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Othman et al. Plast Aesthet Res 2022;9:21 https://dx.doi.org/10.20517/2347-9264.2022.03 Page 5 of 10

Table 3. Major outcomes and follow-up
Author Failure Infection Growth injury RTOR Follow-up
Elbataway et al. [15] 2 3 0 2
[12]
Rinker et al. 3 9 2 5 4.5 years
[13]
Lee et al. 10 0 0 10
[14]
Momeni et al. 2 2 0 4
[16]
Hu et al. 0 0 0 0 14 months
Sui et al. [17] 0 0 0 2
[18]
Khadim et al. 1 0 0 1
RTOR: Return to the operating room.

This study showed that most authors find excellent outcomes with flap success and when long-term studies
are available, pediatric functional results are acceptable. Hesitancy in the pursuit of free flaps in this
population stems in part from the earliest reports describing small vessel caliber, though subsequent reports
and the development of the “super microsurgery” concept have helped mitigate these concerns [8,22,23] . In fact,
further research has shown that vessel caliber is not the limiting factor, but rather vessel mismatch - a more
controllable variable that can be modified by trimming of the larger vessel or expansion of the smaller
vesselmay - be the root of complications [10,24] . Regardless, the flap failure rate was lower than that which is
documented in the adult population for lower extremity trauma reconstruction. This may be for several
reasons – there is likely a higher acuity of patient selection in the pediatric cohort of whom to select to
pursue free-tissue transfer. Further, pediatric trauma may likely be routed to specialized centers at an earlier
time-frame as compared to adults, which can help further lend to an optimized wound bed as opposed to
delaying care [14,25] . Finally, the innate enhanced healing of children and general lack of comorbidities, such as
diabetes, peripheral vascular disease, and smoking status, may also contribute to improved outcomes [3,6-9,26] .
Thus, in the appropriately selected patient, pediatric free tissue transfer appears to be a strong choice, and
this study may suggest that more aggressive pursuit of this option may be indicated based on these results.

Salvage vs. Amputation
Ultimately, the decision to pursue free-flap reconstruction is complex. Prior studies in the adult population
have attempted to describe algorithms for which patients should be salvaged vs. amputated. The famed 2002
Lower Extremity Assessment Project found that amputation is at least non-inferior to salvage . Further,
[4]
numerous studies indicate that many expert trauma centers follow their own niche algorithms and clinical
decision making, and that one specific tool has not yet been validated [5,13,27,28] . Thus, this brings upon a
necessary evaluation on a specific patient by patient specific-basis. The benefits of the pursuit of amputation
are that immediate rehabilitation may soon be sought after. This includes the fitting of an appropriate
prosthesis, which will be adjusted as growth commences, particularly if the child has not yet gone through
puberty. Attempted salvage, while obviously appealing to many children and their families, may be fraught
with complications, including additional revision surgery, extended hospital length of stay, and increased
costs, which may ultimately commence in a secondary amputation, as shown in the adult population [5,29] .
However, the benefits of salvage are psychological, especially at a very young age, and although there is fear
that attempted salvage may compromise growth and ultimately functional outcomes, the results of this
study indicate that this is a relatively rare complication. Therefore, if free tissue transfer is possible, and if
the patient is deemed an appropriate surgical candidate, then free tissue transfer should be highly
considered, given strong outcomes and strong long-term functionality based on the available data [Table 4].

Logistical limitations to salvage
Despite the desire to pursue microvascular reconstruction by the microsurgeon, there are several other