We appreciate the interest of Herlin et al. in our study and are pleased that their group appears to have a similar experience with regard to success rates following microsurgical reconstruction of traumatic lower extremity defects in children. Raising awareness regarding not only the availability of these reconstructive modalities but also that these can be performed rather safely is important to improve access, clinical care, and postoperative outcomes. The authors’ comment on delays in treatment is well taken. We have certainly experienced similar cases in which treatment was delayed for a variety of reasons, such as a perceived notion that these reconstructive options would be associated with an unfavorable risk-to-benefit profile. We did not comment on the issue of treatment delay, as this was not a focus of our investigation. Furthermore, we did not feel that delays in treatment are specific to the pediatric population, as we continue to routinely observe this phenomenon in our adult patients.
We believe that our report contributes to a growing body of literature that young age does not pose a risk factor for microsurgical extremity reconstruction and that, in fact, pediatric patients are in many cases better candidates for these procedures. Reasons include the absence of unfavorable peripheral vascular changes caused by longstanding medical conditions. Thus, the concept of the “reconstructive elevator” that is frequently used in complex extremity reconstruction in adults should be adhered to in a similar fashion in the pediatric population.1
The issue of differences in skin laxity is noteworthy; however, we have not experienced any problems with the use of fasciocutaneous flaps in pediatric patients. Although the degree of primary contraction of the skin is more pronounced in some children compared with adults, we have routinely been able to predict the ability to close the flap donor site primarily based on preoperative pinch test examination. In light of the numerous advantages of fasciocutaneous flaps, such as ease of flap reelevation, permission of unimpeded growth, and other factors, we favor fasciocutaneous flaps whenever possible.2
The authors have no financial interest to declare in relation to the content of communication.
Arash Momeni, M.D.Division of Plastic and Reconstructive SurgeryStanford University Medical CenterPalo Alto, Calif.
Stephen J. Kovach, M.D.Division of Plastic Surgery
L. Scott Levin, M.D.Department of Orthopaedic SurgeryUniversity of Pennsylvania Health SystemsPhiladelphia, Pa.
1. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93:15031504.
2. Momeni A, Lanni M, Levin LS, Kovach SJ. Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population. Plast Reconstr Surg. 2017;139:9981004.