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
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
