Advances in microsurgery have enabled plastic surgeons to camouflage various defects caused by trauma, oncological resection, and chronic ulcers using free-flap reconstruction. These flaps cause a prominent and long scar of >20 cm at the donor site (Fig. 1). However, the criteria for flap selection are mostly based on factors such as wound characteristics, donor-site morbidity, anatomical and physiological properties of the flap, and the surgeon’s preference [1]. In other words, patients’ preferences for donor-site selection from an aesthetic perspective are generally not considered in practice.

In recent times, higher levels of patient education and patient expectations have pressurized surgeons to produce better aesthetic outcomes following free-flap reconstruction [2], and aesthetic preferences have to be considered even in reconstructive surgeries. Currently, the commonly used flaps for lower-extremity reconstruction are the thoracodorsal artery perforator (TDAP), anterolateral thigh (ALT), and superficial circumflex iliac artery perforator (SCIP) flaps.

This study aimed to investigate donor-site preferences based solely on aesthetic perspectives, specifically donor-site scarring, among the general public who have not undergone free-flap surgery, and to evaluate the factors affecting patient preference for free-flap donor-site selection [3-5]. The primary aim of this online-based survey study was to identify the preferred donor sites among the TDAP, SCIP, and ALT flaps, which are the most common donor sites for free-flap reconstruction, from the perspective of patient’s preference.

Of the 315 participants, 181 (57.5%) were male and 134 (42.5%) were female. The mean age of the participants was 42.69 years (standard deviation [SD], ±15.11 years), the mean BMI was 23.23 kg/m² (±3.39 kg/m²), and the mean aesthetic interest score was 3.93 (±0.87). Among the participants, 233 (74.0%) and 82 (26.0%) had low and high BMIs, respectively. Educational levels were categorized as low, middle, or high, with 39 (12.4%), 198 (62.9%), and 77 (24.4%) in each category, respectively. The aesthetic interest score was dichotomized into two groups: 1–3 points (93 participants, 29.5%) and 4–6 points (222 participants, 70.5%) (Fig. 3). A total of 226 respondents (71.7%) reported having scars on their bodies and 115 (36.5%) had undergone previous surgery (Table 1). The mean scores recorded for each flap were as follows: TDAP flap, 3.33 (SD, ±1.55); SCIP flap, 4.46 (±1.47), and ALT flap, 3.14 (±1.74) (Fig. 4). Moreover, the ANOVA results demonstrated that the means differed significantly among the groups. The score for each flap and the preference scores were evaluated separately and were independent of each other. The percentages of the first preference for each flap were as follows: A flap, 21.27%; B flap, 58.41%; and C flap, 20.32% (Fig. 5). In addition, using Bonferroni analysis, B flap (SCIP flap) had a significantly higher score than the A and C flaps; however, there was no statistically significant difference between the TDAP and ALT flaps (Table 2). The chi-square test was performed to evaluate the association between various demographic variables and the first preference for flap choice. The results of the chi-square test showed that sex, age, educational level, and aesthetic interest score of the female group were statistically significant for the response to the most preferred flap. However, the results showed that the presence of scars, history of previous surgery, and aesthetic interest score of the overall groups were not statistically significant (Table 3).

According to the results of the multivariable logistic analysis for the first preference of a flap, the significant variables affecting the first preference of SCIP and TDAP compared to ALT are as follows.

TDAP does not significantly differ from ALT; in other words, no significant variables could be identified. However, in the case of SCIP, we verified that people with lower BMI and females are more likely to prefer SCIP as their first choice (Table 4).

The overall goal for lower-extremity reconstruction plastic surgery is to cover defects and open wounds in the leg, allowing patients to continue their active life with the use of their leg(s), return to work, and avoid amputation with minimal donor-site morbidity. Nowadays, increasing attention is focused on the quality of life and functional and aesthetic results of patients undergoing reconstructive plastic surgeries [6]. Current trend prefers a minimally invasive approach to surgery [7], with reconstruction of the resulting surgical defect using pedicled locoregional flaps or microvascular free flaps receiving more attention. The factors that need to be considered when choosing the flap include the size of the defect to be reconstructed, different tissue types to be replaced, patient preference, and donor-site morbidity [8].

