Reply: The Stitches Could Be the Main Risk for Failure in Perforator-Pedicled Flaps.

Abstract

Sir: We thank Wei et al. for the interest they have shown in our meta-analysis concerning the perforator propeller flap in lower extremity defects.1 We fully agree with them that many risk factors need to be better understood; however, we were not able to identify them from the published studies, merely because the authors did not describe them. Through this meta-analysis, we have shown that age older than 60 years, diabetes, and arteriopathy are significant risk factors for perforator propeller flap complications in the lower extremity, but we are convinced that the risk factors for flap failure are numerous and remain to be identified. For example, experience in detecting perforators with acoustic Doppler imaging and surgical experience of the practitioners are risk factors that we have not been able to analyze, although they seem to be major factors in such procedures.2 Wei et al. speculate that the flap factors are closely associated with complications of perforator propeller flaps, and we agree with them. Nonetheless, their argument cites studies concerning sural flaps and perforator-plus flaps, but in our opinion, these types of flap are not propeller perforator flaps, and no comparison can be made. Many risk factors cannot be found in publications, and we are convinced that the stitches are one of the major causes of failure of perforator propeller flaps, on all locations of the body, but especially in the lower limbs. This risk factor is almost never mentioned in the literature, although we have had frequent experiences of distal necrosis with perforator propeller flaps related directly to stitches that were too tight. Indeed, on the first night, the perforator propeller flap becomes progressively edematous, and inflates. Thus, the stitches performed during surgery become the cause of transversal constriction, leading to venous congestion and finally distal necrosis (Figs. 1 and 2). Nevertheless, we have never seen mentioned in the literature “distal flap necrosis caused by stitches that are too tight.”Fig. 1.: Distal necrosis on a tibial posterior propeller perforator flap related to sutures that are too tight. The stitches were released to limit the expansion of necrosis at 24 hours.Fig. 2.: We note that distal flap necrosis required healing by secondary intention.In our team, we are particularly careful to perform sutures slightly tight on perforator propeller flaps; furthermore, nurses and residents have instructions to release the stitches the first night or in the morning if the latter are responsible for necking or stress on the flap leading to venous congestion. In our experience, we noticed that the flap edema is less pronounced in the upper limb or the trunk compared with the lower limb.3–7 Thus, necrosis related to stitches seems more frequent in lower limbs, but we have not been able to highlight this in our meta-analysis. Finally, as discussed by Wei et al., we are convinced that each perforator propeller flap is different concerning vascularization, but in this meta-analysis, we lacked data to perform stratification by flap type or by flap design. Only a study with a high level of evidence could give a complete response to these queries, but it appears difficult to perform. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Benoit Chaput, M.D.Department of Plastic and Reconstructive SurgeryRangueil University HospitalToulouse, France Christian Herlin, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryLapeyronie University HospitalMontpellier, France Jean-Louis Grolleau, M.D.Department of Plastic and Reconstructive SurgeryRangueil University HospitalToulouse, France Nicolas Bertheuil, M.D.Department of Plastic, Reconstructive and Aesthetic SurgeryHospital SudUniversity of Rennes 1Rennes, France Farid Bekara, M.D.Department of Plastic and Reconstructive SurgeryLapeyronie University HospitalMontpellier, France