- Email: [email protected]
Free flap reconstruction of the maxilla: Is there something missing?
6
5. 6. 7. 8.
9. 10. 11. 12.
13.
14. 15. 16.
Letters to the Editor Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562-9. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2008;16:303-11. Rosenthal EL, Dixon SF. Free flap complications: when is enough, enough? Curr Opin Otolaryngol Head Neck Surg 2003;11:236-9. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092-100. Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010;120:717-23. Barker JH, Furr LA, McGuire S, Cunningham M, Wiggins O, Storey B, et al. Patient expectations in facial transplantation. Ann Plast Surg 2008;61:68-72. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol 2000;19:226-34. McGauran N, Wieseler B, Kreis J, Schüler YB, Kölsch H, Kaiser T. Reporting bias in medical research—a narrative review. Trials 2010;11:37. Kirkham JJ, Dwan KM, Altman DG, Gamble C, Dodd S, Smyth R, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ 2010;340:c365. Pitak-Arnnop P, Sader R, Rapidis AD, Dhanuthai K, Bauer U, Hervé C, et al. Publication bias in oral and maxillofacial surgery journals: an observation on published controlled trials. J Craniomaxillofac Surg 2010;38:4-10. Pitak-Arnnop P, Dhanuthai K, Hemprich A, Pausch NC. Misleading P-value: do you recognise it? Eur J Dent 2010;4:356-8. Crawford JM, Briggs CL, Engeland CG. Publication bias and its implications for evidence-based clinical decision making. J Dent Educ 2010;74:593-600. Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. PLoS ONE 2008; 3:e3081.
doi:10.1016/j.tripleo.2010.07.019
Free flap reconstruction of the maxilla: Is there something missing? In reply: Thank you for allowing us to respond to the letter to the editor by Pitak-Arnnop et al in this journal. The authors are clearly consummate theoreticians and criticize several points that would not be raised had they come from our background of pragmatic surgery. We would like to comment on those points, which are relevant. This study was conducted to evaluate the flap choice and the associated success rate of microvascular free flap reconstruction of the maxilla with regard to the defect size.1 In addition, the rate of prosthetic rehabilitation by implants or conventional prosthetic treatment was investigated. This was not, however, as we make abundantly clear, a controlled study of implants or implant survival, which Pitak-Arnnop et al seem to be concerned with. The comments in this regard are quite
OOOOE January 2011
inappropriate. The follow-up of all patients from February 2000 to December 2009 includes follow-up as part of routine aftercare, which obviously differs depending on what disease process created the defect that was reconstructed (this being the point of the article). As an observational study, complications would be recognized in that time.1 The 18 patients who did not want dental rehabilitation (because they were satisfied with the reconstruction or did not want any surgery) were not willing to receive any prosthesis or dental treatment.1 This is not an unusual finding in most busy centers treating the usual population requiring extensive reconstructive procedures.2-4 The authors of the Letter to the Editor should be aware of the concept that “the ability to do a treatment is not an indication.” As we made clear in the article, this study was primarily a large cohort with different indications for reconstructive procedures of the maxilla. We have no intention of pretending that other data can be artificially drawn from it, and the rate of local or distant recurrence and metastases was not specified, as this would not be comparable with other studies.4,5 For obvious reasons, individual publications can and should address specific issues. We recently published data in relation to patients with oral squamous cell carcinomas of the maxilla and midface reconstructed with free flaps compared with patients receiving no reconstruction (eg, obturator, local reconstruction), which are comparable, but the present cohort is not and we have no desire to stretch credulity.4-6 We were surprised at the comments regarding the “learning curve”; all major established centers carrying out complex microvascular reconstruction have moved beyond the primitive “one-size-fits-all” approach that the authors seem to allude to. Reconstruction of the maxilla is in fact much more complicated than in the mandible and necessitates reconstructive experience with different flaps containing different types of tissues.1-4,7,8 The microsurgical and reconstructive considerations are of prime importance for the patients, for both esthetic and functional reasons.9,10 Pitak-Arnnop et al also call for a univariate analysis between complications of different possible variables. Although the idea is promising, only a small number of complications occurred, resulting in 3 patients with a flap loss.1 Analyzing the discussed variables would lead to nothing new and publishing data without content is not the aim of our group. We can agree with Pitak-Arnnop et al that careful flap selection is of prime importance in the reconstruction of maxillary defects.1,5,6,9,10 This is the essential point of this article and has been clearly stated in the article.1,4 In the present study, we did not need any vein graft or arteriovenous fistula loop. The wound-healing disturbances
OOOOE Volume 111, Number 1
