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Arch Hand Microsurg > Volume 29(1); 2024 > Article
Park, Woo, and Kang: The role of surgical timing in upper extremity free flap reconstruction following trauma: a 10-year single-center, single-surgeon experience



Complex traumatic upper extremity injuries often require microvascular free tissue transfer for adequate soft tissue coverage or functional reconstruction. The need for rapid coverage is acknowledged, but the optimal timing for reconstruction remains a subject of debate.


A retrospective review was conducted of patients who underwent free flap reconstruction for upper extremity injuries after trauma from March 2012 to August 2018 in South Korea at a facility specializing in extremity trauma. Surgical timing was categorized according to the classification of Godina into early (within 72 hours after injury) and delayed (from 72 hours to 3 months after injury) reconstruction. Patients’ demographic characteristics, methods of free tissue transfer, flap failure rates, postoperative infections, total hospital stays, and the number of operations required were analyzed.


In total, 80 free tissue transfers were conducted on 76 patients. The demographics and characteristics of patients in the early and delayed reconstruction groups showed no significant differences. Early reconstruction was associated with a significantly lower infection rate, shorter average hospital stay, and a lower average number of operations, without showing a significant difference in the flap failure rate.


The results of this study indicate that early reconstruction within 72 hours after trauma significantly reduces infection rates, the length of hospital stays, and the number of required operations. This study underscores the importance of timely intervention in upper extremity free flap reconstruction for optimal patient outcomes.


Complex traumatic upper extremity injuries often require microvascular free tissue transfer to achieve adequate soft tissue coverage. Over the past 40 years, reconstructive outcomes for these injuries have significantly improved, owing to advancements in perioperative management and definitive microsurgical reconstruction. Microsurgical techniques offer the optimal treatment for severely traumatized extremities involving fractures or exposed neurovascular structures, preserving vital structures, enabling earlier mobilization, salvaging limbs from impending amputation, reducing the number of operations, decreasing hospital stays and costs, and improving aesthetics [1-5].
Although it is agreed that the exposure of vital structures and orthopedic hardware requires emergent soft tissue coverage, the timing of reconstruction remains a subject of debate. Godina [6] originally recommended wound coverage within 72 hours of injury to prevent complications such as tissue fibrosis, infection, and edema that may hinder local or free flap coverage. Notably, Godina’s seminal article did not distinguish between upper and lower extremity injuries. Subsequently, some authors have advocated for coverage within 24 hours with definitive single-stage reconstruction [7]. In the largest study on this topic to date, Derderian et al. [8] found that reconstruction within the 6-to-21-day period after injury yields the most optimal results. More recent investigators have proposed that changes in perioperative management, including the use of vacuum-assisted closure therapy, allow for safe reconstruction and serial debridements in the subacute period [9]. It has also been suggested that timing may not play a significant role in reconstructive outcomes. However, owing to variations in sample sizes, perioperative management approaches, and operator experience in extremity reconstruction and proper debridement, the clinical significance of these findings remains unclear.
This study presents a 10-year, single-center, single-surgeon experience in upper extremity free flap reconstruction at a specialized trauma center in South Korea. This study aimed to investigate the role of surgical timing in flap loss, infection rate, hospital stay, and the number of operations. To our knowledge, this is the largest series to date in South Korea focusing on upper extremity free flap reconstruction following trauma, based on the timing of reconstruction.


Ethics statement: The protocol of this study was approved by the Public Institutional Review Board (No. P01-202308-01-003). Written informed consent was obtained from the patients for the publication of this report including all clinical images.
A retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction after trauma by a single surgeon (DHK) from March 2012 to August 2018. The data collected included patient demographic characteristics, timing of reconstruction, fracture characteristics, method of free tissue transfer, flap failure, postoperative infection, total hospital stay, and number of operations. The timing classification described by Godina [6] categorizes cases as early (within 72 hours of injury) and delayed (from 72 hours to 3 months after the injury). Flap failure was defined as any flap loss greater than 60% or reexposure of vital structures.
Statistical analysis was conducted to compare groups undergoing early versus delayed reconstruction. The chi-square test was used to evaluate differences in flap failure rate and postoperative infection rate. The independent t-tests were applied to contingency tables to compare the proportions of the total hospital stay and the number of operations among the groups, using IBM SPSS Statistics ver. 19 (IBM Corp., Armonk, NY, USA). Statistical significance was set at the p-value of <0.05 [10].


