Volume 133, Number 2 • Letters REFERENCES 1. Hekner DD, Abbink JH, van Es RJ, Rosenberg A, Koole R, Van Cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg. 2013;132:387–393. 2. Thankappan K, Trivedi NP, Sharma M, Kuriakose MA, Iyer S. Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction. Indian J Plast Surg. 2009;42: 100–103.
Reply: Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Hekner DD, Abbink JH, van Es RJ, Rosenberg A, Koole R, Van Cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg. 2013;132:387–393. 2. Van Cann EM, Koole R. The ulnar forearm free flap for the reconstruction of soft tissue defects in the head and neck area: Free flap outcome and donor site outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:851–854.
Sir:
I read with interest the letter by Dr. Namazi regarding our recent article “Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap.”1 Our study showed less donor-site morbidity following harvest of the ulnar forearm free flap than following harvest of the radial forearm free flap. Therefore, we recommend the ulnar forearm free flap as an alternative for the radial forearm free flap for the reconstruction of soft-tissue defects. Dr. Namazi mentions minimal donor-site morbidity following harvest of the radial forearm adipofascial flap, a modification of the radial forearm free flap. I thank Dr. Namazi for sharing his experience with regard to the donor site. However, we avoid using the radial forearm adipofascial flap because of several drawbacks for the recipient site. Because the radial forearm adipofascial flap misses the protective barrier of the skin, its surface will dry out, the fatty tissue is vulnerable to mechanical damage, and the flap may easily become infected. Flap necrosis and flap loss may be the result. Furthermore, the radial forearm adipofascial flap shows scar formation with wound contraction. Wound contraction can be an advantage in the reconstruction of maxillary defects but is a major disadvantage in most other areas of the oral cavity and oropharynx. Scar formation and wound contraction may cause immobility, restriction of mouth opening, swallowing problems, and speech problems. Worth mentioning is that the flap survival rate of the ulnar forearm free flap equals the flap survival rate of the radial forearm free flap, with the ulnar forearm free flap causing significantly less donor-site morbidity.1,2 We therefore strongly recommend the ulnar forearm free flap for reconstruction of softtissue defects. Once again, I would like to thank Dr. Namazi for his letter. DOI: 10.1097/01.prs.0000438066.76785.a0
Ellen M. Van Cann, M.D., D.M.D., Ph.D.
Department of Oral and Maxillofacial Surgery University Medical Center Utrecht Heidelberglaan 100 P.O. Box 85500 3584 CX Utrecht, The Netherlands [email protected]
A Practical Guide to Free Tissue Transfer Sir:
W
e read with interest the CME article published in July of 2013 written by Roehl and Mahabir entitled “A Practical Guide to Free Tissue Transfer.”1 The authors provided the most updated practical guidelines and also included the evidence-based medicine principles for microsurgical operations. However, we would like to discuss the concept mentioned in the article about intensive insulin therapy for perioperative glucose control in patients with free tissue transfer. The authors suggested that surgeons maintain the patient’s blood glucose at or below 110 mg/ dl through intensive insulin therapy, which can significantly reduce morbidity and mortality (level I).2 The target of glycemic control mentioned herein is lower than 110 mg/dl. This is quoted from the research of intensive glycemic control in critically ill patients in The New England Journal of Medicine in 2001.2 Nevertheless, in the past decade, several reports from large clinical trials have already confirmed that overly strict glycemic control may result in an increasing mortality rate and hypoglycemia risk. According to American Diabetes Association glycemic control guidelines, for critical patients, the blood glucose target is 140 to 180 mg/dl, and for stable inpatients, the glycemic range can be set at approximately 110 to 140 mg/dl.3 In addition, most studies of perioperative glucose control revealed that strict glycemic control did not result in a significant improvement in clinical outcomes; however, it can be achieved with moderate control.4,5 Hypoglycemia will also cause endothelial cell dysfunction, cytokine secretion, inflammation response, sympathetic activation, and vasoconstriction.6 It seems relatively harmful for tissue survival. To sum up, concerning the points mentioned above, our different points of view are proposed. DOI: 10.1097/01.prs.0000437240.30800.d1
He-Jiun Jiang, M.D. Division of Endocrinology and Metabolism Department of Internal Medicine
225e
Plastic and Reconstructive Surgery • February 2014 Yu-Hao Huang, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan Correspondence to Dr. Huang Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University 100 Tzyou 1st Road Kaohsiung 807, Taiwan [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. ACKNOWLEDGMENT The authors thank Sang-Ju Lin for assistance with the grammar in this communication. REFERENCES 1. Roehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg. 2013;132:147e–158e. 2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–1367. 3. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(Suppl 1):S11–S66. 4. Jeschke MG. Clinical review: Glucose control in severely burned patients. Current best practice. Crit Care 2013;17:232. 5. Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254:458–463; discussion 463. 6. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003;26:1902–1912.
