VL flaps are not ALT flaps—why extrapolating data from one does not give information about the other

Dear Sir, We read the paper from Kaminsky, Li, Copeland-Halperin, and Miraliakbari (Kaminsky et al, 2015) on the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction with interest; however, we feel that this paper could be better in mapping the real versatility of the VL flap given the significant morbidity associated with its harvest. In their paper, Kaminsky et al. use various references (Hanasono, Skoracki, & Yu, 2010; Kimata et al., 2000; Rodriguez et al., 2009; Rozen, le Roux, Ashton, & Grinsell, 2009; Townley, Royston, Karmiris, Crick, & Dunn, 2011; Tsuji, Suga, Uda, & Sugawara, 2008) to ostensibly show low donor site morbidity; however, such references are primarily in relation to antero-lateral thigh (ALT) flaps, which are purely fasciocutaneous or myocutaneous involving limited portions of the VL muscle. Of these, only two studies actually mention myocutaneous ALT flaps. One includes some harvesting of the VL muscle with 33% having superficial excision and only 4% having total excision, which is in contrast to the authors series in which all the muscle is utilized, whilst in the other study the whole muscle appears to be lifted, which in fact resulted in a reduction of power and work at maximum extension and flexion. We, therefore, do not accept that these references are a good reflection of the literature or relevant to the author’s series. The quadriceps mechanism is a key structure in lower extremity function with the VL muscle being the largest component of this quadriceps mechanism (Kuo et al., 2001). VL acts as the main extensor of the knee and is a vital mediator in knee locking (Kuo et al., 2001). Literature regarding donor site morbidity following complete VL harvesting is scarce, in particular in relation to stability at the knee joint. In addition, given the plethora of complications associated with the harvest of VL, we believe that other options should be considered. The latissimus dorsi is an extremely reliable and versatile flap due to its large calibre, lengthy neurovascular pedicle, and broad size (May, Lukash, & Gallico, 1981). This allows easy muscle dissection and coverage of large defects, particularly in the lower extremities (May, Lukash, & Gallico, 1981). Minor drawbacks include the need for lateral positioning of patients during its harvest (Posch, Mureau, Flood, & Hofer, 2005). However, it is worth highlighting that any inconvenience caused by manoeuvring the patient during its harvest is in no way comparable to the long term permanent donor-site morbidity associated with of VL harvest. In a similar manner, the gracilis myocutaneous flap has been favored by many surgeons for its use in extremity reconstruction due to its swift dissection and minimal donor-site morbidity (Whitaker et al., 2012). Its relatively small size with its unique long, slim profile and pedicle of >7 cm in length, has made it a popular choice in reconstruction of small to moderate-sized defects (Whitaker et al., 2012). Furthermore, once the epimysium is releases, the flap spreads as a sheet, providing coverage to defects with a larger surface area (Vranckx et al., 2004). The senior author in this reply routinely uses gracilis for effective coverage of the exposed anterior tibial surface in open fractures. In summary, we believe the findings of this paper are not appropriate in recommending the VL flap, especially given the limited evaluation of the functional complications associated with its use, in particular when more successful options are already available in managing patients with open lower limb fractures.