Free Flap Reconstruction in Burns: A Systematic Review of Current Practices and Evidence

ABSTRACT

Background

The use of microsurgery remains extremely limited in burn management despite offering an alternative in cases where conventional burn reconstruction techniques fall short. This systematic review aims to evaluate the success of microsurgical burn reconstruction in both acute and chronic burn patients and compare it to other surgical modalities as reported in current literature.

Methods

Adhering to PRISMA guidelines, a systematic literature search was conducted across Ovid Medline, Embase, PubMed/Google Scholar databases, spanning publications from 2005 to 2023. Thirteen studies met inclusion criteria. Data were sorted into categories such as study details, patient demographics, burn information, surgical management, and outcomes.

Results

The studies encompassed 396 microsurgical reconstructions with a wide age range and varied anatomical regions for both primary and secondary reconstruction. The most common burn etiology was flame, and most acute burn surgeries were performed five to 22 days after injury. The most common acute and nonacute complications were partial necrosis and hematomas, respectively. Findings revealed an average success rate per flap of 92.7% and 95.7% for acute and reconstructive free flaps, respectively.

Conclusion

Microsurgery offers a promising alternative for complex burn injuries where conventional reconstructive options are exhausted or fall short. However, its success is contingent on patient selection, timing of intervention, and perioperative patient care. The success rate and complication profile of acute microsurgical burn reconstruction are similar to that seen in trauma reconstruction. Secondary microsurgical burn reconstructions have similar success rates to those seen in other elective flaps, such as breast reconstruction. Current usage of microsurgery in burns is low, yet the majority of literature supports expanding its application in the field.

1. Introduction

Although microsurgery has become the gold standard for the reconstruction of numerous traumatic and oncologic defects, it has generally been avoided in the treatment algorithm of acute and chronic burns. Like trauma, acute burns often present with complex defects, including deep necrosis and coagulation issues (Ziegler et al. 2020; Ball et al. 2019). On a global scale, flaps are frequently performed for exposed vital structures, such as bones, joints, tendons, and nerves. However, in the United States and areas without advanced plastic surgery, these exposed structures are usually treated with skin substitutes. If these modalities fail, amputation is frequently performed. Chronic burn deformities lack skin elasticity and are associated with scar contractures that limit function (De Lorenzi et al. 2001). Release and grafting and skin substitutes are modalities frequently used for such deformities; however, they are often unsuccessful, leaving patients with permanent aesthetic and functional limitations.

Even though microsurgical reconstruction is complex, it can allow for better coverage when compared to other techniques, such as grafts and skin substitutes, leading to accelerated healing (Alessandri Bonetti et al. 2024). Despite the potential for improved outcomes, a 2020 study by Perrault et al. indicated that only 0.2% of more than 300,000 acute burn patients receive microsurgical reconstruction (Perrault et al. 2020). Proposed explanations for this low acceptance of microsurgery in the treatment algorithm for burns are multiple, such as the increased risk of thrombosis from acute burn inflammatory physiology (Baumeister et al. 2005). Furthermore, there have also been concerns about progressive tissue necrosis, but the validity of these concerns remains a topic of debate (Pessoa Vaz et al. 2018; Jabir et al. 2014). More concerning arguments have been proposed by studies conducted in the 1990s that have indicated much higher rates of failure with primary free flaps in burn patients compared to other patients (Platt et al. 1996). Secondary free flaps in burn patients within these same studies were indicated to have similar failure rates to trauma patients (Jabir et al. 2014). An obvious yet more challenging theory to substantiate is that the burn and microsurgical fields operate largely independently, often with minimal overlap in first‐line surgical techniques, research focus, or clinical collaboration.

This study aims to examine the current literature pertaining to both acute and chronic microsurgical burn reconstruction. In this systematic review, we aim to (1) investigate the current patient demographics and burn types for microsurgery, (2) explore outcomes after burn microsurgery, and (3) discuss the recommendations in current literature in relation to this technique.