Free flaps commonly used and preferred in lower-extremity reconstructions are the SCIP, ALT, and TDAP flaps, which are briefly described below.

The SCIP flap, which was first introduced by Koshima in 2004 [9], can be considered an evolution of the groin flap. From the reconstructive perspective, the advantage of the SCIP flap is that a very thin flap can be obtained, but the relatively short harvestable pedicle length is a disadvantage [9]. The ALT flap is advantageous in lower-extremity reconstruction because it provides all the benefits of a soft tissue envelope, including vascularized fascia, adequate subcutaneous fat, and full-thickness skin. The use of ALT limits the need for secondary procedures such as skin grafting and other revision flap procedures [10]. However, the disadvantage of the ALT free flap is that it is technically less predictable in terms of structure owing to the wide range of anatomical variations, which is a limitation in donor selection [11]. The TDAP flap has its limitations from a surgical perspective as it is typically performed in the prone or lateral positions. However, it can also be harvested in the supine position, offering the advantage of securing a sufficiently long pedicle [12].

The choice of the free-flap donor, which is selected according to the defect, is dependent on the size, thickness, composition, and pedicle length of the flap [9]. It is important to understand that these anatomical considerations should be considered; however, they are not absolute criteria. For example, various studies have been conducted on the SCIP flap to compensate for its short pedicle length, and efforts are ongoing to overcome this disadvantage [13]. For TDAP, techniques for supine-only harvesting have been proposed to overcome the associated positioning limitations [14]. Once these anatomical limitations are overcome, the aesthetic point of view must be considered from the perspective of plastic surgery and is related to donor-site scar and donor-site selection.

However, most studies have reported on wound morbidity, undesired surgical outcomes, and recurrence rates. Some studies have been conducted on donor-site preference, and few studies have examined donor-site preference in the general public who have not undergone surgery, considering only donor-site scarring [3-5]. Notably, a patient’s preference for the donor site was not statistically correlated with the success of free-flap procedure [15]. That is, the surgeon and patient might have different perspectives on what is important. Therefore, further studies are needed to explore the variables that affect patients’ preferences for donor sites. To the best of our knowledge, few studies have directly compared patient preferences, specifically evaluating aesthetic considerations such as donor-site scarring, for these three flaps among the general public who have not undergone free-flap surgery, based on online surveys.

This study holds significance as it represents a patient-centered online survey focusing on lower-extremity free-flap reconstruction, exclusively examining aesthetic aspects and analyzing various factors influencing donor-site selection for lower-extremity free flaps based on donor-site scarring. Unlike several other studies that have reported patient satisfaction with latissimus dorsi flaps and other free flaps, such as the Deep Inferior Epigastric Artery Perforator flap [3], this research was conducted among individuals without a surgical history, specifically addressing lower-extremity reconstruction rather than breast reconstruction. One notable advantage of online surveys is their capacity to rapidly recruit a large number of participants while facilitating efficient data organization.

The results indicated that the demographic data such as sex, aesthetic interest score, educational level, and age were statistically significant variables. Lower BMI, female sex, and higher aesthetic interest score were significantly associated with free-flap donor-site preference, suggesting that these factors should be considered when performing free-flap surgery.

Significantly fewer female participants preferred the TDAP flap than male participants, probably because the TDAP flap donor scar is located near the breasts. The preference for the SCIP flap was significantly lower in male participants than in female participants, which could be attributed to the subjective differences between men and women in their aesthetic perception of the inguinal groin. Female participants also had a significantly lower preference for the ALT flap than did male participants, probably because women are more sensitive to thigh exposure. These results are consistent with those of previous sociocultural studies. Shin and Lee [16] reported a significant difference in the degree of shame among patients in a general hospital suggesting that women are more sensitive to the exposure of their perineal area than men, which could also be attributed to social and cultural factors. These results are expected to differ based on ethnicity and should be interpreted in a sociocultural context.

