Long-Term Results of a One-Stage Secondary Debulking Procedure after Flap Reconstruction for Foot

Sir: We read with interest the article entitled “Long-Term Results of a One-Stage Secondary Debulking Procedure after Flap Reconstruction for Foot” by Lin and Quing1 in Plastic and Reconstructive Surgery. The authors described a modified debulking technique, and concluded that this improved procedure achieved better outcomes than the common debulking technique in terms of adequate removal, nerve regeneration, and stable tissue platform for weight-bearing areas. Inspired by the authors, we would like to express some opinions and suggestions. In this article, the interval between initial reconstruction and the debulking procedure was 1 to 87 months, but the method for determining the optimal interval time was not mentioned. Several factors might influence the time interval, such as the mechanism of injury, location of defect, and the type and size of the flap. How much weight was placed on each factor in determining the time interval? In addition, functional and aesthetic outcomes such as nerve regeneration, stabilization of the tissue platform, and color and texture of skin are affected by the time interval. What are the criteria for starting debulking to produce a better outcome? From our point of view, it might be more objective to determine the secondary operative time based on quantified indexes. Microcirculation is an important factor in evaluating the effect of flap transplantation. Among advanced imaging techniques, laser Doppler flowmetry is a representative noninvasive method used to evaluate the vitality of grafts by measuring blood flow velocity, hemoglobin concentration, and oxygen saturation.2 This debulking technique may be easier to popularize and promote if standard criteria are developed according to these parameters. Moreover, we are impressed by the authors’ concept of hindfoot reconstruction using a one-stage secondary debulking technique. However, the thin tissue may not be able to act as a cushion to resist impact because of its mechanical properties. Human acellular dermal matrices are widely used in reconstructive surgery because they are elastic, promoting autologous tissue regeneration and retaining tissue morphology.3 Moreover, the mechanical properties of human acellular dermal matrices may be closer to those of native tissue.4 Furthermore, multilayered acellular dermis has been used to repair cerebrospinal fluid leaks in neurosurgery.5 Thus, multilayered acellular dermis may be a novel method for reconstruction of hindfoot defects. Again, we are intrigued by this article, and wish that the authors could provide a response to our inquiries and suggestions. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Zifei Li, M.D.Jie Luan, M.D., Ph.D.Plastic Surgery HospitalChinese Academy of Medical Science and Peking UnionMedical CollegeBeijing, People’s Republic of China