2. Methods

2.1. Search

Utilizing the PRISMA (Preferred Reporting Items for Systematic reviews and Meta‐Analyses) guidelines, a systematic review of current literature was conducted (Figure S1) (Page et al. 2021). The databases utilized include: Medline, Embase, and PubMed/Google Scholar. The search focused on studies published after 2005 and before 2024. Multiple search terms were applied including: “Microsurgery”, “Microvascular”, “Free Flap”, “Burn(s)”, “Plastic Surgery”, “Reconstruction”, and “Free Tissue Transfer”. These terms were utilized with “AND/OR” conjunctions to increase the selectivity and accuracy of the search.

The search results were first screened by title and then compared with our predetermined exclusion and inclusion criteria. First, abstracts were surveyed for eligibility, followed by full‐text examination. English and non‐English translated studies were considered. The inclusion criteria required studies to focus on the use of microsurgical techniques, including free tissue transfer, in the reconstruction of burn injuries. Eligible studies had to involve human subjects, include at least five patients, and provide measurable clinical outcomes related to microsurgical burn reconstruction. Additionally, studies needed to present original data not previously published. The exclusion criteria included review articles, duplicate studies, meta‐analyses, case studies, studies with less than five patients, non‐burn free flaps, non‐free flaps, and studies that did not report rigorous scientific methods. Furthermore, each study had to have a testable hypothesis with replicable methods, data gathering, and analysis to ensure consistency in this review.

2.2. Data Sorting

Data was extracted into six broad categories: (1) study details, (2) patient demographics, (3) burn characteristics, (4) surgical management, (5) complications, and (6) outcomes. Each category was further broken down into specific entries. Regarding study details, categories recorded included: title, journal, country of study, year of publication, first year of patient enrollment, and years of patient enrollment. Patient demographics information included: sex distribution, average age and range, and any pre‐existing conditions. Data collection related to burn specifics included: location of the burn, type of burn, and the total burn surface area (TBSA) average and range. Variables related to surgical management included: type of flap, timing of the flap, and primary versus secondary flap. For this review, any reconstruction done after 12 weeks (84 days) was considered a secondary reconstruction. Some studies distinguished 6 weeks (42 days) as a cutoff for secondary reconstruction. If the study noted when the flap reconstruction occurred, our 12‐week criterion was utilized; if the study utilized a six‐week cutoff without specifying when flap reconstruction occurred, the flaps were excluded from primary flap criteria to maintain consistency. Complications were divided into acute versus non‐acute and the specific nature was noted. Critically, the flap success rate for primary and secondary free flaps, along with rates of partial or total flap loss, was recorded. Lastly, the outcomes included length of hospital stay and study recommendations on the use of free flaps. Although the data reporting methodology was different between studies, categories were utilized to maximize specificity and inclusivity.

Tables were created in Microsoft Excel and Word (Redmond, WA) and Microsoft PowerPoint (Redomond, WA) was used to generate the PRIMSA chart. GraphPad Prism (Boston, MA) was utilized for the bar and pie charts. Microsoft Excel was used to calculate averages and sums and to compare differences in means and percentages.

2.3. Risk of Bias

Two investigators (CH and MS) independently conducted a quality and bias assessment using a data extraction form, following the Downs and Black (D&B) checklist (Downs and Black 1998). The quality of each study was evaluated based on the established criteria for the D&B score, categorized as excellent (≥ 26), good (20–25), fair (15–19), or poor (≤ 14). Additionally, a level of evidence score was assigned to each study according to the American Society of Plastic Surgeons (ASPS) Level of Evidence (LOE) Rating Scale for Therapeutic Studies (ASPS 2011).