at the neck are also documented in the article and did not affect the outcome of the flaps.1 We do not accept the derogatory suggestion by PitakArnnop et al that we have deliberately created case selection nor do we feel a lesson in the basics of publication bias is needed. Our article describes our experience with maxillary reconstruction in, to the best of our knowledge, one of the largest cohort series that have been published. Artificially, subdividing into different groups within this cohort would lead to an overflowing production of meaningless data that would provide less valid information to the reader as well as exceed the word count of the journal. It is not unusual for academics to make claims about shortcomings of research design in the so-called era of “evidence-based practice.” The clinical reality is that the finite controls required to generate this level of evidence are seldom available and those of us who practice surgery in this demanding field will only ever be able to rely on careful, honest, and valid documentation of results. Thomas Mücke, MD Department of Oral and Maxillofacial Surgery Technische Universität München Klinikum Rechts der Isar München, Germany David A. Mitchell, MB, FDS, FRCS Oral and Facial Specialties Department Pinderfields General Hospital Wakefield, UK REFERENCES 1. Mücke T, Hölzle F, Loeffelbein DJ, Ljubic A, Kesting M, Wolff KD, et al. Maxillary reconstruction using microvascular free flaps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111:50-56. 2. Boyes-Varley JG, Howes DG, Davidge-Pitts KD, Branemark I, McAlpine JA. A protocol for maxillary reconstruction following oncology resection using zygomatic implants. Int J Prosthodont 2007;20:521-31. 3. Peng X, Mao C, Yu GY, Guo CB, Huang MX, Zhang Y. Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562-9. 4. Mücke T, Loeffelbein DJ, Hohlweg-Majert B, Kesting MR, Wolff KD, Hölzle F. Reconstruction of the maxilla and midface—surgical management, outcome, and prognostic factors. Oral Oncol 2009;45:1073-8. 5. Mücke T, Wagenpfeil S, Kesting MR, Hölzle F, Wolff KD. Recurrence interval affects survival after local relapse of oral cancer. Oral Oncol 2009;45:687-91. 6. Mücke T, Wolff KD, Wagenpfeil S, Mitchell DA, Hölzle F. Immediate microsurgical reconstruction after tumor ablation predicts survival among patients with head and neck carcinoma. Ann Surg Oncol 2010;17:287-95. 7. Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002;128:161-6. 8. Triana RJ Jr, Uglesic V, Virag M, Varga SG, Knezevic P, Milenovic A, et al. Microvascular free flap reconstructive options
Letters to the Editor 7 in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2:91-101. 9. Chen HC, Coskunfirat OK, Ozkan O, Mardini S, Cigna E, Salgado CJ, et al. Guidelines for the optimization of microsurgery in atherosclerotic patients. Microsurgery 2006;26:356-62. 10. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the previously operated and irradiated neck. Microsurgery 2009;29:1-7. doi:10.1016/j.tripleo.2010.08.024
A histopathologic comparison between synchronous and single primary oral squamous cell carcinomas To the Editor: We have read with great interest and would like to take the opportunity to comment on the recently published article by Dissanayaka et al.,1 “A histopathologic comparison between synchronous and single primary oral squamous cell carcinomas.” It is hypothesized that synchronous oral squamous cell carcinomas (OSCCs) may present with more aggressive histologic behavior. Hence, the authors compared histologic parameters with known prognostic significance between synchronous and single primary OSCCs. The unexpected results showed that synchronous OSCCs have more aggressive histologic features than single primary OSCC. It is a known fact that OSCCs in 2 different individuals will have different histologic features even if they are age, gender, and site matched, which in turn largely depends on biological behavior and degree of differentiation of OSCC.2 Thus, making it very obvious that the prognosis and survival of patients of the same age and sex with OSCC of the same location will also vary. The same result is expected when comparing histologic features of synchronous with single primary OSCCs. The results of the present study showed a significantly higher number of mitosis, tumor-induced stroma, lymph node metastasis, extracapsular invasion, and more tumor thickness and invasion into deeper areas in single primary OSCC as compared with synchronous OSCCs. We strongly posit that these results could be because of unintentional inclusion of control cases (selection bias) showing more aggressive histologic features. We would also like to question the authors’ selection of only 1 case of primary OSCC showing a verrucous appearance (micro and microscopic) in comparison with 6 cases of synchronous OSCCs. The verrucous appearance is known to have less aggressive histologic features and this must have further exacerbated the bias. Although the authors have made a genuine attempt to shed some light on the behavior of synchronous OSCCs, the results seem to be misleading,
5. 6. 7. 8.
9. 10. 11. 12.
13.
14. 15. 16.
Letters to the Editor Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562-9. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2008;16:303-11. Rosenthal EL, Dixon SF. Free flap complications: when is enough, enough? Curr Opin Otolaryngol Head Neck Surg 2003;11:236-9. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092-100. Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010;120:717-23. Barker JH, Furr LA, McGuire S, Cunningham M, Wiggins O, Storey B, et al. Patient expectations in facial transplantation. Ann Plast Surg 2008;61:68-72. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol 2000;19:226-34. McGauran N, Wieseler B, Kreis J, Schüler YB, Kölsch H, Kaiser T. Reporting bias in medical research—a narrative review. Trials 2010;11:37. Kirkham JJ, Dwan KM, Altman DG, Gamble C, Dodd S, Smyth R, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ 2010;340:c365. Pitak-Arnnop P, Sader R, Rapidis AD, Dhanuthai K, Bauer U, Hervé C, et al. Publication bias in oral and maxillofacial surgery journals: an observation on published controlled trials. J Craniomaxillofac Surg 2010;38:4-10. Pitak-Arnnop P, Dhanuthai K, Hemprich A, Pausch NC. Misleading P-value: do you recognise it? Eur J Dent 2010;4:356-8. Crawford JM, Briggs CL, Engeland CG. Publication bias and its implications for evidence-based clinical decision making. J Dent Educ 2010;74:593-600. Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. PLoS ONE 2008; 3:e3081.
