Letter to the Editor

Muscle versus Fasciocutaneous Free Flaps in Heel Reconstruction: Systematic Review and MetaAnalysis Discussion Christian Herlin, MD1

Raphael Sinna, MD, PhD2

Benoit Chaput, MD3

1 Department of Plastic and Reconstructive Surgery, Burns and Wound

Healing, Centre Hospitalier Universitaire Lapeyronie, Montpellier, France 2 Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire, Amiens, France 3 Department of Plastic, Reconstructive and Aesthetic Surgery, Burns, Centre Hospitalier Universitaire Rangueil, Toulouse, France

Address for correspondence Christian Herlin, MD, Department of Plastic and Reconstructive Surgery, Centre Hospitalier Universitaire de Montpellier, 371, avenue du doyen Gaston Giraud, Montpellier 34295, France (e-mail: [email protected]).

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J Reconstr Microsurg 2015;31:240–242.

We read with great interest the article entitled “Muscle versus Fasciocutaneous Free Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis”1 by Fox et al. We congratulate the authors for this review and would like to share our experience regarding the coverage of the weightbearing area of the heel. As reported previously,2,3 we favor perforator free flaps for covering the weight-bearing area of the heel, based on their following numerous advantages: • Easier conformation of the flap shape and thickness at the donor sites. The thickness can be chosen by adapting the level of flap raised,4,5 including the fat present above and below the superficial fascia, with or without inclusion of the deep fascia. • Guaranteed low donor site morbidity, without functional sequela. Even in case of a thigh donor site, walking on crutches and recovery are more rapid than with muscle flaps in our experience. • Greater variability in donor sites, the location of which is usually selected in conjunction with the patient. We emphasize the important advantage of color Doppler tracking, which allows switching between donor sites, isolating the courses of useful perforating branches, and measuring the thickness of the adipose layer on either side of the plane of the superficial fascia. • The possibility of performing a T-shaped anastomosis in some cases, avoiding end-to-end anastomoses, which substantially devascularize the foot and can be more difficult to perform. • The possibility of reinnervation for anterolateral thigh (ALT), thoracodorsal artery perforator (TAP), and superfi-

received August 28, 2014 accepted September 6, 2014 published online November 11, 2014

Fig. 1 Anterolateral thigh flap harvesting with a portion of the lateral femoral circumflex vessels (LCFA and LCFV) and a branch of the lateral femoral circumflex nerve (LCFN). Typically, an end-to-side or a T-shaped anastomosis on the tibial posterior artery is performed as a double vein anastomosis end to end on the great saphenous and posterior tibial vein. Nerve anastomosis is performed in an end-to-side fashion on the posterior tibial nerve.

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DOI http://dx.doi.org/ 10.1055/s-0034-1395941. ISSN 0743-684X.

Letter to the Editor

In our experience, the problem of shearing was resolved by harvesting above the plane of the superficial fascia,5 and the healing was improved by insetting the flaps tangentially using a sigmoidal suture.6 In the heel, we currently reserve muscle flaps, such as partial latissimus dorsi or gracilis muscle flaps, for the filling of the calcaneal cavities after surgery for osteomyelitis or composite resection of a tumor. We have completed over 30 perforator free flaps (ALT, TAP, SCIP, and superior gluteal artery perforator [SGAP]) for this indication, with 70% being ALT flaps. Nerve coaptation was performed in 25% (►Fig. 1) and in four cases, a strip of fascia lata allowed us to reconstruct the Achilles tendon, which had also been injured. Although the current literature, which comprises only 11 series, does not allow the drawing of conclusions, we feel that it is important to emphasize that the use of muscle flaps predates the use of perforator flaps for this indication. In this location, perforator free flaps offer advantages compared with muscle or classical fasciocutaneous flaps, such as the radial forearm flap. Perforator flaps are clearly underrepresented in this article (ALT, 1.2%). Therefore, it is

likely that the findings of a similar meta-analysis performed in the near future will confirm the decision by numerous teams to switch their practice from muscle to perforator free flaps for this location.

References 1 Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle

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versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg 2015;31(1): 59–66 Herlin C, Lievain L, Qassemyar Q, Michel G, Assaf N, Sinna R. Freestyle free perforator flaps for heel reconstruction [in French]. Ann Chir Plast Esthet 2013;58(4):283–289 Menez T, Chaput B, Bonte A, et al. Long-term functional evaluation of complex traumatic heel defects reconstructed by flap. Ann Chir Plast Esthet 2014 Oct 6. pii: S0294–1260(14)00142–3. doi: 10.1016/ j.anplas.2014.09.001. [Epub ahead of print] Hong JP, Yim JH, Malzone G, Lee KJ, Dashti T, Suh HS. The thin gluteal artery perforator free flap to resurface the posterior aspect of the leg and foot. Plast Reconstr Surg 2014;133(5): 1184–1191 Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free flaps. Plast Reconstr Surg 2007;119(1):186–193 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125(3):924–934

Journal of Reconstructive Microsurgery

Vol. 31

No. 3/2015

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cial circumflex iliac artery perforator (SCIP) flaps. The use of nerve coaptation seems to improve the stability of the flap over time3.

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Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis discussion.

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