3. Results

A total of 370 studies were identified utilizing Ovid Medline (n = 27), Ovid Embase (n = 16), and PubMed/Google Scholar (n = 327). Of the 370 total studies identified, 13 studies met the inclusion criteria (Figure 1). The studies are listed in Table S1 (Ziegler et al. 2020; Alessandri Bonetti et al. 2024; Pessoa Vaz et al. 2018; Yen et al. 2018; Brewin et al. 2020; Hold et al. 2009; Ofer et al. 2005; Jabir et al. 2015; Pan et al. 2007; Acartürk and Bengür 2020; Uslu 2019; Angrigiani et al. 2017; Parwaz et al. 2014). Years of publication ranged from 2005 to 2023 and the studies were published in 10 different countries. A minimum follow‐up time of 1 year was reported by all studies, however, a follow‐up time as long as 29 years was reported. There were 396 flaps included in the analysis. Although there was a wide range of ages (9 months to 92 years), the mean age ranged from 19.7 to 59.6 years with the average patient age across all studies of 37.0 years. There were 219 males and 179 females in total (Figure 2). Hold et al. utilized both free and pedicled flaps but did not separate the demographic data, so their direct data was utilized in congregate (Hold et al. 2009). This may have led to inflated numbers for their total number of patients enrolled and minimally altered the average age.

FIGURE 1.

Schematic depicting search diagram, based on PRISMA guidelines, for this systematic review.

FIGURE 2.

Stacked bar chart of the gender and population size per study. Refer to Table S1 for the individual studies. Asterisk indicates total number of male and female patients in study and is not exclusive to free flap patients.

3.1. Flap Types, Total Body Surface Area, and Surgical Timing

Perioperative patient characteristics are recorded in Table 1. Average TBSA ranged from 7.4% to 36.5%, with individual patient burns ranging from 1.0% to 90.0%. One study did not offer a range and two did not report TBSA (Hold et al. 2009; Acartürk and Bengür 2020; Angrigiani et al. 2017). More patients underwent secondary microsurgical reconstructions (n = 244 patients across nine studies, 61.6%) compared to primary reconstructions (n = 152 patients across 10 studies, 38.4%). (Ziegler et al. 2020; Alessandri Bonetti et al. 2024; Pessoa Vaz et al. 2018; Yen et al. 2018; Brewin et al. 2020; Hold et al. 2009; Ofer et al. 2005; Jabir et al. 2015; Pan et al. 2007; Acartürk and Bengür 2020; Uslu 2019; Angrigiani et al. 2017; Parwaz et al. 2014) Six studies utilized both techniques in their patient populations (Alessandri Bonetti et al. 2024; Yen et al. 2018; Brewin et al. 2020; Hold et al. 2009; Ofer et al. 2005; Jabir et al. 2015).

TABLE 1.

Flap types, total body surface area (TBSA), and surgical timing per study.

Study	Total flaps	Primary flaps	Secondary flaps	TBSA average (%)	TBSA range (%)	Surgery < 5 days	Surgery 5–22 days	Surgery 23–42 days	Surgery 43–84 days
(Pessoa Vaz et al. 2018)	18	18	—	10.5	2–40	1	9	5	3
(Yen et al. 2018).	7	2	5	25.5	4–48	—	2	—	—
(Ziegler et al. 2020)	14	14	—	10.8	1–57	1	8	5	—
(Brewin et al. 2020)	46	7	39	19.9	1–90	—	5	2	—
(Hold et al. 2009)	10	8	2	20	—	—	3	5	—
(Ofer et al. 2005)	42	21	21	—	—	2	11	8	—
(Jabir et al. 2015)	25	22	3	19.5	0.5–65	2	11	7	2
(Pan et al. 2007)	38	38	—	7.4	1–55	9	23	6	—
(Acartürk and Bengür 2020)	5	—	5	—	—	—	—	—	—
(Uslu 2019)	11	11	—	14.8	5–30	—	5	5	1
(Angrigiani et al. 2017).	160	—	160	—	—	—	—	—	—
(Parwaz et al. 2014)	7	—	7	36.5	25–60	—	—	—	—
(Alessandri Bonetti et al. 2024)	13	11	2	8.9	2–37	1	2	8	—

Time to surgery also varied significantly between studies. The timing was split based on the most common reported metric, which was either less than 5 days, between 5 and 22 days, between 23 and 42 days, and between 42 and 84 days. Although some studies reported exact days, this was not common practice. In total for primary reconstruction, 51.6% of surgeries were completed between 5 and 22 days of the burn (n = 78). Only 33.7% were completed from 23 to 42 days (n = 51), 16.1% were completed in less than 5 days (n = 16), and 4.0% were completed from 42 to 84 days (n = 6) (Figure 3). From 42 to 84 days, some studies utilized the six‐week cutoff for primary reconstruction and did not specify the time to surgery, so the data for these burns were not included. These numbers were likely minimal and would not affect the frequency of timing.