Age also plays a crucial role in patient preference, because younger patients prefer the SCIP flap. These differences can be attributed to generational differences in perceptions of exposure. Older individuals prefer ALT or TDAP flap because they might be more conservative regarding exposure. In other words, older individuals are less resistant to the ALT flap than younger individuals. A previous sociocultural study suggested that the relationship between age and fashion tendencies also plays a role in patient preference. The elderly population might be characterized by a more conservative style of dressing than young adults [17]. This is likely to affect patient’s reluctance regarding exposure and scarring, as reflected in the survey results. These results are consistent with those observed for aesthetic interest scores. Individuals who are more aware of aesthetics are more sensitive to scar exposure.

In this study, we found that among the three most common free-flap donor sites, that are SCIP, ALT, and TDAP, the SCIP flap was preferred by respondents as a donor-site harvest. However, the preferences are purely based on an aesthetic point of view and do not consider existing functional and vascular-related factors; hence, the results should be interpreted with caution. Surgeons should understand the advantages and disadvantages of the SCIP flap from various perspectives. While Koshima et al. [9] introduced the versatility and reliability of the SCIP flap, several previous studies have revealed that the SCIP flaps are disadvantageous owing to the need for dissection of a smaller perforator, a short pedicle, and anastomosis of smaller-caliber vessels [18]. In addition, the SCIP flap’s variations and uncertainties in the vascular blood supply present challenges, and it has failed to gain broad acceptance, at least outside of Asia [19]. It is important for a surgeon to fully understand the advantages and disadvantages of these free flaps and make an appropriate donor-site decision based on the patient’s individual characteristics.

Moreover, the mean age of the survey respondents (42.69 years) was correlated with the average age of the actual patients (41.10 years) who underwent free-flap reconstruction in the lower extremities [20], which may enable prevention of age-related bias. Hence, our findings can be directly applied by real-world surgeons when making decisions regarding donor-site selection.

The limitations of this survey-based study are as follows. First, none of the survey respondents underwent free-flap reconstruction. It would be more meaningful to conduct the same survey on patients who have actually undergone free-flap reconstruction in lower extremity. Second, this study was conducted in a single ethnic group (only East Asians [South Korea]). Studies involving more ethnic groups are likely to yield diverse results. A study by Garg et al. [21] reported that that African American patients perceived their scars more negatively than Caucasian patients in terms of appearance, symptoms, psychosocial status, health, career, and sexual well-being. Additionally, differences in susceptibility to scarring have also been reported in the literature, wherein Asian and African patients are more vulnerable to aggressive scarring than Caucasian patients [22]. These results indicate that non-Caucasian patients have worse perceptions of scar color than their Caucasian counterparts, possibly because of the hyperpigmentation of melanin-rich skin [21]. Third, the analysis of expert preferences (medical doctors and plastic surgeons) was excluded, and further studies will be conducted on their differences in preference compared with the general public.

Considering these limitations, subsequent investigations should seek to corroborate the present findings in a clinical context by engaging patients who have undergone lower-extremity reconstruction. Evaluating postoperative satisfaction, donor-site morbidity, and aesthetic perception within this population would allow for a more accurate comparison between public preference and the perceptions of surgically treated patients. Such prospective validation would substantially enhance the translational value of our results and refine the understanding of patient-specific psychosocial and aesthetic determinants informing donor-site selection in reconstructive microsurgery.

This patient-centered study investigates donor-site preferences from an aesthetic perspective, specifically donor-site scarring, among individuals who have not undergone free-flap surgery, based on an online survey. Following the resolution of anatomical and clinical disadvantages, the SCIP flap emerges as the most preferred among the three primary flaps used in lower-extremity reconstruction (SCIP, TDAP, and ALT flaps). When other conditions are similar, prioritizing the SCIP flap from an aesthetic standpoint, considering donor-site scarring, is recommended. However, no clear preference was evident between TDAP and ALT. The discussion delves into the various donor-site locations and assesses statistically significant demographic variables identified in this study. An essential outcome is the need to develop an algorithm facilitating free-flap donor-site selection tailored to the individual requirements of patients.