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Othman et al. Plast Aesthet Res 2022;9:21 https://dx.doi.org/10.20517/2347-9264.2022.03 Page 3 of 10

Extracted outcomes included flap failure, re-operative rates, and serious infection, defined as those
requiring intravenous antibiotics and/or operative debridement.

Articles were excluded if they only discussed anatomical regions aside from the lower-extremity or if there
were etiologies other than trauma in which specific details could not be extracted. Articles were also
excluded if they used a method of reconstruction of other soft-tissue free flaps. If articles described a
mixture of lower-extremity and non-lower extremity reconstruction, but specific results of the lower-
extremity reconstruction could not be described, they were excluded. Further, editorials, abstracts, review
articles, and technique articles were excluded.

RESULTS
Following the initial search, 313 articles were identified. Screening at the abstract level provided 27 articles
for full-text review. After final full-length article review, a total of 7 articles were deemed appropriate for
inclusion [Figure 1].

Six of seven studies included were published after 2012, with one being published in 2005. The greatest
number of flaps included in a study was 53, with the lowest being 23. Patients were from 2 to 17 years old
throughout the studies. Anatomic location was heterogenous, with greater than 60% of subjects focusing
solely on foot and ankle defects, while the others were mixed. Traumatic etiology varied largely between
studies, with a diverse mix included. Motor vehicle, motorcycle, and pedestrian vs. motor vehicle accidents
were the most common etiologies for traumatic defects, comprising greater than 75% of total etiology. Also
included were alterative-terrain vehicles, gunshot wounds, lawn mower accidents, and falls. Lawn mower
accidents were only responsible for foot/ankle defects, while all other etiologies comprised defects at various
levels [Table 1] [12-18] .

2
When available, defect sizes ranged within studies, with most being under 120 cm . However, one study had
2
defect sizes as large as 600 cm . Timing of reconstruction varied, though the majority of studies performed
the free flap procedure within 7-10 days after the index presentation of injury. When examining the choice
of flap selection, the latissimus dorsi was the most commonly used flap (37.4%), with the anterolateral thigh
being the second most common (25.5%). The next most common was the scapular/parascapular (15.6%)
and deep inferior epigastric flaps (10.1%). Other utilized flaps included the rectus abdominis (3.3%) serratus
(1.6%), gracilis (5.3%), groin flap (2.4%), tensor fascia lata, deltoid, radial forearm, lateral arm, and
thoracodorsal perforator flap (all: 0.4%). In total, fascial flaps compromised the majority of flaps (54%)
compared to muscle-based flaps (46%). The most commonly used recipient vessel was the anterior tibialis
(49.5%) and posterior tibialis vessels (45.3%). The peroneal artery and dorsalis pedis are less described
[Table 2].

Most studies reported strong flap outcomes. In total, there was a 6.5% flap failure rate. Return to the
operating room was more common, required in 8.7% of cases, while serious infection (requiring prolonged
intravenous antibiotics and/or operative debridement) was present in 5.8% of cases. Unfortunately, follow-
up time was rarely reported in these studies [Table 3].

DISCUSSION
Lower extremity trauma presents unique challenges often requiring a multi-disciplinary approach from
trauma surgeons, orthopedic surgeons, vascular surgeons, plastic surgeons, and often experts from other
fields depending upon exact etiology, the extent of bony and soft-tissue loss, and presentation patterns .
[19]
Due to limited soft-tissue mobility in young children, local pedicled flaps can often be limited in ability to