FIGURE 3.

Pie chart analysis of surgical timing for acute primary free flaps (secondary flaps not included). Asterisk indicates data that was affected by the 6‐ versus 12‐week cutoff based on study reporting.

Locations and etiology of burns at presentation are noted in Figure 4. The location of the presenting burn is represented in Figure 4A. The most common burn location was the neck (n = 181, 48.9%), followed by the arm (n = 77, 20.8%) and the lower extremity (n = 46, 12.4%). Other locations noted included the hand, head, and trunk. The neck was a predominant location due to Angrigiani et al. and its 150 secondary neck reconstructions (Angrigiani et al. 2017). The mechanism of burn is represented in Figure 4B. The most common burn etiology was flame (n = 82, 39.4%), followed by electrical (n = 72, 34.6%), and scald (n = 15, 7.2%). Other reported mechanisms of burn included chemical, contact, crush, thermal, friction, and explosive burns. Multiple patients were classified under one or more categories. Different references utilized varying syntax that was similar, but the direct syntax of the burn type was recorded (Figure 4). The most common flap type used was the extended circumflex scapular flap (n = 160), which was solely from the study by Angrigiani et al. The next most common was the anterolateral flap (n = 86), latissimus dorsi (n = 32), parascapular flap (n = 27), radial forearm (n = 16), lateral arm (n = 11), rectus abdominis (n = 10), gracilis (n = 7), scapular (n = 6), and deep inferior epigastric perforator (n = 5) (Angrigiani et al. 2017). The other flaps utilized were all less than five.

FIGURE 4.

Pie charts analysis of burn location and burn type for both primary and secondary free flaps.

Success rates of primary and secondary microsurgical reconstructions by study are included in Figure 5. The success rate varied more for primary flaps with a range of 76.0% to 100.0%, with the majority of studies demonstrating a high success rate (100.0% for n = 5) (Yen et al. 2018; Brewin et al. 2020; Jabir et al. 2015; Pan et al. 2007; Uslu 2019) out of the 10 studies (Ziegler et al. 2020; Alessandri Bonetti et al. 2024; Pessoa Vaz et al. 2018; Yen et al. 2018; Brewin et al. 2020; Hold et al. 2009; Ofer et al. 2005; Jabir et al. 2015; Pan et al. 2007; Uslu 2019). The average success rate per flap for primary flaps was 92.7% compared to the 95.7% average success rate per flap for secondary flaps. Six studies had a 100.0% success rate, and Brewin et al. and Angrigiani et al. had a 98.0% and 94.0% success rate, respectively (Brewin et al. 2020; Hold et al. 2009; Ofer et al. 2005; Jabir et al. 2015; Acartürk and Bengür 2020; Angrigiani et al. 2017; Parwaz et al. 2014).

FIGURE 5.

Clustered bar chart of the success rate of primary versus secondary flaps by article.

Acute and non‐acute complications are displayed in Table 2. Acute complications include partial and/or distal necrosis (n = 32, 43.2%), total flap loss (n = 16, 21.6%), venous insufficiency (n = 8, 10.8%), wound infection (n = 6, 8.1%), arterial thrombosis (n = 5, 6.7%), arterial insufficiency (n = 4, 5.4%), and pedicle damage from harvesting (n = 3, 4.0%). Non‐acute complications include hematoma, delayed healing, scarring (which includes widening, hypertrophic, and contraction), and secondary procedures; although secondary procedures are often planned and intentional. These secondary procedures varied widely and included liposuction, debulking, and aesthetic‐centered surgeries.

TABLE 2.

Table of acute (left) and non‐acute (right) complications.

