Microvascular free flap reconstructions for large traumatic soft tissue defects: a case series of operative strategy and early clinical outcomes

Background Microvascular free flap reconstruction is an important option for large traumatic soft tissue defects, but trauma specific data remain limited, particularly for heterogeneous injury patterns involving multiple anatomical regions. This study describes operative strategies, reconstructive outcomes, complications, and early functional status in a retrospective trauma cohort treated at a multidisciplinary center. Methods This retrospective descriptive case series included 24 adult patients who underwent microvascular free flap reconstruction for traumatic soft tissue defects between January 2021 and April 2026. Eligible defects measured at least 50 cm² or involved exposure of critical structures. Patient level clinical outcomes and flap level reconstructive characteristics were analyzed separately. Each independent microvascular transfer was counted once, while composite or chimeric constructs sharing a common vascular pedicle were counted as a single transfer. Results In our series 29 independent microvascular free flap transfers were performed for index defects most commonly involving the lower extremity (16/24, 66.7%), followed by head and neck/ face/skull base (5/24, 20.8%), and upper extremity (2/24, 8.3%). Only one patient presented multiple anatomical regions. Anterolateral thigh was the most common type of flap (12/29, 41.4%), followed by parascapular or scapular flaps (5/29, 17.2%) and lateral arm flaps (4/29, 13.8%). Four patients (4/24, 16.7%) experienced flap or pedicle compromise requiring operative intervention: one flap was successfully salvaged in place, one initial flap was completely lost and replaced with a new free flap, and two patients required an additional free flap after compromise of the initial reconstruction. Definitive soft tissue coverage was documented in 23/24 patients (95.8%). Postoperative infection and wound dehiscence each occurred in 4/24 patients (16.7%). Median LOS was 22 days with a median follow up period of 2 months. Heterogeneity of functional outcomes across anatomical regions was reported descriptively. Conclusion Microvascular free flap reconstruction provided definitive soft tissue coverage in 23 of 24 patients in this heterogeneous trauma cohort. Management of flap compromise included same flap salvage, replacement after complete initial flap loss, and additional free flap reconstruction. These findings describe institutional operative strategies and early clinical outcomes but do not establish treatment effectiveness. Interpretation is limited by the retrospective design, small sample size, heterogeneous injuries, variable follow up, and absence of standardized functional outcome instruments.