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Discussion: Secondary Refinements of Free Perforator Flaps for Lower Extremity Reconstruction

T skills of a lawyer are required to properly evaluate the article by Hui-Chou et al. on secondary refinements of perforator flaps to the lower extremity. How should one interpret the concluding sentence of the abstract that “Initial flap selection with free perforator flaps, meticulous inset, and secondary refinements provide superior functional and aesthetic outcomes”? Everything depends on how the reader chooses to emphasize or associate different clauses of this critical sentence. Interpretation 1: “Initial flap selection with free perforator flaps . . . provide[s] superior functional and aesthetic outcomes.” One can jump to interpretation 1 by emphasizing the first half of the sentence. Initial flap selection with free perforator flaps (italics mine) is in contradistinction to the use of muscle flaps. This dovetails well with the previous writing of the senior author.1 Throughout the article, the characteristics of ideal flaps, including minimal donorsite morbidity, no muscle loss of the donor site, long pedicle, flap monitoring, and smooth tendon gliding of the recipient site, are emphasized. Two additional factors rendering a flap ideal would be the ability to later lift the flap for an orthopedic procedure and to contour the flap to ideal dimensions. The authors associate the two flaps used in this series, the anterolateral thigh flap and the groin flap, with these ideal characteristics and specifically write of the difficulties of reelevating and tailoring muscle flaps. Under interpretation 1, this article does not in any way support superior functional and aesthetic outcomes (italics mine) with perforator flaps in comparison with muscle flaps. There are no functional outcome measures presented other than flap survival and limb salvage. There is no muscle flap group for comparison of limb salvage rates and for orthopedic complications, such as malunion, nonunion, and osteomyelitis. Twenty-seven of 70 (39 percent) patients underwent a total of 40 later orthopedic interventions of the fracture site, and this sounds relatively high. The choice of staged orthopedic reconstruction, however, rests with the orthopedic team and in part reflects the high degree of complexity of these patients at a major referral center for trauma. The anterolateral thigh flap is not shown to have superior functional outcomes in comparisons with alternatives. There are no head-to-head comparison of the donor-site morbidity of the anterolateral thigh perforator flap in comparison with small muscle flaps, such as the gracilis muscle. Gracilis muscle flaps are documented to have minimal to no donor-site morbidity with elevation2 and can be splayed open to cover relatively large defects. The documentation of improved aesthetics with perforator flaps in comparison with other types of treatments is not present in the article. There are no evaluations by the surgeons, the patients, or team members of the aesthetics of the recipient site. There are no scales and no patient-reported outcomes. We have four long-term results of beautifully contoured lower extremity skin flaps but little else to judge the utility of this flap choice. Nor is there any mention of the donor site. There are neither pictures nor evaluations of the donor site. In another study of 32 anterolateral thigh donor sites closed primarily, only 69 percent of patients judged their donor sites to be “good.”3 From Table 2, I calculate that eight of the 70 patients required skin grafts of the donor site. Case 2 seems to have been a very wide flap, and the article does not document the handling of the donor site in this patient. Skin grafts of the donor site have the potential to decrease both postoperative thigh aesthetics and function,4 though a recent large study did not show them to be overly detrimental.5 Perhaps a skin-grafted muscle flap for case 2