Study	Wound infection	Venous insufficiency	Arterial thrombosis	Arterial insufficiency	Pedicle damage	Partial/distal necrosis	Total flap loss	Hematoma	Delayed healing	Scarring	Secondary procedures
(Pessoa Vaz et al. 2018)	—	—	2	—	—	1	2	2	—	—	—
(Yen et al. 2018)	1	—	—	—	—	1	—	—	—	—	—
(Ziegler et al. 2020)	1	2	1	—	—	—	1	1	—	—	—
(Brewin et al. 2020)	—	2	—	—	—	—	1	4	5	8	13
(Hold et al. 2009)	2	—	1	—	—	—	3	2	—	—	—
(Ofer et al. 2005)	1	—	2	—	—	—	5	2	—	—	—
(Jabir et al. 2015)	2	—	—	—	—	4	—	—	—	—	—
(Pan et al. 2007)	—	—	—	—	—	3	—	—	—	—	23
(Acartürk and Bengür 2020)	—	—	—	—	—	—	—	—	—	—	—
(Uslu 2019)	—	—	—	—	—	—	—	—	—	1	—
(Angrigiani et al. 2017)	—	2	—	4	3	22	3	—	—	—	—
(Parwaz et al. 2014)	—	—	—	—	—	1	1	—	—	—	3
(Alessandri Bonetti et al. 2024)	1	2	—	—	—	—	2	2	3	—	7

3.2. Risk of Bias and Quality Score

The risk of bias and quality assessment for the included studies were conducted using the D&B checklist. Of the 13 studies evaluated, the mean (SD) D&B score was 17.31 (0.48) (Table S1), with all studies scoring between 17 and 18, indicating moderate to good methodological quality. The mean ASPS LOE was 4.00 (0.00), as all studies received an LOE score of 4, reflecting that the included studies were primarily case series or retrospective analyses.

4. Discussion

While microsurgery has been built and developed around trauma reconstruction, very little work has been done in the burn field using microsurgery (Bharani and Yeo 2023). Based on this systematic review, microsurgical reconstruction in burns can be broadly divided into acute (primary) or chronic (secondary) reconstruction. This review, along with other studies, utilizes 12 weeks as the acute (primary) cutoff. While setting a clear time‐based delineation between these groups is subject to debate, pathophysiology is not. Patients undergoing acute or chronic reconstruction are vastly different patients. In the acute setting, the patients are often hemodynamically unstable and plagued by a state of systemic inflammation, infection, and catabolism (Jeschke et al. 2020). In the chronic state, patients have often recovered from these systemic insults; however, they have functional limitations from scar contractures (Goverman et al. 2017). Our analysis focuses on these groups separately.

4.1. Timing of Microsurgical Reconstruction in Acute Burns Is Delayed Compared to Trauma Reconstruction

In a 2019 paper by Lee et al. the researchers found that trauma free flap reconstruction performed within 3 days of injury had superior outcomes (Lee et al. 2019). This is consistent with the Godina et al. landmark paper in 1986 which recommended early intervention for microsurgical trauma reconstruction (Godina 1986). Although the timing seems to be increasing in recent literature, other reviews and sources indicate that early reconstruction is still the predominant modality for microsurgical trauma reconstruction (Lee et al. 2019; Zhang et al. 2019; Haykal et al. 2018; Harrison et al. 2013; Kolbenschlag et al. 2015). In this review for acute burns, the most common timing was between 5 and 22 days. The two least common surgical timing, according to our data, included less than 5 days with a prevalence of 10.6% and 42 to 84 days with a prevalence of 3.9%. Approximately one‐third of the patients had microsurgical reconstruction between 23 and 42 days post‐burn, and roughly half of the primary microsurgeries were performed between 5 and 22 days.

While trauma literature has shown that early free flap coverage is associated with reduced complications and flap failure, timing is less of a deciding factor for choice in burn reconstruction (Pessoa Vaz et al. 2018). It takes several days for burn wounds to declare themselves and for debridement to be initiated, and exposure of vital structures often lags behind debridement and failure of conventional burn techniques such as skin substitutes (Brewin et al. 2020). Furthermore, major burns are life‐threatening injuries for which the adage “life over limb” applies perhaps more than any other area of reconstructive microsurgery. Pushing for early coverage may result in a patient being taken to the operating room prematurely for a long procedure while they are still unstable, posing an unnecessary risk to their survival. Second, early flap coverage, before their other wounds are well on their way to healing, may result in the patient requiring further debridement and blood loss, possible sepsis, and hemodynamic instability that can threaten the flap in its early postoperative period (Ibrahim et al. 2015).

