De-epithelization of free flaps is useful for contour correction and filling up of
the dead space, essential in head and neck reconstruction and, at times, done in other
areas of reconstruction using pedicled or free flaps.
We have developed a safe and faster de-epithelization technique of flaps with minimal
risk of injury to the subdermal plexus. We recommend using a diamond coated round
burr of size 3.5 mm to 5 mm mounted over a micromotor at 30,000 rpm to de-epithelize
flaps under loupe magnification ([Fig. 1], [Video 1]). Partial necrosis of the flap is a significant risk factor seen after de-epithelization
due to injury to the subdermal plexus, particularly when the thickness of the skin
is too thin. Thus, direct visualization of the dermal plexus under loupe magnification
is required. While using burr, normal saline should be constantly irrigated to prevent
overheating and damage to the dermal plexus. Irrigation also helps in the gliding
movement of the burr over the skin. Razor blades, scissors or conventional scalpel
blades are regularly used for de-epithelization. Still, they carry the risk of injury
to the subdermal plexus and take a longer time when large areas are to be de-epithelized.
De-epithelization with burr takes not more than 2 to 5 minutes, depending on the size
of the area to be de-epithelized. This technique involves less surgical assistance
than the classical approach in which traction and countertraction are needed and is
more effortless, handy, and requires less skill. This technique prevents over-thinning,
compensating for filling up the dead space created due to resection. Authors sometimes
faced difficulty during de-epithelizing the flap margins, which is overcome by trimming
the margins by 2 to 3 mm after de-epithelization of the marked area is over. The other
minor issue is that a minuscule amount of skin is left behind at points near the hair
follicle, which has never caused any problems at follow-up. We have experience with
more than 30 cases with this technique without any complications. Thus, we recommend
this technique to reconstructive surgeons for faster, effortless, and more effective
de-epithelization of flap skin paddle.
Video 1 Demonstration of flap de-epithelisation procedure.
Fig. 1 Flap de-epithelisation with burr.
