I am pleased to be able to respond to the letter submitted by Drs. Weum and de Weerd.1 Their original article on a sensate medial dorsal intercostal artery perforator flap for cervicothoracic midline defects was published in Annals of Plastic Surgery in October of 2009. Our CME article was published in December of the same year,2 which did not really allow us to include it in our review article at the time of writing it. However, therein lies the value of letters submitted to the Editor. One often learns more from these brief articles, allowing for intellectual discussion, than from the original article.
The technical article of these authors is a very elegant reconstructive option for the difficult-to-reach reconstructive area of the upper back, and it also describes the advantages specific to perforator flaps. This is certainly a valuable addition to the techniques available for anyone involved in these types of reconstructions. Fundamentally, the authors raised three issues for further discussion:
- The specific reconstructive advantages of perforator flaps by virtue of their design.
- The potential advantage of sensate flaps and the reliability of that sensation.
- The efficacy of perforator fasciocutaneous flaps in combating infection in contrast to muscle flaps.
I shall address each of these in turn. First, we seldom give credit to those who were almost ahead of their time in developing “designer” flaps based on individual arteries.3 Soon after the clinical descriptions of the latissimus dorsi musculocutaneous flap, the search was on for other vascular territories and the dorsal trunk was investigated thoroughly, including the cutaneous territories of the posterior intercostal arteries.4 The “reverse” latissimus dorsi muscle and musculocutaneous flap was a refinement that enabled this flap to be elevated on specific paraspinal perforators, which then facilitated the design of a flap around the specific pivot point and arc of rotation of the perforating vessels.5,6 Although not isolating specific perforating vessels, the transverse back flap, based on paraspinal iliolumbar perforating vessels, is reliable for closing sacral defects, but this flap necessitated skin grafting the donor site.7
Perhaps one of the early publications that is not given sufficient credit is that of Kroll and Rosenfield,8 who designed perforator flaps for midline back wounds. They described perforator flaps with advantages of not having to sacrifice important muscle function, finding any vessel (named or unnamed) to custom-design a flap to fit any defect, increasing the arc of rotation by dissecting out a longer vascular pedicle, and not having to skin graft the donor site. This publication well preceded the plethora of perforator flap research that subsequently ensued. Drs. Weum and de Weerd have successfully added their stamp to this area of knowledge.
Second, the authors have shown that sensation is well preserved in the medial dorsal intercostal artery perforator flap by Semmes-Weinstein monofilament testing. This may not perhaps be able to be generalized to other types of reconstruction and it also assumes that the angiosome territory is the same as the neural territory. The radial forearm flap, for example, receives innervations from multiple sources, and the “dominant” sensory nerve may not innervate the entire flap.9 Furthermore, neurocutaneous flaps may not always carry the same sensory discrimination at the original donor, and sensory outcome may depend on the “stretch” placed on the nerve, as has been shown for fingertip reconstruction.10 In those in whom the index finger was reconstructed with large homodigital neurovascular advancement island flaps, the finger was excluded from fine pinch and the middle finger was substituted in 12.5 percent of reconstructions.10
Although intuitively it may seem logical to add protective sensibility to reconstructive flaps, sensation has not necessarily been shown to provide as important an advantage as one might think. Even with sensory foot reconstruction, patients often offload from the reconstructed part, and provision of sensation does not necessarily reduce the incidence of flap breakdown in pressure-bearing areas.11 Other factors also seem to play a role. Nonetheless the authors are to be congratulated on achieving excellent sensation in their reconstructions.
Third, it has traditionally been taught that muscle flaps are able to control infection better than fasciocutaneous flaps12,13 and certainly better than random flaps.14 However, as Drs. Weum and de Weerd pointed out with several reference sources in their original article, this does subsequently seem to have been refuted. With the added sophistication of intraoperative and preoperative mapping of perforator size and blood flow, such as with color Doppler ultrasonography, and being certain that only the specific angiosome territory is raised with the flap and reducing any random components to a minimum, one would expect these flaps to be as successful as muscle flaps in the treatment of contaminated wounds, provided that all the deeper dead space is obliterated by the flap and that the flap has a good blood supply. I have enjoyed the opportunity to respond to these authors' thought-provoking letter.
David T. Netscher, M.D.
Division of Plastic Surgery
Baylor College of Medicine
6624 Fannin Street, Suite 2730
Houston, Texas 77030
1.Weum S, de Weerd L. The sensate medial dorsal intercostal artery perforator flap as an option for treatment of dorsal cervicothoracic midline defects. Plast Reconstr Surg
2.Netscher DT, Baumholtz MA, Bullocks J. Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk). Plast Reconstr Surg
3.Milton SH. Pedicled skin flaps: The fallacy of the length/width ratio. Br J Surg
4.Saijo M. The vascular territories of the dorsal trunk: A reappraisal for potential flap donor sites. Br J Plast Surg
5.Bostwick J III, Scheflan M, Nehai F, Jurkiewicz MJ. The “reverse” latissimus dorsi muscle and musculocutaneous flap: Anatomical and clinical considerations. Plast Reconstr Surg
6.Stevenson TR, Rohrich RJ, Pollock RA, Dingman RO, Bostwick J III. More experience with the “reverse” latissimus dorsi musculocutaneous flap: Precise location of blood supply. Plast Reconstr Surg
7.Hill HL, Brown RG, Jurkiewicz MJ. The transverse lumbosacral back flap. Plast Reconstr Surg
8.Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg
9.Boutros S, Yuksel E, Weinfeld AB, Alford EL, Netscher DT. Neural anatomy of the radial forearm flap. Ann Plast Surg
10.Foucher G, Smith D, Pempinello C, Braun FM, Citron N. Homodigital neurovascular island flap for digital pulp loss. J Hand Surg (Br.)
11.May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction for extensive defects of the foot: A clinical and gait analysis study. Plast Reconstr Surg
12.Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg
13.Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: Experimental and clinical correlation. Plast Reconstr Surg
14.Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg
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