4.2. Success Rates for Primary Microvascular Burn Reconstructions Were Similar to Trauma, and Secondary Reconstructions Were Similar to Elective Free Flaps

In our review of the available literature, the average success rate for primary free flaps under acute conditions was 92.7%, which is comparable to the current free flap literature in trauma. In a 2023 systematic review by Koster et al. on free flap failure in lower extremity trauma, they reported a success rate of 94.7% for the initial free flap in 28 primary literature sources (Koster et al. 2023). In traumatic upper extremity injuries, Gupta et al. reported a single‐site success rate of 95.7% (Gupta et al. 2015). These results were comparable despite the burn reconstructions being delayed when compared to trauma reconstructions, and therefore, in an inflammatory phase.

Secondary free flaps also had similar success rates (95.7%) to similar elective procedures, such as autologous breast reconstruction. A 2015 review by Massenburg et al. of 6855 patients between 2005 and 2012 for autologous breast reconstruction reported a success rate of 97.9% (Massenburg et al. 2015). The data from this review indicates no significant difference between success rates of primary versus secondary free flaps (92.7% versus 95.7%). Free flaps should be considered for the acute phase based on similar success rates to secondary burn and traumatic injury free flaps.

4.3. Age and Sex Are Not Factors for Indicating Microsurgical Reconstruction in Burns; Lower TBSA Is

In the studies analyzed, there were no age cutoffs, suggesting that the surgeons performed on a varying population, as indicated by the large range in age. Gender differences varied greatly between each study, with a total of 219 males and 179 females. Similarly to sex and age, there was a large range in individual burn percentage (1.0% to 90.0%), although the average for each study was less than 40.0%. This could indicate that with lower TBSA burns, microsurgical reconstruction would be best indicated due to overall patient stability. While it was not clearly described in the studies, it is reasonable to assume that the largest TBSA is associated with higher overall morbidity and mortality and is likely subject to more liberal use of amputations rather than limb salvage. Unfortunately, it is impossible to extract from the available data whether early coverage was associated with smaller TBSA burns.

4.4. Flame and Electrical Burns Are Most Commonly Associated With Microsurgical Reconstruction

The most common burns observed in patients were flame and electrical, comprising 39.4% and 34.6% of all the burn types, respectively. The location of the burn was predominantly neck due to Angrigiani et al. and their secondary reconstructions (n = 160, 48.9%) (Angrigiani et al. 2017). Without Angrigiani et al., the most common locations were arm, lower extremity, and hand burns (n = 77, 46, 38, respectively). The most used flap in Angrigiani et al. was the extended circumflex scapular flap for secondary neck reconstruction (n = 160, 41.2%) (Angrigiani et al. 2017). Excluding Angrigiani et al., the most common flaps were anterolateral thigh, latissimus dorsi, and parascapular flaps (n = 86, 32, 27, respectively). Unfortunately, most of the literature did not delineate early versus late reconstruction, making it difficult to obtain flap data that is separated into acute versus chronic. The most common acute complication was partial necrosis at a rate of 8.1% per flap for both primary and secondary flaps combined. In comparison, the traumatic lower extremity free flap partial necrosis rate in a 2023 paper by Liu et al. was 13.1%, and similarly, a 2022 paper by Kondra et al. reported a partial necrosis rate of 9.4% (Liu et al. 2023; Kondra et al. 2022).

Elective procedures (e.g., autologous breast reconstruction) allow for an accurate comparison of partial necrosis rates similar to those observed in secondary free flaps. When examining the rates of partial necrosis in autologous breast reconstruction, Abedi et al. found a flap necrosis rate of 15.2% (Abedi et al. 2016). The combined percentage for this review is lower yet comparable to the reported literature for free flaps in trauma and elective procedures. This may be due to poor perfusion pressure, infection, poor flap design, or other factors. The most common non‐acute complication was hematomas, as secondary procedures (liposuction, debulking, and other revision procedures) were not complications but instead planned operations post‐flap.

