Beyond Flap Survival: Aesthetic Satisfaction and Patient-Reported Outcomes in Microsurgical Lower Limb Reconstruction

BACKGROUND: Traditional measures of success in lower limb reconstruction have focused on flap survival, often overlooking aesthetic and patient-reported outcomes. However, postoperative dissatisfaction with contour, colour, and donor site appearance remains common. This study aimed (1) to retrospectively assess aesthetic outcomes and revision rates after lower limb reconstruction and (2) to evaluate patient-reported aesthetic satisfaction using a dedicated questionnaire. METHODS: A single-surgeon cohort of 73 patients who underwent lower limb reconstruction was analysed. Demographics, reconstruction type and aesthetic revision procedures were reviewed. Patients were grouped as free flaps (n=44) or local perforator flaps (n=29). A 20-item aesthetic questionnaire, divided equally between donor and recipient domains, was administered at 12 months postoperatively. Responses were recorded on a 5-point Likert scale and analysed. RESULTS: Thirteen patients (17.8%) underwent secondary aesthetic refinement, most commonly liposuction, with a higher revision rate after free flaps (24.1%) than local flaps (11.9%; p=0.04). Among 44 respondents, donor site satisfaction was significantly greater in the local flap group for contour (p=0.0021), scar appearance (p=0.0004), skin colour (p=0.008) and comfort when clothed (p=0.02). Recipient site scores showed no significant differences. Several patients who had not expressed dissatisfaction during follow-up reported concerns when completing the questionnaire, suggesting the presence of previously unexpressed aesthetic concerns. CONCLUSIONS: In this exploratory study, aesthetic satisfaction after lower limb reconstruction appeared to be influenced by donor site-related factors, with local perforator flaps showing higher donor-site satisfaction scores than free flaps. Systematic use of aesthetic-focused patient-reported outcome measures may help identify unvoiced concerns and support shared decision-making. These findings support the importance of integrating aesthetic considerations into contemporary lower limb reconstruction.