Sir:
We deeply appreciate the comments by Cherubino et al. in response to our study demonstrating that a superthin superficial circumflex iliac artery perforator (SCIP) flap is a reliable reconstructive option for functional surgery in the treatment of subungual melanoma.1 We agree that an ulnar artery perforator free flap can also be an invaluable option for coverage of soft-tissue defects on the thumb or finger, enabling “like-with-like” reconstruction and providing thin, pliable soft tissue without the need for flap defatting. Moreover, reconstruction of hand digital defects using this flap usually does not require general anesthesia, and brachial plexus anesthesia may be sufficient. Despite these strengths and excellent outcomes as stated in the letter, however, there are several concerns with use of the ulnar artery perforator free flap as a general option for the reconstruction of digital defects following functional surgery in the treatment of subungual melanoma.
One of the main drawbacks of the ulnar artery perforator flap is the short pedicle length, which was reported to be approximately 2 cm on average in several anatomical studies.2,3 This short pedicle may not be sufficient to reach recipient vessels in some cases, including those with extensive periungual defects or those lacking suitable recipients in the vicinity of the defect. A relatively conspicuous donor-site scar is another disadvantage of this flap, compared with that of a SCIP flap. This weakness can be more exaggerated when harvesting of a large flap is needed, as this requires skin grafting of the donor site. Moreover, its suggested benefits of avoiding general anesthesia can be limited in a considerable proportion of cases. Subungual melanoma often develops in the toes (39 percent of cases in our series), and invasive lesions often require lymph node operations, including axillary or inguinal sentinel lymph node biopsy and primary lesion ablation (41.5 percent of cases in our series),1 for which the simple brachial plexus anesthesia may not be adequate.
A superthin SCIP flap can be applied regardless of lesion location (on either the finger or the toe), of defect size, or of need for lymph node surgery. Harvest of this flap with the same technique, although requiring general anesthesia, can simplify surgical planning and ensure reliable outcomes. Scars in the inguinal area will be inconspicuous. Primary defatting does not seem to significantly compromise flap perfusion, as shown in our study. Generally, when a perforator is securely captured, small flaps are less affected by primary thinning than larger flaps.
Because of these strengths, the superthin SCIP flap can serve as a potent reconstructive option in functional surgery for subungual melanoma, and can be adopted in most cases. The ulnar artery perforator flap can be a valid alternative for the reconstruction of thumb or finger defects in certain circumstances.
DISCLOSURE
Neither of the authors has a financial interest to declare in relation to the content of this communication.
Kyeong-Tae Lee, M.D.
Goo-Hyun Mun, M.D., Ph.D.
Department of Plastic Surgery
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul, Republic of Korea
REFERENCES
1. Lee KT, Park BY, Kim EJ, et al. Superthin SCIP flap for reconstruction of subungual melanoma: Aesthetic functional surgery. Plast Reconstr Surg. 2017;140:12781289.
2. Han HH, Choi YS, Kim IB, Kim SH, Jun YJ. A perforator from the ulnar artery and cutaneous nerve of the hypothenar area: An anatomical study for clinical application. Microsurgery 2017;37:4956.
3. Kim SW, Jung SN, Sohn WI, Kwon H, Moon SH. Ulnar artery perforator free flap for finger resurfacing. Ann Plast Surg. 2013;71:7275.
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