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Page 8 of 10 Othman et al. Plast Aesthet Res 2022;9:21 https://dx.doi.org/10.20517/2347-9264.2022.03

artery, damage to this vessel has been shown to be prognostic of worsened flap outcomes, including failure,
takebacks, and major complications, and may potentially serve as a surrogate for the extent of trauma and
micro-inflammatory milieu [27,37,38,40] .

Limitations
There are several limitations to this study, given the study design. Many studies describing lower extremity
reconstruction combine oncologic and traumatic etiology; however, given the associated zone of injury,
vessel manipulation, and complex patient status of trauma patients, these could not be combined, causing a
significant loss of sample size and limiting the number of studies for inclusion. There is likely a component
of selection bias with patients, and increasing liberal use of free flaps in this population may render
worsened outcomes. Due to the desire to capture studies with moderate patient sample sizes in order to
discern trends, some smaller case series were also not included. Additionally, the exact timing of
reconstruction was not immediately discerned though most reconstruction occurred within 7-10 days, and
this has previously been shown to have positive effects on flap outcomes, representing an upgrade in the
original Godina paradigm likely due to advanced local wound care and vacuum assisted closure
therapy [27,39] . Finally, despite this, most studies are extremely small and heterogenous, rendering absolute
conclusions difficult, though the early reports indicate strong success.

In conclusion, free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads
to powerful outcomes. 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.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis,
acquisition, writing, and interpretation: Othman S, Knobel D
Provided administrative, technical, and material support: Knobel D

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no relevant conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2022.