Article

Skin flap-like wounds debridement considerations: What to do in Emergency Department

skin flap-like woundsdebridementconsider”>American Journal of Emergency Medicine 37 (2019) 1585-1599

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Skin flap-like wounds debridement considerations: What to do in Emergency Department

Reference

[1] Qiu D, Wang X, Wang X, Jiao Y, Li Y, Jiang D. Risk factors for necrosis of skin flap-like wounds after ED debridement and suture. Am J Emerg Med 2019 May;37(5):828-31. https://doi.org/10.1016/j.ajem.2018.07.049.

Dear Editor,

We have carefully read the article by Qiu et al. [1] published in American Journal of Emergency Medicine. We would like to acknowl- edge the authors for the evidence presented and also thought that some issues should be addressed.

The management of flap-like wounds is a frequent problem at the Emergency Department. There is scarce available bibliography about the optimal manner to manage this kind of wounds. This leads to an ac- tion based on individual experience and “common sense” when adopting a conservative or aggressive attitude in initial attention.

Frequently, in flap-like wounds located in functional or aesthetic areas, the most widespread attitude is to be more conservative at the initial moment, reevaluating the situation after a few days. However, based on the evidence from the study, do the authors believe that a flap-like wound with several factors of poor prognosis of the exposed should be handled more aggressively from the initial assessment in the Emergency Department? Also, do any of the factors imply a change in therapeutic management over others?

Funding

Authors disclose no funding.

Declaration of Competing Interest

Authors declare no conflict of interest.

Alberto Sanchez-Garcia, MD* Enrique Salmeron-Gonzalez, MD Elena Garcia-Vilarino, MD Nieves Vanaclocha, MD

Plastic and Reconstructive Surgery Department, University and Polytechnic Hospital La Fe, Avenida Fernando Abril Martorell, 106, 46026 Valencia,

Spain

*Corresponding author at: Antonio Sacramento 11, Valencia,

Comunidad Valenciana 46013, Spain.

E-mail address: [email protected].

Alfonso Valverde-Navarro, PhD Department of Human Anatomy and Embriology, University of Valencia, Valencia, Avenida Blasco Ibanez, 13, 46010, Valencia, Spain

Reply: Skin flap-like wounds debridement considerations: What to do in emergency department

Sir:

Our article entitled “Risk factors for necrosis of skin flap-like wounds after debridement and suture in the emergency room” published in American Journal of Emergency Medicine, presented therapeutic man- agement of flap-like wounds with some plastic surgical techniques. We appreciate the careful review of our work and hope to offer clarification on the questions raised by the readers.

First, the characteristic of a flap-like wound is determined by its con- figuration. These special wounds are characterized by discontinuity and damage to the structure of soft tissue, with one side of the tissue con- nected to the wound base by a pedicle and the remaining tissue de- tached. In some cases, the Blood supply of the narrow flaps was quite tenuous because it derived perfusion from the intact dermal attach- ment. To avoid secondary operation, we insist the narrow tenuous flap should be excised when the surrounding soft tissue is sufficient.

Second, “trap door deformity” after wound healing is another crucial factor that we should take into consideration in primary care [1]. These unfavorable lumpy deformities are often produced by the formation of elevations of U-shaped flaps, and the flaps have been created when the striking force is not perpendicular. With the day going on, the

https://doi.org/10.1016/j.ajem.2019.05.041

4 May 2019

Fig. 1. The formation of “trap door deformity”. (a) A U-shaped flap was created when the striking force was not perpendicular; (b) the beveled wound was managed with simple interrupted percutaneous sutures; (c) “Trap door deformity” formed after healing.

0735-6757/(C) 2019

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