This article is a continuing discussion of the above cited article. It is that it useful for two reasons. First, it discusses the statistical errors that may cause misinterpretation of results in retrospective studies known as “confounding errors.” While the discussion in general is useful in regards to its general use in study interpretation, it also highlights the need for prospective randomized controlled studies to truly develop the highest level of evidence.
Second, it discusses the confounding errors that could cause one to incorrectly conclude that fasciocutaneous flaps are the most unaesthetic reconstructive method in dorsal hand coverage. The authors simply point out that wound size may be a variable which is associated with both the choice of flap type and the rate outcome (aesthetic rating of the reconstruction). If venous flaps could be used for all sizes of reconstruction, then randomizing them vs. fasciocutaneous or muscle and skin graft flap reconstructions to all sizes of wounds would lead to a more valid conclusion of superiority of one method over the other. However, venous flaps can only be used reliable for small wounds, which may, independently, provide a more aesthetic wound to reconstruct. They also require the largest donor site defect and are then more apt to require skin grafting or have more wound complications. Likewise, the largest wounds requiring larger flaps such as the ALT may have been the most unaesthetic wounds to begin with and thus the type of flap may not be the only determinant of the ultimate reconstruction outcome.