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Background:. Free tissue transfer is usually considered as a last resort in severe burn cases, when skin substitutes and local flaps are not viable options. Prior studies have demonstrated a free flap loss rate ranging from 0% to 44%. The aim of this study is to identify the ideal timing to perform free flap reconstruction in acute burn-related injuries to minimize free flap loss. Methods:. A systematic review and meta-analysis was performed and reported according to PRISMA guidelines. PubMed, Embase, Web of Science, and Cochrane Library databases were queried. The review protocol was registered on PROSPERO database (CRD42023404478). Three time intervals from day of injury were identified: (1) 0–4 days, (2) 5–21 days, and (3) 22 days–6 weeks. The primary outcome was total free flap loss. Results:. A total of 17 articles met inclusion criteria. The analysis included 275 free flaps performed in 260 patients (88% men, 12% women) affected by acute burn injuries. The pooled prevalence of free flap failure in the three time intervals (0–4 days, 5–21 days, and 22 days–6 weeks) were 7.32% [95% confidence interval (CI): 2.38%–20.37%], 16.55% (95% CI: 11.35%–23.51%), and 6.74% (95% CI: 3.06%–14.20%), respectively. Conclusions:. Free flap reconstruction carries a high risk of failure in patients with acute burn. However, timing of the reconstruction appears to influence surgical outcomes. Free flap reconstruction performed between 5 and 21 days from burn injury had a trend toward higher flap loss rates and should be discouraged.

Background:. Severe acute burn injuries represent a challenge to the reconstructive surgeon. Free flap reconstruction might be required in cases of significant critical structure exposure and soft tissue deficits, when local options are unavailable. This study aimed to determine the free flap complication rate in acute burn patients. Methods:. A systematic review and meta-analysis were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and registered on the International Prospective Register of Systematic Reviews database (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was the free flap failure rate. Results:. The study identified 31 articles for inclusion. A total of 427 patients (83.3% men, 16.7% women) accounting for 454 free flaps were included. The mean patient age was 36.21 [95% confidence interval (CI), 31.25–41.16]. Total free flap loss rate was 9.91% [95% CI, 7.48%–13.02%], and partial flap loss was 4.76% [95% CI, 2.66%–8.39%]. The rate of venous thrombosis was 6.41% [95% CI, 3.90%–10.36%] and arterial thrombosis was 5.08% [95% CI, 3.09%–8.26%]. Acute return to the operating room occurred in 20.63% [16.33%–25.71%] of cases. Stratified by body region, free flaps in the lower extremity had a failure rate of 8.33% [95% CI, 4.39%–15.24%], whereas in the upper extremity, the failure rate was 6.74% [95% CI, 3.95%–11.25%]. Conclusion:. This study highlights the high risk of free flap complications and failure in acute burn patients.