Comments on “Partial second‐toe pulp free flap for fingertip reconstruction: Experience and surgical tips to minimize complications” and the use of adipofascial perforator flap for fingertip reconstruction

Dear Editor, We read with great interest the article from Kwon et al. (2021) entitled “Partial second-toe pulp free flap for fingertip reconstruction: Experience and surgical tips to minimize complications. ” We would like to congratulate the authors for the extreme clarity and fulfillment of their report: we do believe that the partial secondtoe pulp free flap (PSTP) for fingertip reconstruction was made easier to the novice microsurgeon. We share the common thought that none of the available methods within the reconstructive ladder has been confirmed as the most appropriate for fingertip reconstruction, and that local flaps reconstruction retains some downsides (i.e., paucity of soft tissue surrounding). In terms of flap survival, the authors reported 7% partial flap necrosis and 7% of venous congestion with PSTP (Kwon et al., 2021); in our recent report about 15 cases of fingertip reconstruction with an adipofascial perforator flap, the same rate of partial necrosis was documented (Losco et al., 2019). No donor site complications were recorded by both study groups. However, among the local flaps, as described in our article (Losco et al., 2019), adipofascial flap retains several peculiar benefits. First, the scarring at the donor site is minimal. In our series donor site wound is limited to the ulnar or radial midlateral line and two shortcuts on the dorsum of the middle phalanx. Scarring does not involve the volar touch; thus, scar location is not affecting the functional outcome. The donor site of a free flap is located far from the joint of the injured finger, but the scar consequent to recipient vessels preparation could cause functional problems due to a contracture; moreover, the donor site closure is likely to be achieved through a skin graft (70% of cases in authors' series). In our series, satisfactory results in terms of range of motion (ROM) and sensation were obtained: average ROM was 89 and 71 for proximal and distal interphalangeal joints respectively, and the median static 2-point discrimination test, evaluated at the edge of the fingertip, was 4.5 mm (range, 3–8 mm) above the bone stump; the discrimination was evaluated as excellent in 11 fingers and good in 4 according to the classification of the American Hand Surgery Association. Instead, Kwon and colleagues assessed ROM and the absence of functional issues through an interview: the output was very satisfactory. Postoperative fingertip sensation was not evaluated. Second, unlike a propeller flap, the adipofascial flap is turned over, thus the risk of vessel kinking is eliminated. Finally in case of sharp cut injury, an adipofascial flap, due to the flat geometry, could grant the adequate bone coverage and support for nail regrowth (Losco et al., 2020) without the excessive bulging we could expect as result of PSTP. In our series, complete regrowth of the nail lamina was achieved after about 6 months in all but one patient whose nail lamina took longer. We believe that, especially in hand and fingers reconstruction, the reconstructive option should achieve texture and thickness match with the recipient site, advocating an “aesthetic friendly” reconstruction (Cherubino et al., 2021). In our series, the aesthetic satisfaction of the patient was estimated subjectively on a scale of 5 points, and 12/15 fingers were rated with the highest mark. Kwon et al. did not mention the levels of amputation seen in their series and patient's reported aesthetic satisfaction; on the other hand, our report did not outline the operative times. A free flap harvested from the toe has several weak points when compared to an adipofascial flap including the need for general anesthesia and double operative field. Operative time could be prolonged due to the adjunctive procedures (i.e., vein and/or skin grafting at the donor site); the need for monitoring the flap should also be taken into account (Trignano et al., 2018). However, PSTP is an excellent reconstructive weapon in “partially degloved” fingertips with relevant bone exposure (figure 4 in authors' report) and soft tissue defects of significant size. A true comparison regarding functional and aesthetic outcome between the authors' (Kwon et al., 2021) and our (Losco et al., 2019) report could not be performed due to the limitations stated in both papers. In summary, we congratulate the authors for describing this systematization of PSTP free flap for fingertip reconstruction; the key steps of a challenging technique were thoroughly illustrated and several tips were provided. We agree that further studies are necessary to elucidate and try to develop an algorithm for fingertip reconstruction. Gold standard in fingertip reconstruction is yet to be found. The setting of trauma is unpredictable and many variables should be taken into account: type/level of trauma, surgeon's experience and patients' desires and expectations are the most confounding variable that neither a randomized controlled trial could reduce. Received: 11 September 2021 Revised: 12 November 2021 Accepted: 19 January 2022