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Dear Sir,
It was with great interest that we read the article by Dr. Schiavon et al. [1]. The use of Integra® dermal regeneration template versus flaps for reconstruction of full-thickness scalp defects involving the calvaria: A cost–benefit analysis. We congratulate the author on this important study, its outcome and conclusion where the point is made that in cases of patients with scalp defects larger than 100 cm2 for whom major surgery is needed, the treatment with Integra® seemed to be less expensive than the treatment with free flaps or pedicle flaps. Besides the lower cost of treatment, we found three advantages to the uses of dermal substitute in full-thickness scalp reconstructive surgery [2]: (1) Reconstruction with Integra® is a relatively simple and short procedure when compared to alternative approaches; the patient’s state (shock, infection and instability), the treatments initiated (vasopressins) and the local conditions of the recipient site (local inflammation) might contraindicate certain extensive and difficult operative procedures, such as free flaps [2,3,4]. (2) The method uses an off-the-shelf tissue substitute. In other words, if an initial application of Integra® fails or needs to be revised, no native tissue is lost. This technique avoids donor-site functional morbidity and scars [3, 4]. (3) The technique allows for a significant degree of contour restoration after extensive tissue loss. In the case of insufficient resurfacing or insufficient bulk, two or three layers of Integra® can be added to the first layer using the same procedure. The major disadvantage of tissue flaps is the persistent bulky aspect at the end of the procedure. Conversely, skin grafting is an inherently two-dimensional technique and can result in a hollow at the reconstructed side when compared to the contralateral non-operated side [2].
We have one question: Do you have any experience with the use of Integra as a complementary tool for free flap pedicle coverage in full-thickness scalp reconstruction? Indeed, in addition to the advantages of dermal matrix for complex reconstruction described in the literature, we have found supplementary benefits for the specific indication of free flap pedicle coverage. It avoids skin tension and compression at the level of the pedicle. A compression of the free flap pedicle would result in a thrombosis of the vessels and flap necrosis. Furthermore, a hematoma at the level of the pedicle will be highly visible due to the change of color of the Integra®. This renders this complication easy to identify permitting rapid intervention: The Integra can be removed easily while awaiting surgical revision. This avoids compression of the pedicle and thrombosis of the vessels.
Recently, Leclère et al. [5] published a series of 10 reconstructive procedures including free flaps with Integra, where Integra was used to cover the free flap pedicle. This shows that dermal matrices are not in competition but complementary to conventional flap procedures and that their development and growing indications will contribute to better surgical management of patients. The study of Schiavon et al. clearly demonstrates that this development is performed within reasonable costs. University plastic surgery departments should all contribute to the research, refinements and development of dermal matrix that has proven its efficacy and place in the reconstructive ladder [6].
References
Schiavon M, Francescon M, Drigo D, Salloum G, Baraziol R, Tesei J, Fraccalanza E, Barbone F (2016) The use of integra dermal regeneration template versus flaps for reconstruction of full-thickness scalp defects involving the calvaria: a cost-benefit analysis. Aesthetic Plast Surg 46(6):901–907
Weigert R, Leclère FM, Delia G, De Luca L, Al Mutairi K, Casoli V (2015) Long-term patient-reported functional and cosmetic outcomes following severe traumatic foot and ankle wound reconstruction with acellular dermal matrix. J Cosmet Laser Ther 17(6):321–329
Helgeson MD, Potter BK, Evans KN, Shawen SB (2007) Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma 21:394–399
Lee LF, Porch JV, Spenler W, Garner WL (2008) Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg 121:1256–1262
Leclère F, Desnouveaux E, Casoli V (2016) Acellular dermal matrix: new applications for free flap pedicle coverage a prospective study in 10 patients. J Cosmet Laser Ther 25:1–12
Janis JE, Kwon RK, Attinger CE (2011) The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg 127:205–212
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FM Leclère has no conflict of interest to declare.
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Leclère, F.M. The Use of Integra® Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost–Benefit Analysis. Aesth Plast Surg 41, 472–473 (2017). https://doi.org/10.1007/s00266-016-0765-z
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DOI: https://doi.org/10.1007/s00266-016-0765-z