A total of 80 free tissue transfers were conducted on 76 patients with an average follow-up period of 192 weeks (range, 127–530 weeks). The distribution of free tissue transfers between the early reconstruction group and the delayed reconstruction group showed no significant difference (Table 1). Additionally, no significant differences were observed in demographics, mean age, smoking status, or the prevalence of hypertension and diabetes mellitus. The reconstruction procedures utilized various types of free flaps, including anterolateral thigh (ALT) flap, radial artery superficial palmar branch flap, venous flap, toe pulp flap, posterior interosseous artery flap, toe transfer, vascularized fibular bone flap, and medial sural artery perforator flap (Fig. 1). Notably, the specific types of free flaps used varied significantly between the two groups.
Rates of flap failure, postoperative infections, number of operations, and duration of hospital stays were assessed between early and delayed reconstruction groups (Table 2). The late reconstruction group showed significantly higher rates of postoperative infections, longer hospital stays, and a greater number of surgeries compared to the early reconstruction group. There was no significant difference in the flap failure rate. During the postoperative course, the early reconstruction group underwent three reoperations, all due to venous congestion. Meanwhile, in the delayed reconstruction group, there were nine reoperations, two for arterial occlusion and seven for venous congestion.

1. Case 1

A 22-year-old male patient sustained a right forearm injury caused by a belt machine. Surgery was performed 2 hours after the injury under brachial plexus block (BPB). Following extensive irrigation, the wounds were assessed and showed both ulnar and radial bone shaft fractures with extensive forearm soft tissue defects, but no major neurovascular injury. After thorough debridement and fixation of both bones, negative pressure wound therapy (NPWT) was applied for temporary wound coverage. Thirty-six hours after the initial injury, a suprafascial ALT free flap was used for coverage. Bone union was achieved 6 months postoperatively. Despite a residual thumb extension lag, the patient had a good overall outcome (Fig. 2).

2. Case 2

A 54-year-old male patient suffered a third-degree friction burn to the dorsum of the left hand from a motorcycle traffic accident. Massive irrigation and radical debridement were performed BPB. Defects were noted in the second extensor digitorum communis (EDC) and extensor indicis proprius (EIP) tendons, along with soft tissue defects on the dorsum of the hand. The extensor digitorum minimi was transferred to the second EDC and EIP. Temporary coverage was provided using an acellular dermal matrix. Two days later, a suprafascial ALT free flap was used to cover the defect. Healing was observed without complications. Rehabilitation commenced one week postoperatively with a dynamic splint, leading to a favorable outcome 6 months following the surgery (Fig. 3).


In this study, the authors reviewed a single center, W General Hospital, and a single surgeon’s 10-year experience with traumatic upper extremity free flap reconstruction. The focus was on surgical outcomes, length of hospital stays, and the number of surgeries, depending on the timing of the operation. The primary goal of upper extremity reconstruction is to achieve early and optimal functional recovery. Adequate soft tissue coverage is crucial, and microvascular free tissue transfer is often necessary for reconstructing complex upper extremity injuries. Several landmark studies have shown that complication rates in extremity reconstruction vary with the timing of the reconstruction. Godina [6] reported decreased failure rates when free tissue reconstruction was performed within 72 hours of injury. However, other authors have advocated for emergency microvascular free tissue transfer within 24 hours [7]. Additionally, several studies have indicated that reconstruction can be safely delayed into the subacute period [8].
Recent advancements in NPWT and the use of temporary acellular dermal matrices (ADM) have provided methods to cover wounds with local infection control [11]. This development has seemingly diminished the distinction between immediate and delayed reconstruction over the past two to three decades. However, our study results indicate that delayed reconstruction is still associated with significantly more complications. We observed increased rates of infection, and a greater number of operations compared to early reconstruction. In particular, the length of hospital stay was significantly associated with the timing of upper extremity reconstruction. The mean hospital stay was 24.3 days when reconstruction was performed within 72 hours, indicating potential implications for patient morbidity, notably infection, and healthcare costs, which warrants further investigation. This suggests that, despite these new applications like NPWT being mentioned extensively, they have not entirely eliminated the need for timely reconstruction. Indeed, Georgescu and Ivan [7] advocate for reconstruction in the immediate period (within 24 hours), citing reduced edema and inflammation, less vessel spasm, and lower chances of harboring infections. Our findings reinforce the idea that, even with the option of using temporary ADM or NPWT, it is reasonable to perform reconstruction within 72 hours after thorough debridement, rather than delaying it unnecessarily.
The present study was limited by its retrospective design. In addition, loss to follow-up prevented us from collecting return time to work data in patients. Furthermore, over the course of this time period, improvements to trauma care, antibiotics, dressing materials, and anesthetic techniques significantly improved, which limits the conclusions that may be drawn from the study as a whole [12]. Our study did not consider patients as heterogeneous with regard to other trauma injuries and overall trauma injury severity, which may have taken precedence with regard to extremity reconstruction. There is a clear need for additional research on the relationship among timing, injury type, injury level, and associated complications to determine the most appropriate timing for such reconstructions. In the matter of setting a time limit within which one must act, considerable debate exists. Although this study chose the traditional 72 hours, there is controversy and potential statistical biases [12]. Therefore, the most crucial point is that the wound should be well-debrided and be in a fresh and clean state for reconstruction. Although there is no need to intentionally delay the reconstruction process, the results derived from a single surgeon’s 10-year experience at a single center are believed to be clinically significant.


