Reply to Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies

Letter to the Editor: Morbidity of the Free Fibula Flap Reconstruction in Head and Neck Malignancies

We would like to thank Asokan et al for reading and commenting on our recently published study on postpostoperative complications in patients undergoing mandibular reconstruction with the fibula free flap (FFF).[1] In their Letter to the Editor, they bring forth matters that need further clarification, which we would like to comment on.

First, we share the authors' opinion on the central role of the tracheostomy in the airway management of head and neck cancer patients. The indication for an elective tracheostomy should not only encompass intraoperative convenience. As the authors bring forward, the (postoperative) respiratory control is of equal, if not of more importance. At our institution, we try to uncuff the tracheostomy as soon as possible, on the condition that the patient is able to communicate and execute commands. With this protocol, we try to reduce the possibility of iatrogenic injuries, especially in the form of “stormy extubations” with possible damage to vascular anastomosis in the operative site. We could not obtain individual data regarding the duration of postoperative mechanical ventilation. The main reason is the retrospective character of the study, as the design relies on adequate record keeping. It is also not our hospital protocol to mechanically ventilate in the postoperative phase.

In our study, we did not mention the incidence of the vascular anatomic variations of the FFF. This was not an objective of this study. It was not possible to retrieve adequate information regarding the anatomic variation of the FFF.

Prior malignancies were found in 14 patients (16.3%). The data were incorrectly displayed in Table 2 of the article[1] and therefore need rectification. Univariate and multivariable analyses do not need rectification as the values were correctly processed in the analyses. The prior malignancies were located in lung (n = 1), mamma (n = 3), non-Hodgkin lymphoma (n = 1), bladder (n = 1), thyroid gland (n = 1), leukemia (n = 1), skin melanoma (n = 1), unknown (n = 5), and second primary in the head and neck region (n = 2). Note that two patients had multiple prior malignancies. The prevalence of prior malignant disease is in concordance with other free flap populations.[2] As only two reconstructions were performed for recurrent diseases in the head and neck area, the contribution to the complication rates is most likely limited.

Preoperative radiotherapy could not be associated with an increased risk for postoperative complications in our study. However, the literature is discordant regarding this topic.[3] [4] Although we did not explore this subject, preoperative radiotherapy could have a negative effect on the operating area, causing tissue fibrosis with tissue contraction and compromising the vascularization. Thereby, the reconstruction becomes more challenging and resource consuming. In the authors' opinion, patients with preoperative irradiated surgical sites should not be denied free flap reconstruction, per se, despite a possible increased risk for postoperative complications.

In our analysis, we found significantly greater surgical complications (p = 0.03) and prolonged hospitalizations (p = 0.002) for reconstructions involving the anterior mandible. An additional partial glossectomy was associated with a decreased risk for surgical complications (p = 0.001). Similar to the Asokan et al's hypothesis, we tried to associate the decreased risk with the type of defect. As reconstructions of true lateral defects (L defect according to Jewer et al[5]) have lower complication rates compared with defects with involvement of the central mandible (C defect according to Jewer et al[5]), one could expect overrepresentation of the true lateral defects in patients undergoing a partial glossectomy. However, the data do not support this theory. In our population, 20 patients underwent an additional partial glossectomy. Six (30%) of those 20 patients underwent a true lateral reconstruction (L defect), and the other 14 patients had involvement of the central segment (LC defect: n = 3, LCL defect: n = 11). In the group without a partial glossectomy, 39% of the defects were classified as true lateral. This finding contradicts the hypothesis and was therefore rejected. It should be noted again that the sample size was small, which could have led to underpowered statistics. As Asokan et al find the explanation of decreased mobility of the surgical area debatable, we are open to suggestions.

• References

• 1 Lodders JN, Schulten EA, de Visscher JG, Forouzanfar T, Karagozoglu KH. Complications and risk after mandibular reconstruction with fibular free flaps in patients with oral squamous cell carcinoma: a retrospective cohort study. J Reconstr Microsurg 2016; 32 (6) 455-463
• 2 Lodders JN, Parmar S, Stienen NL , et al. Incidence and types of complications after ablative oral cancer surgery with primary microvascular free flap reconstruction. Med Oral Patol Oral Cir Bucal 2015; 20 (6) e744-e750
• 3 Choi S, Schwartz DL, Farwell DG, Austin-Seymour M, Futran N. Radiation therapy does not impact local complication rates after free flap reconstruction for head and neck cancer. Arch Otolaryngol Head Neck Surg 2004; 130 (11) 1308-1312
• 4 Clark JR, McCluskey SA, Hall F , et al. Predictors of morbidity following free flap reconstruction for cancer of the head and neck. Head Neck 2007; 29 (12) 1090-1101
• 5 Jewer DD, Boyd JB, Manktelow RT , et al. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg 1989; 84 (3) 391-403 , discussion 404–405