We read with great interest the article by Momeni et al. entitled “Microsurgical Reconstruction of Traumatic Lower Extremity Defects in the Pediatric Population.”1 We would like to congratulate the authors for their great experience, the quality of their analysis, and their conclusions, which improve the available literature in this field. We agree with the authors that many erroneous data on vasospasm and vessel caliber have limited the use of free flaps in this context. However, other important data that have also contributed to this limitation are not discussed by the authors.
First, in the pediatric population, lower leg composite trauma is often treated by surgeons that are slow to contact microsurgical reconstruction teams. During this time, solutions such as negative-pressure wound therapy improve wounds much faster in pediatric patients than in adults.2 This frequently results in autonomous management by these teams, characterized by waiting for sufficient improvement of the traumatic wound to allow the use of pedicle flaps or skin grafts. Figure 1 shows a typical case of major sequelae of the lower limb resulting from poor initial management.
The second important point concerns the origin of the discrepancy between the use of free perforator flaps in adults and children. Over the past 5 years, we have used various flaps to cover lower limb traumatic wounds, usually muscle free flaps in children younger than 10 years [14 of 23 (60.8 percent)] and fasciocutaneous perforator flaps (i.e., anterolateral thigh, superficial circumflex iliac perforator, thoracodorsal artery perforator, and parascapular) in those older than 10 years [196 of 274 (71.5 percent)]. This difference is attributable not to a change in our practice but rather to the lack of cutaneous laxity of perforator flap donor sites in growing children. The baseline cutaneous surface tension is often important in young children and must be taken into consideration (Fig. 2) during preparation and conformation of the flaps. In some cases (n = 3), we could not directly close the donor site (usually for anterolateral thigh). We therefore had to skin graft the donor site and instead used secondary skin expansion for donor-site repair.
With regard to the success rate, we found results similar to those of Momeni et al. over the past 5 years, with similar coverage failure rates between the adult [12 of 274 (4.4 percent)] and pediatric populations [one of 23 (4.8 percent)]. Similar to the authors, we did not find any significant arterial ischemia secondary to vasospasm. In contrast, vasospasm was more common in children during perforator intramuscular pathway dissection. The vasospasm resolved each time after this phase of sampling.
Finally, we agree with the authors that microsurgical reconstruction of lower limb trauma in children should be promoted. The need for elastic integumentary coverage is more prevalent in growing children, given the risks of functional disability and secondary retraction. This observation should promote the use of cutaneous perforator flaps where possible, taking into account the proportion of body surface area, particularly in the pediatric population. The lack of dermal laxity of donor sites in some children should not be a limitation for this use.
The authors have no financial interest to declare in relation to the content of this communication.
Christian Herlin, M.D., Ph.D.Plastic and Reconstructive Surgery and Burns UnitPlastic and Craniofacial Pediatric Surgery UnitCHU MontpellierMontpellier, France
Raphael Sinna, M.D., Ph.D.Plastic, Reconstructive, and Aesthetic Surgery UnitCHU PicardieAmiens, France
Farid Bekara, M.D.Plastic and Reconstructive Surgery and Burns UnitPlastic and Craniofacial Pediatric Surgery UnitCHU MontpellierMontpellier, France
Marion Delpont, M.D.Pediatric Orthopedic Surgery UnitCHU MontpellierMontpellier, France
Swany Dast, M.D.Plastic, Reconstructive, and Aesthetic Surgery UnitCHU PicardieAmiens, France
Benoit Chaput, M.D.Plastic, Reconstructive, Aesthetic Surgery and BurnsUnitCHU RangueilToulouse, France
1. Momeni A, Lanni M, Levin LS, Kovach SJ. Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population. Plast Reconstr Surg. 2016;139:9981004.
2. Rentea RM, Somers KK, Cassidy L, Enters J, Arca MJ. Negative pressure wound therapy in infants and children: A single-institution experience. J Surg Res. 2013;184:658664.