Factors influencing the choice of a free-flap donor site in lower extremity reconstruction from an aesthetic perspective: a cross-sectional analysis of public sentiment from an internet-based questionnaire

Purpose: Several donor-site morbidities associated with free-flap have been studied in recent years. However, little research has examined patients’ preferences for the donor- site selection from an aesthetic perspective, particularly regarding donor-site scarring, and the factors influencing these preferences in lower-extremity reconstruction. This study aimed to design an online questionnaire to assess aesthetic preferences for donor sites of the thoracodorsal artery perforator (TDAP) flap, superficial circumflex iliac artery perforator (SCIP) flap, and anterolateral thigh (ALT) perforator flap, which are the most commonly used lower-extremity reconstruction procedures at our institution. Additionally, the study sought to identify factors associated with the preferential selection of specific donor sites.Methods: A total of 315 participants were included in this study. Participants completed internet-based questionnaires containing images of three donor sites. All functional or surgical details were intentionally excluded so that only aesthetic preference was evaluated. The relationships between aesthetic preference and demographic factors influencing donor-site selection were analyzed.Results: Among the demographic variables, sex, age, aesthetic interest score, and level of education were found to significantly influence donor-site selection. The results showed that the SCIP flap was statistically preferred over both the TDAP and ALT flaps. Preferences for the TDAP and ALT flaps did not differ significantly.Conclusion: If other factors can be easily addressed, the patient and surgeon should agree on a donor site that minimizes scar visibility. It is also important for surgeons to recognize that patient characteristics such as sex, age, level of education, and aesthetic interest significantly affect donor-site choice. Therefore, surgeons should carefully consider each patient’s aesthetic preferences in the context of their clinical condition.