Response to Letter to the Editor: Nomenclature of Thin and Super-Thin Flaps—Comment on: Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity

The authors and myself welcome your critical appraisal of our 2017 article, “Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity”[1] published in the journal, building upon prior work at our single institution that introduced thin flap outcomes in a US cohort.[2]

Primarily, thinned anterolateral thigh (ALT) flaps or those ALT flaps elevated superficial to the crural fascia and periscarpal plane have not grown in popularity in the United States to date despite rates of obesity and the close relationship between obesity and lateral thigh thickness. As published, we find the thinned ALT flaps ideal in circumstances for lower extremity reconstruction and, in particular, use during limb salvage.[3]

At the time of writing our article, Narushima et al were yet to publish their 2018 article in the Journal of Plastic and Reconstructive Surgery which in turn resulted in conflicting language.[4] We do not disagree, a consistent nomenclature is paramount. We also believe that nomenclature system should be anatomically based and rely on the vascular anatomy so-well described by Saint-Cyr et al[5] and Narushima et al. We should avoid a nomenclature system based solely on measurable flap thickness—ignoring the anatomic bases of the perforasome, subdermal plexus, and choke vessels so as to avoid unpredictable results.

As such, Narushima et al's classification is most practical from thinnest to thickest: (1) split-thickness skin graft = partial dermis, (2) full-thickness skin graft = full dermis, (3) composite tissue graft = composite tissues without vascular supply, (4) super-thin flap = subdermal plexus, (5) thin flap = periscarpal or suprascarpal, (6) suprafascial flap = superficial to crural fascia, and (7) subfascial flap = deep to crural fascia.

We should also avoid combining groups, that is, calling “thin flaps” a combination of both periscarpal and subdermal to avoid further confusion. Further investigation is required to determine flap outcomes and complication rates in a U.S. cohort of patients undergoing primary subdermal elevation.

• References

• 1 Diamond S, Seth AK, Chattha AS, Iorio ML. Outcomes of subfascial, suprafascial, and super-thin anterolateral thigh flaps: tailoring thickness without added morbidity. J Reconstr Microsurg 2018; 34 (03) 176-184
• 2 Seth AK, Diamond S, Iorio ML. Outcomes of an early protocol for dependent conditioning in lower extremity microsurgical free flaps. J Reconstr Microsurg 2017; 33 (09) 670-678
• 3 Diamond S, Doval AF, Scott B, Iorio ML. Limb preservation with suprafascial and thin perforator flaps: salvaging osteomyelitis, Charcot collapse and critical limb ischemia. Plast Aesthet Res 2019; 6: 20
• 4 Narushima M, Yamasoba T, Iida T. , et al. Pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 351e-360e
• 5 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544