Reanimation ·
Arteriovenous fistulae are abnormal communications
between arteries and veins, leading to bypass of the
normal capillary bed circulation, often with progressive
enlargement giving rise to multiple complications. They
are categorised as “high flow” vascular anomalies, and
their management is frequently troublesome.
The acquired arteriovenous fistula usually results from
an identifiable traumatic insult. The precipitating event is
often a penetrating injury, although other factors have
been cited as causative—blunt injury, infection and
changes in local haemodynamics can also initiate changes
leading to such vascular anomalies.
We present a case of an arteriovenous fistula arising in
a pectoralis minor free flap, a rare occurrence in free
muscle transfers in head and neck surgery.
The patient, a 42-year-old woman, underwent surgical excision of
an acoustic neuroma in 1991. This resulted in permanent VII nerve
damage and a dense right facial palsy. The following year a cross
facial nerve graft was performed in an attempt to reanimate her
face. She was referred to Norwich plastic surgery department
3 years later for a further opinion.
At the first consultation, it was obvious that the facial nerve
graft had failed. A two stage reanimation procedure was planned to
correct the asymmetry.
In 1995, the first stage was performed. Using general anaes-
thesia, sural nerve was coapted to branches of the left facial nerve
in the zygomatic region. The graft was then tunnelled through the
upper lip to lie in the right cheek. Eighteen months later, a positive
Tinel’s sign demonstrated activity within the nerve graft in the right
cheek, and the second stage could proceed.
In June 1997 the second stage was performed, again under a
general anaesthetic. A standard facelift incision was used to
identify the now functional nerve graft and to prepare a suitable bed
for the free tissue transfer. The pectoralis minor muscle was
harvested and secured in this right cheek area. Here, it was
revascularised using the facial artery and vein. An end-to-end
anastomosis with 10/0 nylon was performed for both vessels and a
second vein from the flap was anastomosed end-to-side to the facial
vein. The flap was reinnervated using the cross facial nerve graft.
The muscle was sutured to the upper lip and oral commisure using
6/0 non-absorbable monofilament sutures.
The patient made an uneventful recovery. Review in 1998
revealed a functional flap. This was providing innervated muscle to
the lower half of the face, restoring symmetry.
The patient represented in July 2001 with a submandibular
swelling. On examination this swelling was soft and fluctuant. It
was a well circumscribed lesion, approximately 3 cm in diameter,
with a palpable thrill. On auscultation, a bruit was detected with the
classical machinery-like murmur associated with arteriovenous
fistulae. There was still function in the flap.
Ultrasound scanning showed the lesion was composed almost
entirely of vessels, exhibiting low resistance and high flow
T. W. Collin (
) · P. Morris · E. Sassoon · T. J. O’Neill
Department of Plastic and Reconstructive Surgery,
Norfolk and Norwich University Hospital (NHS Trust),
Norwich, NR4 7FP, UK
Tel.: +44-1603-286286, Fax: +44-1603288378