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Page 2 of 10 Othman et al. Plast Aesthet Res 2022;9:21 https://dx.doi.org/10.20517/2347-9264.2022.03

Conclusion: Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to
powerful outcomes. Recent trends indicate increasing usage of perforator flaps. This study shows that based on
existing data, free flap utilization for pediatric patients is an adequate modality for repair, and may warrant greater
consideration moving forward.

Keywords: Reconstructive surgery, pediatric trauma, pediatric lower extremity, microsurgery, soft-tissue, free-
tissue transfer

INTRODUCTION
The burden of trauma to the lower extremity presents multi-faceted obstacles to patients, including
[1,2]
psychological trauma, functional deficits, and increased health costs . For the surgeon, lower extremity
trauma has long presented difficult challenges to achieve adequate reconstruction, and the success of this
reconstruction, including vascular, bone, and soft-tissue elements, is heavily correlated with successful limb
salvage. Although research has shown that some patients benefit from amputation over limb salvage, the
correct decision centers upon a patient-centric approach and involves heavy counseling that necessitates
case by case analysis [1,3-5] . This is magnified in the pediatric population, which presents increased
[6-9]
considerations, including long-term sequalae, compared to their adult counterparts .
A multi-disciplinary collaborative approach between trauma surgeons, vascular surgeons, orthopedic
surgeons, and plastic surgeons is optimal in order to achieve the best possible outcomes. Unfortunately, the
literature is limited regarding objective guidelines for appropriate treatment algorithms, as most current
reports detail individual-institution experiences [3,7,10-12] . This is especially highlighted when examining the
pediatric population, as this unique cohort of patients presents its own set of questions that many surgeons
do not have great experience with nor do not feel as comfortable managing. From a vascular perspective, the
revascularization of small vessels may be limited due to either vessel size or out of scope of practice for
experienced vascular surgeons [6-11] . Similarly, the microsurgeon may also have difficulty with the vessel
caliber when free tissue transfer is necessary, as well as challenges with appropriate flap selection.

Given the unique cohort of patients that present in the pediatric setting, the aim of this article was to
succinctly describe existing treatment patterns for free tissue transfer used to manage pediatric lower
extremity trauma. We hypothesize that a heterogenous approach is taken across centers and surgeons who
manage these defects, given the relatively small incidence of pediatric lower extremity trauma that requires
comprehensive soft-tissue management.

METHODS
A full literature review was conducted using the databases PubMed, Web of Science, and Embase. With the
assistance of a medical librarian, a search string strategy was devised using the following terms and
synonymous variations in phrasing and spelling: Lower-extremity OR lower-limb OR leg OR ankle OR foot
AND trauma AND pediatric OR pediatric AND free flap OR free tissue transfer.

Inclusion criteria encompassed articles describing soft-tissue free-tissue transfer reconstruction of the lower
extremity secondary to trauma of pediatric patients (aged 18 or younger) of articles published within the last
15 years (2005-2020). Only articles with at least 20 patients who suffered from traumatic etiology were
included. Relevant articles were also extracted from citations on article reviews wherever applicable. There
was no minimum mean/median follow-up time. Only articles written in the English language or with an
available English translation were considered. All case-series and retrospective studies were included.