DISCUSSION

Discussion of the article "Free medial arm graft"

Discusión del artículo "Injerto libre braquial medial"

The authors describe a case that resolved well, from a reconstructive vantage point, using a free medial arm graft (FMAG). They note that although this flap offers many advantages for the reconstruction of the head and neck, it is little used in daily practice.

It should be noted that the lower arm graft in some departments has been, and in other departments continues to be, the battle horse of reconstructive surgery of the head and neck for soft tissue defects. It unquestionably has many good qualities like consistent anatomy, ideal pedicle length and diameter, thin skin, and technical simplicity. It also has some important disadvantages, such as leaving the vascularization of the hand exclusively dependent on the ulnar artery, an unattractive scar in the donor zone in the best of cases and, in the worst, dramatic changes when the free skin graft is lost or palmar tendons are exposed. Loss of sensitivity in the thumb area is also common and uncomfortable for the patient, but it does not necessarily occur. Despite the fact that this is surely the flap that has been used most widely in the world, alternatives with less morbidity must be sought.

We congratulate the authors for trying to find a substitute for the lower arm graft. The problem is whether the free medial arm graft is the ideal solution for reconstructing the soft tissues of the head and neck and the other alternatives that may exist.

The answer to the first question is that it does not seem to be the ideal solution because there are important technical disadvantages: short pedicle, irregular diameter of the receptor vessels of the neck, variable anatomy, and the need for a more complex dissection technique. On the other hand, tissue availability is limited. In any case, we concur fully with what the authors say in the conclusions about FMAG being just another option for the reconstruction of the head and neck.

The answer to the second question is that, our opinion, there are other alternatives. We would like to mention that one of them, the free lateral arm graft, is similar in almost every way to FMAG. We have used it four times to close pharyngocutaneous fistulas and to reconstruct defects in the floor of the mouth when the facial artery is available. However, without denying the possible indications of these microvascularized grafts, in our opinion perforating vessel grafts set aside the rest in the reconstruction of soft tissue defects of the head and neck as the first indication. Their advantages are low morbidity, possibility to close directly, absence of limitations due to anatomic variations, long pedicle, and good vessel diameter. The main disadvantages are greater technical difficulty and increased operating time, but this improves considerably with practice.

We can illustrate this with a clinical case. A 64-year-old man without a medical history of interest presented a lesion 7 cm in its largest diameter in the right temporal region, bleeding and an ulcerated appearance. Biopsy disclosed basal cell epithelioma (Fig. 1).

Enlarged excision of the lesion was performed (Fig. 2) with repair of the defect using an anterolateral thigh graft (Fig. 3).

The postoperative result at 6 months was excellent (Fig. 4).

Miguel Burgueño

Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz, Madrid. España

References

1. Shyh-Jou Shieh, MD, Haw-Yen Chiu, Jui-Chin Yu, Shin-Chen Pan. Reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105:2349.        [ Links ]

2. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421.        [ Links ]

3. Wei FC, Jain V, Ortho MC, y cols. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast and Reconstr Surg 2002; 109:2219-26.        [ Links ]