No Level Assigned This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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].