Prefabricated Flaps or Grafts? (2008)

Sir: As we have a particular interest in postburn reconstruction, our attention was drawn to the novel article by Houle and Neumeister.1 Close reading reveals some curious aspects of reconstructive surgical practice that perhaps need to be highlighted to give some perspective to alternative strategies. The report begins with a description of a most unfortunate patient who had sustained a very severe burn and brain damage. The report continues that because of the severity of the contractures of his left wrist and elbow and the length of his fingernails, a chronic ulcer developed on his chest wall. Again, this seems surprising, as it is a simple matter to trim fingernails and even apply padded mittens to prevent such self-trauma. The use of a free perforator flap to treat a contracture in a brain-damaged patient would certainly not be our first choice, and there are graduated options of serial splinting and gradual distraction with external fixation. Joint release can be achieved by incising the scar proximal and distal to the joint and leaving intact scar to cover vital structures, and the defects can be grafted or closed with Integra (Integra LifeSciences Corp., Plainsboro, N.J.). A further note is to realize that under the scar in a burn patient there is a plentiful supply of tissue for free fascial and muscle flaps that can be transferred and subsequently grafted. Having decided on a free tissue transfer, it was unusual that the authors then failed to define the defect before raising the flap. We regard this as an essential prerequisite to flap harvesting because of the variability of release that can be achieved and the unpredictable dimensions of the defect. This certainly accords with principle 17 in Millard’s wonderful text.2 During the raising of the flap, disaster struck and, presumably, as the flap rapidly became discolored, the venous perforator vessel was damaged. The details are not clear, but it appears that an attempt was made to elevate the flap before locating the perforator, which is again unusual. We have previously described our pragmatic approach to anterolateral thigh flap harvest that addresses this point.3 The rapidity with which the postoperative necrosis appears to have developed is unusual, as this flap would appear to now be a graft albeit with subcutaneous tissue. The alternative is that the flap was fully circumcised and the venous flow was damaged but an arterial input was maintained. In that case, this is a prime indication for leech therapy. The opportunity for salvage having been missed, the only option was to then discard the skin island, and it was at this stage that the authors considered dissecting out the descending branch of the lateral femoral circumflex artery and leaving a cuff of muscle, presumably around the muscle perforator. One wonders where the fascia over the muscle has gone, but this was possibly raised with the flap in the initial operation. The pedicle was covered with a Gore-Tex (W. L. Gore & Associates, Flagstaff, Ariz.) graft and pedicle. The Gore-Tex and muscle cuff were all then covered with Integra. Five months later, the left elbow contracture was released surgically and tissue was raised from the right thigh and transferred to the antecubital defect. The tissue raised comprised the descending branch of the lateral circumflex femoral artery; the new dermal matrix, and a surrounding cuff of normal skin. This “cuff” was needed because of the size of the defect, so this time, a standard sequence of creating the defect first appears to have been followed. Nevertheless, the cuff died, leaving a 3-cm deficiency in width of reconstructive tissue. We are not told how much muscle was left underneath the dermal matrix, but we have to assume that there was some subdermal tissue to support a subdermal capillary plexus. The rather strange longitudinal makings in Figure 4 possibly represent the orientation of the descending branch of the LSFA and indicate that there has been significant reduction in width of the reconstructed thigh defect. As such, it would appear that the prefabricated “flap” comprised a vascular pedicle covered with Integra and surrounded by a full-thickness reconstructed skin graft. No follow-up details are reported with regard to long-term outcome. This report illustrates a series of errors at worst and oversights at best in the management of a postburn contracture. Despite the seeming lack of cutaneous donor sites in the complex burn survivor, Integra can be used to resurface areas of scar to allow subsequent flap harvest, and we have described this in a report of a series of microsurgical reconstructions in children.4 In summary, we commend the honesty of the authors in presenting this extraordinary case and their method of converting a tragedy into a triumph. It will, however, not be a technique that we will be in a hurry to try, and we suggest that it should not be hailed as an innovation. Andrew Burd, M.D. Tor W. Chiu, M.D. Stepanie Lam, M.D. Satish P. Bhat, M.D. S. Y. Ying, M.D. Division of Plastic, Reconstructive and Aesthetic Surgery Department of Surgery Chinese University of Hong Kong Prince of Wales Hospital Shatin, Hong Kong