Microvascular free tissue transfer in acute and secondary burn reconstruction

The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit.

All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival.

Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft.

Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.