ABSTRACT

KEY WORDS: Burn injury, Free flaps

INTRODUCTION

Reconstructive surgery following burn injuries poses a significant challenge, particularly when deep tissue structures are exposed or functional deformities develop. Although superficial or limited wounds may be managed with skin grafts or local flaps, more extensive injuries, especially those involving exposed tendons, bones, joints, or neurovascular structures, often require free tissue transfer. The decision to use a free flap hinges not only on the characteristics of the defect but also on the condition of the recipient vessels, which may be compromised in burn zones. This is especially true in electrical injuries, where vessel integrity is difficult to assess and anastomosis must be performed well outside the injury zone. Preoperative imaging with Doppler ultrasonography, handheld Doppler, or computed tomography angiography is essential for flap planning and recipient vessel mapping.

Here, we present a structured approach to flap selection in burn reconstruction and share our clinical experience with various types of free flaps in burn patients, including indications, outcomes, and challenges encountered.

METHODS AND DISCUSSION

Flap type is selected based on the depth, location, and size of the defect, as well as the availability and reliability of donor sites. Very thin flaps, such as the superficial temporal artery fascial flap (STAFF), serratus anterior fascial flap (SAFF), and radial forearm flap (RFFF), are suitable for small, superficial defects, especially in delicate areas like the hands or face. Despite their excellent pliability and vascularity, donor site morbidity can be a concern, particularly with the RFFF, where aesthetic dissatisfaction, sensory disturbances, and tendon exposure have been frequently reported.^1-3

Thin flaps, including the superficial circumflex iliac perforator (SCIP) and anterolateral thigh (ALT) flaps, are often used in moderate-sized defects or post-contracture release. The ALT flap offers great versatility, with minimal donor-site morbidity and adaptability in thickness depending on the defect’s needs (Figure 1). Systematic reviews and cohort studies have consistently demonstrated that ALT flaps are associated with lower donor-site morbidity compared with RFFF, especially in terms of wound dehiscence, functional impairment, and aesthetic outcomes.^4-7 The SCIP flap is particularly useful for hand reconstruction in thin patients due to its low profile and good vascularity.

Bulkier flaps, such as the latissimus dorsi, gracilis, and rectus abdominis flaps, are preferred for covering large or cavitary wounds where 3-dimensional reconstruction is necessary. These muscle-based flaps offer robust vascular supply and are useful in infected or high-risk wound environments. However, donor-site complications, such as seroma, hematoma, and functional limitations, have been highlighted in large cohort analyses, particularly with the latissimus dorsi flap.⁸

Between 2021 and 2025, 116 burn patients were treated in our burn unit. Among them, 25 required free tissue transfer for reconstruction. Although we generally treated trunk burns with skin grafts, deeper extremity injuries with exposed bone or tendon or fasciotomy-related defects necessitated flap reconstruction (Figure 2). Early flap coverage protected critical structures, reduced infection rates, and shortened healing time, findings that are in line with prior reports on early free flap reconstruction in burns and trauma.^6,7

Although artificial dermal substitutes (eg, Integra, MatriDerm, AlloDerm) have advanced the management of full-thickness skin defects, they fall short in providing volume, vascularity, or coverage over exposed vital structures. Their effectiveness is limited in avascular or infected wounds, making them complementary, rather than alternative, tools to free flap reconstruction.

CONCLUSIONS

Burn reconstruction, particularly in patients with deep tissue loss or exposed critical structures, requires meticulous planning, proper timing, and multidisciplinary coordination. Early free flap application plays a vital role in improving wound healing, preserving function, preventing secondary contractures, and achieving favorable aesthetic outcomes. Although dermal substitutes are valuable for superficial wound preparation, they cannot replace the structural, vascular, and volumetric advantages of free tissue transfer. Our clinical experience underscores that individualized flap selection, guided by defect characteristics and donor site evaluation, is key to successful reconstruction. Ultimately, an integrated approach combining free flaps and adjunctive therapies offers the best path to optimal recovery in complex burn cases.

REFERENCES

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