Microsurgical Reconstruction of the Oral Cavity with Free Flaps from the Anterolateral Thigh and Radial Forearm: Example of Confounding by Indication? A Reply

See original letter here.

Letter to the Editor

Rohleder NH, Kesting MR

Technische Universität München, Department of Oral and Maxillofacial Surgery, Munich, Germany

To the Editors:

Thank you for the opportunity to reply to the letter from Post et. al., in which the authors express their opinion that our results concerning the higher frequency of donor site morbidity among patients with a radial forearm free flap (RFFF) when compared to those with an anterolateral thigh free flap (ALTFF) are subject to confoundation. Although we agree with the authors that a further analysis that relates donor site morbidity to weight and / or the general and specific vascular state of the patient would be interesting, such an analysis could not be provided because no scaled measure of the patients vascular state had been obtained. The vascular state had been assessed visually by the radiologist during the preoperative CT evaluations. However, our statement that donor site morbidity is higher among RFFF than ALTFF has been confirmed in recent studies (e.g., Liu et al. investigated soft-tissue head and neck reconstructions with 53 RFFF and 21 ALTFF and report that "ALT flaps had fewer impacts to donor site functionality than RF flaps")[1].

The authors further question the necessity of statistical analysis with respect to the correlation between operation time or flap size to ALTFF. We believe that statistical tests should be performed even in questions with apparently "logical" conclusions. We agree with the authors that an additional regression analysis might have added interesting results and we will consider this approach in our subsequent studies. However, it might be challenging to find an appropriate measure for the suggested inclusion of the "skill of the surgeon."


1. Liu WW, Li H, Gou ZM, Zhang Q, Yang AK, Liu XK, et al. Reconstruction of soft-tissue defects of the head and neck: radial forearm flap or anterolateral thigh flap? Eur Arch Otorhinolaryngol. 2011;268(12):1809-12.

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