INVITED COMMENTARY This paper shows the experience of a single unit of sur- into different systems in the neck which might be a geons and compares very favourably with other published branch of the internal jugular vein and external jugular work. In my own experience [1] the results improved with vein, or sometimes a pharyngeal vein. increasing experience in terms of overall flap survival. The complications of the donor site are in keeping with Unusually this series has a relatively high incidence of many other published series and it is noted that this group partial failure which may indicate incorrect flap elevation grafted all the donor sites. In my current practice for oral or a prolonged ischaemia which results in incomplete per- and oralpharyngeal cancer, the donor site is now closed fusion of the flap. The length of surgery is also quite long, with a ulnar transposition flap. If a larger skin flap is re- with an average of 11 h, when compared to our own series quired, then I favour a different free flap, such as a lateral averaging 7.5 h. This may indicate a prolonged ischaemia arm flap. It is interesting that this paper also had a case of or difficulties in in-setting the flap. The authors them- reduced perfusion of the hand necessitating an immediate selves have noted a relatively high complication rate in vein graft very similar to that published by Jones and wound dehiscence and hematoma, and also a relatively O'Brien in 1985 [2]. high incidence of infection. Although the patients are cov- This only serves to emphasise the importance of as- ered by antibiotics, it could be that infection, partial de- sessing this donor site and taking great care in pre opera- hiscence and hematomas are all connected, and part of tive and per operative elevation of the flap. The bone har- the same problem. I note that they cover the patients with vesting technique which we have described previously [1] antibiotics for a relatively short time (48 h) and yet they certainly lessens the instance of fracture and it is now our use an agressive anticoagulant regime which includes di- practice frequently to insert cancellous bone grafts taken pyridamole (Persantin) proplylactic thromboytic therapy with a trephine from the iliac crest at the time of surgery with heparin and dextran ª40º. My own practice is to re- to promote consolodation and healing of the bone. strict anticoagulants to propylactic thrombolytic therapy This paper does, however, illustrate the importance of which in our unit is currently 5000 units subcutaneous the experience of the surgical team. It would also be inter- heparin bd. The high incidence of hematoma and subse- esting to know whether the ischaemia time and the overall quent problems could well relate to this groups anticoag- length of the operation time has decreased with increasing ulation regime. Four of the patients had to undergo sec- experience. ondary surgery related to hematomas, two where the anas- tomosis were patent, and in two the anastomosis was thrombosed. References The majority of this groups' problems appear to be 1. Soutar DS, Ray AK (1992) The radial forearm flap in head and with venous drainage. Certainly the veins in the radial neck reconstruction. In: Jackson IT, Summerlad BC (eds) Recent forearm flap can be small and this is particularly notice- advances in plastic surgery 4. Churchill Livingstone able in women. Throughout our own series of 175 cases, 2. Jones BM, O'Brien CJ (1985) Accute ischaemia of the hand re- failure rate was always higher in women than in men. sulting from elevation of a radial forearm flap. Br J Plast Surg There is little value to anastomosing both venae comitan- 38:396±397 tes since they communicate throughout the pedicle. If ve- nous drainage has to be improved, then it is better to anas- D. Soutar tomose a venae comitans and a separate superficial subcu- Canniesburn Hospital, Bearsden taneous draining vein. Preferably the veins should be put Glasgow G61 1QL, Scotland European Journal of Plastic Surgery Springer Journals


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Copyright © 1998 by Springer-Verlag Berlin Heidelberg
Medicine & Public Health; Plastic Surgery
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