Our study demonstrates that in cases of upper extremity injuries, early reconstruction leads to better outcomes. Although the flap failure rate was not significantly different, the early reconstruction led to fewer postoperative infections, shorter hospital stays, and fewer surgeries, compared to delayed reconstruction. These findings underscore the importance of timely surgical intervention and the appropriate selection of reconstructive techniques to optimize patient recovery and minimize complications.

Conflicts of interest

The authors have nothing to disclose.




Fig. 1.
Pie charts showing the percentage and types of free flaps used for early (A) and delayed (B) reconstruction. ALT, anterolateral thigh; PIA, posterior interosseous artery; RASP, radial artery superficial palmar branch; VFG, vascularized fibular graft.
Fig. 2.
Early reconstruction of right forearm injuries. (A) Preoperative clinical photograph. (B) Immediate postoperative X-ray. (C) Intraoperative clinical photograph after debridement. (D) Immediate postoperative photograph of suprafascial anterolateral thigh free flap reconstruction. (E–G) Six-month postoperative photographs and X-ray.
Fig. 3.
Early reconstruction of a third-degree burn on hand dorsum. (A) Preoperative clinical photograph of a third-degree burn on the dorsum of the hand. (B) Intraoperative clinical photograph after debridement. (C) Photograph showing the transferred extensor digitorum minimi to the second extensor digitorum communis and extensor indicis proprius. (D) Immediate postoperative photograph of suprafascial anterolateral thigh free flap reconstruction. (E, F) Six-month postoperative photographs.
Table 1.
Patient demographics and free flaps used in early and delayed reconstruction cases
Characteristic Early reconstruction Delayed reconstruction Total p-value
No. of cases 35 (43.8) 45 (56.2) 80 (100)
Sex, male:female 31:4 37:8 68:12 0.430
Age (yr) 44.7 (19–63) 47.5 (18–63) 46.3 (18–63) 0.313
Smoking 14 (40.0) 17 (37.8) 31 (38.8) 0.840
Diabetes mellitus 6 (17.1) 9 (20.0) 15 (18.8) 0.745
Hypertension 7 (20.0) 9 (20.0) 16 (20.0) >0.999
Method of free tissue transfer 0.001
 Anterolateral thigh flap 13 33 46
 RASP flap 13 3 16
 Venous flap 5 4 9
 Toe pulp flap 2 0 2
 Posterior interosseous artery flap 1 1 2
 Toe transfer 1 2 3
 Fibular bone flap 0 1 1
 Medial sural artery perforator flap 0 1 1

Values are presented as number (%), number only, or mean (range).

RASP, radial artery superficial palmar branch.

Table 2.
Clinical outcomes following early and delayed surgical reconstruction
Variable Early reconstruction (n=35) Delayed reconstruction (n=45) p-value 
Flap failure 1 (2.9) 5 (11.1) 0.058
Postoperative infection 4 (11.4) 12 (26.7) 0.009
Length of hospital stay (day) 24.3±2.312 47.9±5.801 <0.001
No. of operations 3.1±2.892 5.8±2.414 <0.001

Values are presented as number (%) or mean ± standard deviation.


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