Plastic and Reconstructive Surgery • February 2014 we would argue that this only serves to support our conclusion that high machine suction is equivalent to low machine suction. No one has ever reported harmful effects of lower suction pressures. We have reviewed the letter to Plastic and Reconstructive Surgery in April of 2013 by Tambasco et al.4 discussing histology of fat harvested with various degrees of suction pressure. Having performed similar experiments, we can appreciate the time and effort involved in undertaking such research. It is true that the conclusions of our original article differ than those in the letter to Plastic and Reconstructive Surgery by Tambasco et al. Before agreeing or disagreeing, however, we would need more information. First, what type of statistical analysis was conducted to calculate statistical significance between the sample groups, and was there more than one sample per study group that was analyzed for histology? It would be difficult to claim that there was a statistically significant difference if the p value was not less than 0.05 or if n = 1. Second, how can the authors differentiate in their histology the cytoplasmic membrane rupture versus sectioning artifact that is very commonly seen in adipocyte histology? We have looked at countless histologic slides for membrane rupture and have determined that it cannot be reliably used as an endpoint. Instead, we look at the degree of inflammation, fibrosis, and vacuoles, which are all markers of graft injury and much more easily determined. Third, how can the authors infer long-term fat graft survival at day 0? Most in the field agree that a longterm model is needed. We too have investigated day-0 data, but they clearly do not reliably relate to long-term graft survival. Therefore, we have published long-term data using a proven small-animal model. We aim to answer clinically relevant scientific questions. In this case, what effect do these variables have on long-term fat graft survival in vivo? We agree wholeheartedly that standardizing a procedure is difficult. Our intention is to provide a deeper understanding of the variables that significantly affect fat grafting and to stimulate much needed research. We all look forward to the day when there is a standard technique that optimizes all of the significant variables, but the data do not yet exist. There are numerous variables that still warrant investigation and peer review before we can comfortably support or claim a “standard” technique. DOI: 10.1097/01.prs.0000437250.70704.04
Jeffrey H. Lee, M.D. Michael C. McCormack, M.B.A. William Gerald Austen, Jr., M.D. Massachusetts General Hospital Boston, Mass. Correspondence to Dr. Austen Massachusetts General Hospital Boston, Mass. 02114
224e
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph MA, Austen WG Jr. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg. 2013;131:1125–1136. 2. Tambasco D, Arena V, Grussu F, Cervelli D. Adipocyte damage in relation to different pressures generated during manual lipoaspiration with a syringe. Plast Reconstr Surg. 2013;131:645e–646e. 3. Rodriguez RL, Condé-Green A. Quantification of negative pressures generated by syringes of different calibers used for liposuction. Plast Reconstr Surg. 2012;130:383e–384e. 4. Tambasco D, Arena V, Finocchi V, Grussu F, Cervelli D. The impact of liposuction cannula size on adipocyte viability. Ann Plast Surg. E-published ahead-of-print July 9, 2013.
Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap Sir: read with great interest an article written by Hekner et al. This article was published in August of 2013 and concerns donor-site morbidity of radial and ulnar free flaps.1 The authors’ study nicely showed less donor-site morbidity associated with the ulnar forearm free flap compared with the radial forearm free flap and recommended the ulnar forearm flap as a good alternative. I share the views of Hekner et al. but would like to address my practice and complete the discussion of Hekner et al. by introducing another good alternative that has less donor-site morbidity. The radial forearm free flap is a popular and ancient flap for defect reconstruction, but other alternatives have been proposed because of a few limitations of the flap. The main disadvantages of the radial forearm free flap are hair growth at the recipient site and donor-site morbidity. Dissatisfaction with the donor site and poor take of the skin graft are major donor-site morbidities. The adipofascial radial forearm flap does not have the problem of hair growth, and avoids a skin graft on the forearm donor site. Not only does the free radial forearm adipofascial flap have good aesthetic and functional outcome with minimal recipient- and donor-site morbidity, but also flap harvesting involves minimal technical modification.1,2 Therefore, the adipofascial radial forearm flap should be considered as an alternative radial forearm flap.
I
DOI: 10.1097/01.prs.0000437242.38424.60
Hamid Namazi, M.D. Shiraz University of Medical Sciences Shiraz, Iran
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
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
Jeffrey H. Lee, M.D. Michael C. McCormack, M.B.A. William Gerald Austen, Jr., M.D. Massachusetts General Hospital Boston, Mass. Correspondence to Dr. Austen Massachusetts General Hospital Boston, Mass. 02114
224e
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph MA, Austen WG Jr. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg. 2013;131:1125–1136. 2. Tambasco D, Arena V, Grussu F, Cervelli D. Adipocyte damage in relation to different pressures generated during manual lipoaspiration with a syringe. Plast Reconstr Surg. 2013;131:645e–646e. 3. Rodriguez RL, Condé-Green A. Quantification of negative pressures generated by syringes of different calibers used for liposuction. Plast Reconstr Surg. 2012;130:383e–384e. 4. Tambasco D, Arena V, Finocchi V, Grussu F, Cervelli D. The impact of liposuction cannula size on adipocyte viability. Ann Plast Surg. E-published ahead-of-print July 9, 2013.
Donor-Site Morbidity of the Radial Forearm Free Flap versus the Ulnar Forearm Free Flap Sir: read with great interest an article written by Hekner et al. This article was published in August of 2013 and concerns donor-site morbidity of radial and ulnar free flaps.1 The authors’ study nicely showed less donor-site morbidity associated with the ulnar forearm free flap compared with the radial forearm free flap and recommended the ulnar forearm flap as a good alternative. I share the views of Hekner et al. but would like to address my practice and complete the discussion of Hekner et al. by introducing another good alternative that has less donor-site morbidity. The radial forearm free flap is a popular and ancient flap for defect reconstruction, but other alternatives have been proposed because of a few limitations of the flap. The main disadvantages of the radial forearm free flap are hair growth at the recipient site and donor-site morbidity. Dissatisfaction with the donor site and poor take of the skin graft are major donor-site morbidities. The adipofascial radial forearm flap does not have the problem of hair growth, and avoids a skin graft on the forearm donor site. Not only does the free radial forearm adipofascial flap have good aesthetic and functional outcome with minimal recipient- and donor-site morbidity, but also flap harvesting involves minimal technical modification.1,2 Therefore, the adipofascial radial forearm flap should be considered as an alternative radial forearm flap.
I
DOI: 10.1097/01.prs.0000437242.38424.60
Hamid Namazi, M.D. Shiraz University of Medical Sciences Shiraz, Iran
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
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