Are the New Changes in Our Operating Rooms Really Making Us Safer and Better Surgeons? Sir:
P
lease accept this letter in response to the Editorial by Steven R. Buchman, M.D., published in Plastic and Reconstructive Surgery in May of 2013. Although some may find the forced communication of the World Health Organization time-out burdensome, the process has been proven to significantly reduce surgical morbidity and mortality in a multinational controlled trial.1 In fact, preventing iatrogenesis and managing the risks faced by both patients and the operative team requires substantial planning by and engagement from the entire operative team. The author’s military analogy further belies his point. Would any commanding officer undertake
226e
any risky mission without first discussing the plan of action with the team and apprising every member of his or her role in it? If even the most routine military endeavor bears unforeseen risks, is it not the leader’s responsibility to have and discuss contingency planning before boarding the helicopters? Even a professional sports team has a plan for victory that is discussed and reviewed thoroughly by all members of a team before kickoff. Is it not more important for the surgical team to do so before the first incision? Perhaps this kind of briefing would be unnecessary if we all performed only the same operative procedures every day with the same team members. Alas, every day in the academic operating room brings new disease processes, varying procedures, neophyte team members, and a renewed bolus of trainees. Is it then reasonable to assert that safety in the environment can be maintained through the vigilance of the attending surgeon alone? The work of Robert Helmreich, Ph.D., in the field of cockpit linguistics (and other published work by human factors experts who have studied high-reliability industries) shows that many commercial flights crashed before the advent of Crew Resource Management because members of the flight crew felt hesitant to speak up or restate their concerns about potentially fatal errors or conditions they had observed. Detailed analyses of cockpit voice recorders revealed that steep hierarchies and hostile environments set up by senior captains were determinants in many of these events. Empowering members to “speak up” increased not only team resilience but also the likelihood of successfully navigating future unplanned adverse events.2–7 In the same way, introducing and acknowledging each team member by role and first name does not diminish the surgeon’s leadership; on the contrary, it presents an opportunity to clearly establish the “command voice” for the team, especially important in the event of an unforeseen crisis. We can all agree that Navy SEALs show effective teamwork. Navy SEAL officer Eric Greitens says this is because of a repetitive practice of “Plan, Execute, Debrief. Debrief as team, learn from your mistakes working together as team. Being open to the idea that every single time their practice was improving.”8,9 The three parts of the World Health Organization time-out reiterate this: check the patient into the operating room; pause to verify and discuss the plan immediately before the procedure; and, lastly, debrief. Finally, as practiced by the flight crews at the National Aeronautics and Space Administration, using first names reinforces the ability of those with expertise to speak up when unforeseen dangers emerge from the fog. Finally, denying the risk of fire in an operating room is foolhardy at best given the common presence of open flames and the oxygen-enriched environment. Everyone present in the operating room should know the specific risks, prevention strategies, and contingency plans in case of fire. Failing to do this is like
Reply: Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Hekner DD, Abbink JH, van Es RJ, Rosenberg A, Koole R, Van Cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg. 2013;132:387–393. 2. Van Cann EM, Koole R. The ulnar forearm free flap for the reconstruction of soft tissue defects in the head and neck area: Free flap outcome and donor site outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:851–854.
Sir:
I read with interest the letter by Dr. Namazi regarding our recent article “Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap.”1 Our study showed less donor-site morbidity following harvest of the ulnar forearm free flap than following harvest of the radial forearm free flap. Therefore, we recommend the ulnar forearm free flap as an alternative for the radial forearm free flap for the reconstruction of soft-tissue defects. Dr. Namazi mentions minimal donor-site morbidity following harvest of the radial forearm adipofascial flap, a modification of the radial forearm free flap. I thank Dr. Namazi for sharing his experience with regard to the donor site. However, we avoid using the radial forearm adipofascial flap because of several drawbacks for the recipient site. Because the radial forearm adipofascial flap misses the protective barrier of the skin, its surface will dry out, the fatty tissue is vulnerable to mechanical damage, and the flap may easily become infected. Flap necrosis and flap loss may be the result. Furthermore, the radial forearm adipofascial flap shows scar formation with wound contraction. Wound contraction can be an advantage in the reconstruction of maxillary defects but is a major disadvantage in most other areas of the oral cavity and oropharynx. Scar formation and wound contraction may cause immobility, restriction of mouth opening, swallowing problems, and speech problems. Worth mentioning is that the flap survival rate of the ulnar forearm free flap equals the flap survival rate of the radial forearm free flap, with the ulnar forearm free flap causing significantly less donor-site morbidity.1,2 We therefore strongly recommend the ulnar forearm free flap for reconstruction of softtissue defects. Once again, I would like to thank Dr. Namazi for his letter. DOI: 10.1097/01.prs.0000438066.76785.a0
Ellen M. Van Cann, M.D., D.M.D., Ph.D.
