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Pediatric Free Flap Reconstruction: An 18-Year Experience at a High-Volume Pediatric Center
Miriam Meghnagi
*1, Nisha K. Vora
1, Yuri Choi
1, Garvey Cummings
1, Anushka Gattu
1, Zachary Valenzuela
1, Oksana A. Jackson
1, David Low
1, Stephen J. Kovach
2, Cassandra A. Ligh
11Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; 2Division of Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
Background:Pediatric free flap reconstruction presents unique technical challenges due to smaller vessels, vessel size mismatch, and vasospasm. Literature remains limited due to low case volumes, though outcomes appear comparable to those in adults. We present the largest pediatric free flap cohort reported since 2008 to describe outcomes and present operative considerations.
Methods:A retrospective review was conducted of all free flap reconstructions performed at a tertiary pediatric referral center (2007-2025). Demographics, indications, flap selection, technical variables, perioperative medications, and outcomes were recorded.
Results:159 pediatric patients underwent free flap reconstruction (mean age, 12.3 yrs, range, 1-26). Indications included malignancy (35.8%), congenital anomalies (22.0%), trauma (18.9%), benign tumor (16.4%), and other acquired conditions (6.9%).
Common donor sites were fibula (45.3%), anterolateral thigh (14.5%), and gracilis (13.2%). The most frequent recipient sites included mandible (21.9%), facial soft tissue (18.8%), foot (18.8%), lower leg (7.5%), humerus (6.9%), and femur (6.3%).
Arterial anastomoses were end-to-end in 78.6%. Two venous anastomoses were performed in 64.8% of flaps; vein grafts were required in 52.2%. Vessel size mismatch was noted in 13.2%. Intraoperative anastomotic revision was performed in 13.2% of cases.
Intraoperative heparin was used in 37.3% and tranexamic acid in 8.2%. Postoperatively, 22.9% received heparin and 78% aspirin.
Arterial thrombosis occurred in 2.3%, and venous thrombosis in 1.9%. The takeback rate was 7.5%. Overall flap success was 98.7%; partial flap loss occurred in an additional 4.4%. Revision surgery was required in 46.5%. Median follow-up duration was 582 days (IQR, 218.5-1373.5).
Conclusion:These findings demonstrate that pediatric flap reconstruction can be performed safely and reliably across diverse indications and provide one of the largest modern outcome benchmarks for pediatric microsurgery. Flap success rates were high, with complication profiles comparable to those in adults.
Models adjusted for BMI, tissue expander size, and axillary irradiation. OR > 1 indicates higher odds with early exchange.
Back to 2026 Abstracts
Models adjusted for BMI, tissue expander size, and axillary irradiation. OR > 1 indicates higher odds with early exchange.
