Free Flap Failure and Complications in Acute Burns: A Systematic Review and Meta-analysis

Abstract

Background: Severe acute burn injuries represent a challenge to the reconstructive surgeon. Free flap reconstruction might be required in cases of significant critical structure exposure and soft tissue deficits, when local options are unavailable. This study aimed to determine the free flap complication rate in acute burn patients. Methods: A systematic review and meta-analysis were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and registered on the International Prospective Register of Systematic Reviews database (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was the free flap failure rate. Results: The study identified 31 articles for inclusion. A total of 427 patients (83.3% men, 16.7% women) accounting for 454 free flaps were included. The mean patient age was 36.21 [95% confidence interval (CI), 31.25–41.16]. Total free flap loss rate was 9.91% [95% CI, 7.48%–13.02%], and partial flap loss was 4.76% [95% CI, 2.66%–8.39%]. The rate of venous thrombosis was 6.41% [95% CI, 3.90%–10.36%] and arterial thrombosis was 5.08% [95% CI, 3.09%–8.26%]. Acute return to the operating room occurred in 20.63% [16.33%–25.71%] of cases. Stratified by body region, free flaps in the lower extremity had a failure rate of 8.33% [95% CI, 4.39%–15.24%], whereas in the upper extremity, the failure rate was 6.74% [95% CI, 3.95%–11.25%]. Conclusion: This study highlights the high risk of free flap complications and failure in acute burn patients.

Free Flap Failure and Contracture Recurrence in Delayed Burn Reconstruction: A Systematic Review and Meta-analysis

“…These are relatively low rates, comparable to free flap loss rates in other populations such as oncological patients, and lower than the rate of flap loss in acute burn patients. [66][67][68] Furthermore, we assessed the rate of contracture recurrence after delayed free flap burn reconstruction and found it to be only 0.62%, which was extremely low. All three contracture recurrences after free flap reconstruction reported in literature occurred in the hand.…”

Outcomes of Muscle versus Fasciocutaneous Free Flap Reconstruction in Acute Burns: A Systematic Review and Meta-analysis

“…Our group recently conducted a systematic review and meta-analysis of the literature and estimated the absolute risk for free flap failure in acute burns to be around 10%. 3 However, studies have shown flap loss rates as high as 44%. 7 Therefore, further research efforts are necessary to identify factors and solutions that can minimize the risk of flap failure and optimize outcomes for these patients.…”

“…33 The simultaneous local and systemic hyperinflammatory response caused by larger burn injuries may contribute to the increased risk of flap failure. 3,4,33 It has been postulated that electrical injuries may be associated with a higher risk of flap loss, but significant differences have not been identified in various studies. [24][25][26] However, conclusions on flap loss differences due to burn etiology are limited due to the low level of evidence and lack of comparative analysis in the available literature.…”

“…2 In cases involving extensive defects and exposure of critical structures such as bone, tendons, or neurovascular tissues, a robust and durable reconstruction through well-vascularized and healthy tissue transfer becomes the optimal choice. 3 Although soft tissue defects resulting from a burn injury can be managed with local flaps, their application is sometimes limited by the wound size of involvement of local tissues in the zone of injury. 4,5 Free flap reconstruction offers a viable solution for early repair of complex, large defects, particularly when dealing with exposed bone, nerves, or tendons, and when local flaps are unsuitable or contraindicated.…”

“…Prior studies have demonstrated an incidence of flap loss of 10%, with studies reporting a rate as high as 44%. 3,6,7 Operating after day 21 postinjury can reduce risks. Free flap selection for acute burn injuries depends on defect size, donor availability, pedicle length, and vessel diameter.…”