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Page 6 of 10 Othman et al. Plast Aesthet Res 2022;9:21 https://dx.doi.org/10.20517/2347-9264.2022.03

Table 4. Algorithm to free flap harvest and selection
Factors to free flap harvest
Patient medically stabilized
Extensively exposed bone, tendon, or neurovasculature
Vascular and orthopedic fixation
Adequate wound debridement
Wound bed preparation and temporization with negative pressure wound therapy
Absence of local flap options
Efficient timing (Ideal under 10-30 days when possible)
Flap selection
-Perforator flap UNLESS
-Extensive, three-dimensional defect
-Inadequate donor site, tissue surface area, or donor site damage

factors that may hinder availability from achieving successful soft tissue transfer. In situations where
extensive vascular injury is involved, or where prolonged ischemic time exists, there may be difficulty in
achieving re-vascularization. Pediatric vascular surgery is not a standalone sub-specialty, and vascular
surgeons may not have the experience with tiny vessels [30,31] . In this case, the microsurgeon may take on the
role of micro-anastomosis to pursue re-vascularization, though there may be unfamiliarity with these
procedure types . Further concern over limited reports and surgeon experience with pediatric free tissue
[31]
transfer to the lower extremity following trauma have impeded wider spread use. Timing of reconstruction,
ideal flap type, and concerns over physiological vasospasm have introduced hesitancy in harvest [7-9,11] .
Despite the fact that the use of free tissue transfer has been reported upon successfully, some of these
remain technically challenging cases. Vessel caliber and surgeon inexperience are limiting factors in
applicability, as well as previously described poor surgical outcomes that are historical but nonetheless may
perpetuate [8,14,22,23] . Post-operatively, many centers do not have the expertise to care for pediatric free-flaps,
and post-operative protocols, such as dangle protocols, are largely unexplored in the pediatric population
compared to their adult counterparts .
[32]

Flap selection
The selection of flap is an oft-debated topic in microsurgery, particularly in the setting of lower extremity
trauma. Historically, the muscle-based flap was the dominant flap selected; however, in recent years, the
fascial-based perforator flap has become an increasingly popular option [33,34] . The advantages of the
perforator flap are the ease of harvest, lower donor site morbidity, greater pliability for areas of thinner
surrounding soft tissue, such as the ankle, and greater ease in re-elevation if necessary, which may often be
the case when there is extensive bony damage requiring orthopedic hardware and orthopedic revision [9,35] .
Donor site morbidity, in particular, is a critical discussion point in the pediatric patient, as muscle sacrifice
can have adverse effects on growth, functional, and aesthetic outcomes, thus lending an additional
important consideration for utilizing perforator flaps. The muscle base flap was once preferred due to its
bulky nature, which afforded the ability to contour dead space and complex three-dimensional defects.
Prior research also indicated that the muscle base flap provided a strong blood supply that was beneficial in
aiding the eradication of bacterial infection. However, this comes with the caveat of increased donor site
morbidity, and a decreased cosmetic outcome that may require subsequent de-bulking procedures [9,14,33,35,36] .
The psychological adversity afforded by worsened cosmesis should especially be highlighted in children, as
this may have adverse effects on their mental and social growth. More recent research from several high-
volume trauma centers has indicated that perforator flaps and muscle flaps likely have similar outcomes,
and thus it appears that perforator flaps are gaining popularity and that each defect must be evaluated on a
patient-by-patient basis.