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imageDelayed hypopharyngeal perforations in tetraplegics are a rare but potentially life-threatening complication of anterior cervical spine instrumentation. To date, no established treatment regimen exists for these situations. A patient with traumatic tetraplegia sub-C4 was admitted to the hospital 14 days after anterior spinal fusion with an infected hypopharyngeal perforation. After hardware removal, the spine was restabilized with a composite free osteomusculocutaneous fibula with the flexor hallucis longus muscle closing the mucosal defect. However, it was lost because of external venous compression. After 54 days, definitive reconstruction was achieved with a delayed supraclavicular artery flap. Follow-up endoscopy showed a closed and mucosalized defect. Composite free flaps are intriguing for complex hypopharyngeal and spine defects; however, they can undergo fatal external compression due to postoperative swelling in this area. Supraclavicular flaps might serve as a rescue alternative, offering unimpaired neck mobility that is crucial for tetraplegics, adequate tenuity for the hypopharynx, and reliable blood supply without large vessels in the field.

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