Department of Oral and Maxillofacial Surgery University Medical Center Utrecht Heidelberglaan 100 P.O. Box 85500 3584 CX Utrecht, The Netherlands [email protected]
A Practical Guide to Free Tissue Transfer Sir:
W
e read with interest the CME article published in July of 2013 written by Roehl and Mahabir entitled “A Practical Guide to Free Tissue Transfer.”1 The authors provided the most updated practical guidelines and also included the evidence-based medicine principles for microsurgical operations. However, we would like to discuss the concept mentioned in the article about intensive insulin therapy for perioperative glucose control in patients with free tissue transfer. The authors suggested that surgeons maintain the patient’s blood glucose at or below 110 mg/ dl through intensive insulin therapy, which can significantly reduce morbidity and mortality (level I).2 The target of glycemic control mentioned herein is lower than 110 mg/dl. This is quoted from the research of intensive glycemic control in critically ill patients in The New England Journal of Medicine in 2001.2 Nevertheless, in the past decade, several reports from large clinical trials have already confirmed that overly strict glycemic control may result in an increasing mortality rate and hypoglycemia risk. According to American Diabetes Association glycemic control guidelines, for critical patients, the blood glucose target is 140 to 180 mg/dl, and for stable inpatients, the glycemic range can be set at approximately 110 to 140 mg/dl.3 In addition, most studies of perioperative glucose control revealed that strict glycemic control did not result in a significant improvement in clinical outcomes; however, it can be achieved with moderate control.4,5 Hypoglycemia will also cause endothelial cell dysfunction, cytokine secretion, inflammation response, sympathetic activation, and vasoconstriction.6 It seems relatively harmful for tissue survival. To sum up, concerning the points mentioned above, our different points of view are proposed. DOI: 10.1097/01.prs.0000437240.30800.d1
He-Jiun Jiang, M.D. Division of Endocrinology and Metabolism Department of Internal Medicine
225e
Plastic and Reconstructive Surgery • February 2014 Yu-Hao Huang, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan Correspondence to Dr. Huang Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University 100 Tzyou 1st Road Kaohsiung 807, Taiwan [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. ACKNOWLEDGMENT The authors thank Sang-Ju Lin for assistance with the grammar in this communication. REFERENCES 1. Roehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg. 2013;132:147e–158e. 2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–1367. 3. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(Suppl 1):S11–S66. 4. Jeschke MG. Clinical review: Glucose control in severely burned patients. Current best practice. Crit Care 2013;17:232. 5. Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254:458–463; discussion 463. 6. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003;26:1902–1912.
Are the New Changes in Our Operating Rooms Really Making Us Safer and Better Surgeons? Sir:
P
lease accept this letter in response to the Editorial by Steven R. Buchman, M.D., published in Plastic and Reconstructive Surgery in May of 2013. Although some may find the forced communication of the World Health Organization time-out burdensome, the process has been proven to significantly reduce surgical morbidity and mortality in a multinational controlled trial.1 In fact, preventing iatrogenesis and managing the risks faced by both patients and the operative team requires substantial planning by and engagement from the entire operative team. The author’s military analogy further belies his point. Would any commanding officer undertake
226e
any risky mission without first discussing the plan of action with the team and apprising every member of his or her role in it? If even the most routine military endeavor bears unforeseen risks, is it not the leader’s responsibility to have and discuss contingency planning before boarding the helicopters? Even a professional sports team has a plan for victory that is discussed and reviewed thoroughly by all members of a team before kickoff. Is it not more important for the surgical team to do so before the first incision? Perhaps this kind of briefing would be unnecessary if we all performed only the same operative procedures every day with the same team members. Alas, every day in the academic operating room brings new disease processes, varying procedures, neophyte team members, and a renewed bolus of trainees. Is it then reasonable to assert that safety in the environment can be maintained through the vigilance of the attending surgeon alone? The work of Robert Helmreich, Ph.D., in the field of cockpit linguistics (and other published work by human factors experts who have studied high-reliability industries) shows that many commercial flights crashed before the advent of Crew Resource Management because members of the flight crew felt hesitant to speak up or restate their concerns about potentially fatal errors or conditions they had observed. Detailed analyses of cockpit voice recorders revealed that steep hierarchies and hostile environments set up by senior captains were determinants in many of these events. Empowering members to “speak up” increased not only team resilience but also the likelihood of successfully navigating future unplanned adverse events.2–7 In the same way, introducing and acknowledging each team member by role and first name does not diminish the surgeon’s leadership; on the contrary, it presents an opportunity to clearly establish the “command voice” for the team, especially important in the event of an unforeseen crisis. We can all agree that Navy SEALs show effective teamwork. Navy SEAL officer Eric Greitens says this is because of a repetitive practice of “Plan, Execute, Debrief. Debrief as team, learn from your mistakes working together as team. Being open to the idea that every single time their practice was improving.”8,9 The three parts of the World Health Organization time-out reiterate this: check the patient into the operating room; pause to verify and discuss the plan immediately before the procedure; and, lastly, debrief. Finally, as practiced by the flight crews at the National Aeronautics and Space Administration, using first names reinforces the ability of those with expertise to speak up when unforeseen dangers emerge from the fog. Finally, denying the risk of fire in an operating room is foolhardy at best given the common presence of open flames and the oxygen-enriched environment. Everyone present in the operating room should know the specific risks, prevention strategies, and contingency plans in case of fire. Failing to do this is like
