Complex Scalp Reconstruction with Super-thin DIEP Free Flap

Dear Sir, With great interest we have read the article “Complex Scalp Reconstruction with Super Thin DIEP Free Flap” by Stanneart et al.1 We congratulate the authors on their valuable work expanding the options for free flap reconstruction of complex scalp defects. The authors appreciate the super-thin deep inferior epigastric perforator (DIEP) flap due to its good contour to the scalp, reliable blood supply, and provision of a large surface area, in addition to its relative low donor-site morbidity and, especially, that it is a muscle-sparing technique. However, we were surprised that the authors did not further discuss the possibility of defect coverage with muscle flaps. In our opinion, muscle flaps have the benefit that they shrink to the anatomical level and result in a better color match than fasciocutaneous flaps when the muscle flap is covered by an unmeshed skin graft. In cases of smaller defects, the split skin graft can even be harvested from intact residual skin of the scalp, which undoubtedly results in the most preferable color match. Recently, Ghorbani2 published a 36-year follow-up report on scalp reconstruction using the free latissimus dorsi muscle flap. He underlined the excellent long-term result with restoration of the scalp to its original shape. As the authors note, one major disadvantage of muscle flaps like the latissimus dorsi muscle flap compared to a fasciocutanious flaps is the donor-site morbidity due to possible muscular functional deficits.1 However, did the authors also take the gracilis muscle flap into consideration? We have published articles on defect coverage of the head and scalp with the gracilis muscle flap.3,4 In our experience, the use of the gracilis muscle flap has the advantage of a constant vascular anatomy with a good pedicle length, without the need of a preoperative computed tomography angiography for planning. In addition, its harvest is straightforward, and the donor-site morbidity is favorable due to the concealed donor-site scar. Moreover, although a muscle must be lost with the gracilis muscle flap, the functional deficit is minimal. Furthermore, for cases with large-sized defects, the gracilis muscle flap can be further enlarged when the epimysium and intramuscular connective tissue of the gracilis muscle, in addition to the perimysium, is split. This should be performed under the microscope to avoid damage of the intramuscular neurovascular supply. With this technique, the originally compact muscle fibers can be spread, resulting in an increase in the flap size by three to four times.5 We appreciate the opportunity to present the gracilis muscle flap as a viable option for defect coverage in complex head and scalp defects and want to encourage the authors to include the gracilis muscle flap in their future preoperative decision-making process. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.