We appreciate the interest of Dr Chaput et al. in our article,1 and we are thankful for the opportunity to respond to their insightful comments. In agreement with the authors, we consider as obsolete the random flap concept and try to approach each reconstructive case adhering to the free-style philosophy.2 The best method to plan and move free-style local perforator flaps is still in debate. As a matter of fact, propeller flaps provide a wider range of motion, allowing the surgeon to reconstruct even distant defects in an elegant and tension-free manner. Nevertheless, we agree with the authors that their use is not always recommended because of the higher risk of venous insufficiency, especially in the elderly population, and the need to skin graft the donor site in medium-size to large defects. On the other hand, the V-Y design guarantees an increased vascular safety, despite its limited advancement and more difficult insetting. In this scenario, after performing a discrete number of cases [about 70 free-style local perforator flaps harvested in the last 3 years at our institution (unpublished data)], we truly believe that an ideal design does not exist, but each case should be approached by taking into consideration the dimensions, orientation, and anatomical site of the defect, as well as distance and anatomical features of the perforator. Our first choice to resurface soft-tissue defects is the V-Y advancement design.3 This model can be applied to almost any anatomical district, but it is contraindicated in the following instances:
- The perforator Doppler signal is only audible in close proximity to the defect.
- A significant advancement is preoperatively considered to be mandatory to obtain a complete, tension-free closure of the defect (narrow and long defects).
- The perforator vessels are judged to be too short to allow for adequate advancement movement (posterior tibial artery, dorsal intercostal artery perforators).
- The flap has to cross bony prominences4 (tibial shaft, elbow, thoracic spines) to reach the recipient site.
In such cases, we tend to adopt the propeller design without any hesitation. Nevertheless, in a discrete number of cases, the choice of the final design has to be postponed until the surgical exploration. In this situation, we adopt a cautious “cut as you go” approach, limiting the explorative incision to the length necessary to expose the perforator vessel. In selected cases, when adjacent free-style flaps can be hypothesized, we suggest performing the explorative incision in between the two flaps, allowing exposure of the perforators of both flaps with a single incision (Figs. 1 and 2). We congratulate the authors for their case series about the use of the “Pac-Man” design.5 We agree with them that the use of this technique may help to close bigger defects compared with the classic V-Y design; nevertheless, bigger flaps need to be planned and an additional scar is required, producing a less attractive cosmetic outcome. In our flap series, we never planned to adopt the Pac-Man design preoperatively, but we had to shift to this particular closure as a salvage procedure in a limited number of patients, in cases of restricted flap advancement (perforator located in the distal tip of the V-Y flap) or to avoid extensive pedicle dissection in elderly patients. Undoubtedly, further studies will be necessary to improve our knowledge about the real reconstructive possibilities provided by each described perforasome. Meanwhile, the key points discussed with the authors may help to optimize functional and cosmetic outcomes and minimize the vascular complication rate.
The authors have no financial interest to declare in relation to the content of this communication. No intramural or extramural funding supported any aspect of this work.
Beniamino Brunetti, M.D.
Stefania Tenna, M.D., Ph.D.
Achille Aveta, M.D.
Igor Poccia, M.D.
Francesco Segreto, M.D.
Paolo Persichetti, M.D., Ph.D.
Department of Plastic, Reconstructive, and
“Campus Bio-Medico di Roma” University
1. Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Free-style local perforator flaps: Versatility of the V-Y design to reconstruct soft-tissue defects in the skin cancer population. Plast Reconstr Surg. 2013;132:451–460
2. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: A further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124(6 Suppl):e419–e426
3. Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Free-style local perforator flaps: Versatility of the V-Y design to reconstruct soft-tissue defects in the skin cancer population. Plast Reconstr Surg. 2013;132:451–460
4. Brunetti B, Tenna S, Aveta A, Poccia I, Segreto F, Persichetti P. Reconstruction of elbow defects with perforator-based propeller flaps. Plast Reconstr Surg. In press
5. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects. Br J Plast Surg. 2000;53:679–689
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