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• W2317289307 abstract "Sir: We read with great interest the letter prepared by Onesti et al., detailing their use of Integra (Integra LifeSciences Corp., Plainsboro, N.J.) in the reconstruction of pediatric lower extremity defects following resection of malignant plantar rhabdomyosarcomas.1 For reconstruction of oncologic defects, or where the primary disease site may be affected by later recurrence or subsequent revision, techniques that use the surrounding tissues in a conservative manner are optimal. Certainly, the use of a dermal substitute is useful following ablative or oncologic surgery, where the tumor margins may be subject to further investigation, because attempts to reestablish original tumor margins following tissue rearrangement or flap reconstruction can be disastrous. Also, in the setting of possible irradiation, a semitemporary reconstruction affords the possibility of the later use of autologous tissue if required for late deformity or exposure. In the pediatric population, where individual patient compliance may be limited without extensive or long-term immobilization, the goals of patient care should emphasize expedient and durable closures. It is important to emphasize that dermal substitutes are not a panacea for all lower extremity defects. The drawbacks are derivatives of the benefits, in that a granulating wound over exposed bone or hardware is suboptimal when compared with a stable flap closure. The biomechanics of the site of reconstruction must also be considered with regard to a long-term solution, with a reconstructive product yielding a tissue density or function similar to the native skin. The thickened glabrous skin and subcutaneous tissue of the plantar foot provides a large cushioning effect on the underlying bone and tendon, and prevents pressure ulceration or fracturing. Reconstructive efforts should replace the defect with tissue that is similar in biomechanical and regional properties. As such, a local or pedicled flap (e.g., medial plantar artery flap) may be the optimal reconstructive solution when tumor margins and patient factors are permitting, especially along the plantar surface of the foot. However, dermal substitutes are acellular and do not rely on early plasmatic imbibition and can therefore be placed over otherwise avascular structures, something that a split-thickness skin graft may not be able to do adequately.2,3 Also, as outlined by Lee et al., skin grafting without adequate underlying soft tissue or over weight-bearing surfaces will cause chronic wound breakdown. For example, a skin graft over the calcaneus can provide local wound closure but will be prone to recurrent breakdown and erosion. A final consideration when using any product should also include the financial impact on the patient. As detailed by Lee et al., a single 8 × 10-inch piece of Integra may cost as much as $2000.3 With this in mind, it behooves the practitioner to use the product in a judicious manner, especially in a financially responsible health care setting, and that either an autologous or alloplastic reconstruction should aim to provide the patient with a definitive reconstruction. Salvage efforts of the lower extremity continue to be complicated by the various techniques of wound coverage in both acute and chronic settings. The prudent use and management of surgical planning, patient expectations, and durable biomechanics will help to provide adequate reconstructive solutions, regardless of what is under the dressing. Matthew L. Iorio, M.D. Christopher E. Attinger, M.D. Department of Plastic Surgery Georgetown University Hospital Washington, D.C." @default.
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• W2317289307 date "2011-08-01" @default.
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• W2317289307 title "Reply: Minimally Invasive Reconstructive Surgery for Complex Oncologic Foot Defects in Children" @default.
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• W2317289307 doi "https://doi.org/10.1097/prs.0b013e31821ef02a" @default.
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