4.5. Indications and Complication Rates Varied Among Studies

Ziegler et al. (2020); Alessandri Bonetti et al. (2024); Ofer et al. (2005) suggest a higher complication rate of free flap reconstruction compared to other procedures. In contrast, Brewin et al. Pan et al. and Asim et al. indicate lower complication rates (Brewin et al. 2020; Pan et al. 2007; Uslu 2019). Pan et al. and Asim et al. directly stated that free flaps can minimize post‐operative complications and hospital stays (Pan et al. 2007; Uslu 2019). Interestingly, Jabir et al. reported that there was no difference in flap success depending on the timing (i.e., whether it was immediate, early, intermediate, or late in terms of free flap survival) (Jabir et al. 2015). In contrast, Hold et al. indicated that for electrical injuries, the “critical window” from six to 21 days should be avoided due to the increase in flap failure and infection rate (Hold et al. 2009). This is also supported by Brewin et al. who stated that electrical injuries have higher risks of venous thrombosis and flap failure (Brewin et al. 2020).

Microsurgical burn reconstruction is currently used in a relatively small subset of acute and secondary burn cases. This could be related to an intrinsically high complication rate seen in this patient population, or to the absence of indications. Bonetti et al. also recommended free flaps “only as the last resort for limb or life‐threatening situations” (Alessandri Bonetti et al. 2024). The available literature places the complication rates seen in acute microsurgical burn reconstruction in the same range as those seen in trauma reconstruction. For secondary reconstructions, the complication rates are similar to those seen in elective free flaps, such as autologous breast reconstructions. This parallel to the trauma and elective microsurgery literature disproves the first premise of the high complication rates seen in burns, which leaves the second premise of absent indications. While we can argue that the indications for burn microsurgery are smaller than those of the trauma counterparts, microsurgery should still be an integral part of a modern burn treatment algorithm. We should not hesitate to offer microsurgical reconstruction to burn patients with adequate indications.

Due to the heterogeneity of the available studies, it was impossible to generate a meta‐analysis. Furthermore, we can identify several biases in the current literature that reduce the data's significance; for example, the studies were retrospective case series. Additionally, there is also selection bias that cannot be controlled because the patient population that receives free flaps versus skin grafts is specifically selected by the physicians.

While to date microsurgery has not been a prevalent modality for burn reconstruction, the available data supports its use in burn patients. However, we acknowledge some inertia to this concept. We suggest that the decline of plastic surgery connections with burn centers has limited access to microsurgery for burn patients. Indeed, access to quality care of all types is threatened as burn education becomes less and less of a priority in general surgery and plastic surgery residencies. As the burn community strives to push the pendulum back in favor of the burn patient, we suggest that microsurgery should become an integral part of the burn treatment algorithm. Further research is recommended in this growing area. Prospective studies, in lieu of retrospective studies, conducted at the same center will allow comparison of free flap to non‐free flap reconstruction; this can increase the level of evidence for recommendations. Because our data suggest similar success rates at the time of procedure, longitudinal studies would be beneficial to compare and elucidate the outcomes of free flap versus alternate reconstructions.

5. Conclusion

Microsurgical reconstruction has demonstrated promising outcomes for both acute and chronic burn injuries, providing a viable option when traditional techniques are insufficient. With a comparable success rate to trauma and elective microsurgical reconstructions, its utility is evident in improving functional and aesthetic outcomes for burn patients. Nevertheless, its limited adoption underscores the need for expanded education, interdisciplinary collaboration, and robust prospective studies to better define indications and refine techniques. By integrating microsurgery into the broader burn treatment algorithm, we can optimize care for patients with complex burn injuries, advancing the field of burn reconstruction to address unmet needs effectively.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1. Preferred reporting items for systematic reviews and meta‐analyses (PRISMA) checklist.

Table S1. Study details and select patient demographics.

Fan, C. , Azam F., Hinson C., et al. 2025. “Free Flap Reconstruction in Burns: A Systematic Review of Current Practices and Evidence.” Microsurgery 45, no. 5: e70086. 10.1002/micr.70086.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.