Comments on “Fenestrated adipofascial reverse flap for the reconstruction of fingertip amputations”

Dear Editor, We thank Sisti et al. (Sisti, Oliver, & Nisi, 2019) for their interest in our recent article (Losco et al., 2019) entitled “Modified single pedicle reverse adipofascial flap for fingertip reconstruction” (Microsurgery, 2019. 39:221–227). We reported our experience with single pedicle homodigital adipofascial flap for fingertip reconstruction. The vascular supply was based on a single perforator; the vessel (contralateral to the defect) was cauterized and divided with the purpose of changing the pivot point and achieving a wider and more lateral rotation. The edge of the adipofascial flap reached the defect tensionless obtaining an adequate bone coverage, even for ulnar and radial tissue losses. We read with great interest the paper from Idone and colleagues (Idone, Sisti, Tassinari, & Nisi, 2017); they performed a modified adipofascial reverse flap for fingertip reconstruction (distally to the nail matrix) in five cases. After the flap was raised, they created a window in the flap in order to avoid a second stage and allow a more anatomical restoration of the nail bed. We think that it is an interesting refinement of the original adipofascial reverse flap described by Ozdemir (Ozdemir, Kilinc, Sensoz, Unlu, & Baran, 2001); they harvested a flap based on two 5-mm-wide pedicles with the aim to restore the continuity of the avulsed nail bed in one surgical stage. The authors highlighted the importance of flap's lateral extension, from the ulnar to radial side; then, the tissue was incised windowshaped in order to respect the flap vascularization. In our opinion, such refinement could not be suitable for a single pedicle flap. After one dorsal perforator has been divided, a window created in the middle of the adipofascial tissue could likely result in vascular impairment and consequent ischemia. We agree that nail matrix preservation is paramount; we observed optimal results in amputations located at the lunula level and distal to it. In our series (Losco et al., 2019), the nail pierced the flap uneventful as described by Hosnuter et al. (Hoşnuter, Kargi, & Babuccu, 2004); complete regrowth of the nail lamina took place in about 6 months (for 14/15 patients) and there was no need for further surgeries, but a careful and consistent outpatient care. In the series reported by Idone, the creation of the “window” allowed a smoother passage over a restored nail bed; furthermore, a normal nail growth had been observed after 3 months of post-operative followup. The fenestration could be one reason of such time discrepancy; however, this is just a speculation that should be further investigated. In conclusion, even if some concerns about building upon our single pedicle technique with flap fenestration were raised, we congratulate the authors for the refinement they described and we also thank them to enter into an interesting correspondence over fingertip reconstruction.