doi:10.1016/j.tripleo.2010.07.019
Free flap reconstruction of the maxilla: Is there something missing? In reply: Thank you for allowing us to respond to the letter to the editor by Pitak-Arnnop et al in this journal. The authors are clearly consummate theoreticians and criticize several points that would not be raised had they come from our background of pragmatic surgery. We would like to comment on those points, which are relevant. This study was conducted to evaluate the flap choice and the associated success rate of microvascular free flap reconstruction of the maxilla with regard to the defect size.1 In addition, the rate of prosthetic rehabilitation by implants or conventional prosthetic treatment was investigated. This was not, however, as we make abundantly clear, a controlled study of implants or implant survival, which Pitak-Arnnop et al seem to be concerned with. The comments in this regard are quite
OOOOE January 2011
inappropriate. The follow-up of all patients from February 2000 to December 2009 includes follow-up as part of routine aftercare, which obviously differs depending on what disease process created the defect that was reconstructed (this being the point of the article). As an observational study, complications would be recognized in that time.1 The 18 patients who did not want dental rehabilitation (because they were satisfied with the reconstruction or did not want any surgery) were not willing to receive any prosthesis or dental treatment.1 This is not an unusual finding in most busy centers treating the usual population requiring extensive reconstructive procedures.2-4 The authors of the Letter to the Editor should be aware of the concept that “the ability to do a treatment is not an indication.” As we made clear in the article, this study was primarily a large cohort with different indications for reconstructive procedures of the maxilla. We have no intention of pretending that other data can be artificially drawn from it, and the rate of local or distant recurrence and metastases was not specified, as this would not be comparable with other studies.4,5 For obvious reasons, individual publications can and should address specific issues. We recently published data in relation to patients with oral squamous cell carcinomas of the maxilla and midface reconstructed with free flaps compared with patients receiving no reconstruction (eg, obturator, local reconstruction), which are comparable, but the present cohort is not and we have no desire to stretch credulity.4-6 We were surprised at the comments regarding the “learning curve”; all major established centers carrying out complex microvascular reconstruction have moved beyond the primitive “one-size-fits-all” approach that the authors seem to allude to. Reconstruction of the maxilla is in fact much more complicated than in the mandible and necessitates reconstructive experience with different flaps containing different types of tissues.1-4,7,8 The microsurgical and reconstructive considerations are of prime importance for the patients, for both esthetic and functional reasons.9,10 Pitak-Arnnop et al also call for a univariate analysis between complications of different possible variables. Although the idea is promising, only a small number of complications occurred, resulting in 3 patients with a flap loss.1 Analyzing the discussed variables would lead to nothing new and publishing data without content is not the aim of our group. We can agree with Pitak-Arnnop et al that careful flap selection is of prime importance in the reconstruction of maxillary defects.1,5,6,9,10 This is the essential point of this article and has been clearly stated in the article.1,4 In the present study, we did not need any vein graft or arteriovenous fistula loop. The wound-healing disturbances
OOOOE Volume 111, Number 1
at the neck are also documented in the article and did not affect the outcome of the flaps.1 We do not accept the derogatory suggestion by PitakArnnop et al that we have deliberately created case selection nor do we feel a lesson in the basics of publication bias is needed. Our article describes our experience with maxillary reconstruction in, to the best of our knowledge, one of the largest cohort series that have been published. Artificially, subdividing into different groups within this cohort would lead to an overflowing production of meaningless data that would provide less valid information to the reader as well as exceed the word count of the journal. It is not unusual for academics to make claims about shortcomings of research design in the so-called era of “evidence-based practice.” The clinical reality is that the finite controls required to generate this level of evidence are seldom available and those of us who practice surgery in this demanding field will only ever be able to rely on careful, honest, and valid documentation of results. Thomas Mücke, MD Department of Oral and Maxillofacial Surgery Technische Universität München Klinikum Rechts der Isar München, Germany David A. Mitchell, MB, FDS, FRCS Oral and Facial Specialties Department Pinderfields General Hospital Wakefield, UK REFERENCES 1. Mücke T, Hölzle F, Loeffelbein DJ, Ljubic A, Kesting M, Wolff KD, et al. Maxillary reconstruction using microvascular free flaps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 111:50-56. 2. Boyes-Varley JG, Howes DG, Davidge-Pitts KD, Branemark I, McAlpine JA. A protocol for maxillary reconstruction following oncology resection using zygomatic implants. Int J Prosthodont 2007;20:521-31. 3. Peng X, Mao C, Yu GY, Guo CB, Huang MX, Zhang Y. Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562-9. 4. Mücke T, Loeffelbein DJ, Hohlweg-Majert B, Kesting MR, Wolff KD, Hölzle F. Reconstruction of the maxilla and midface—surgical management, outcome, and prognostic factors. Oral Oncol 2009;45:1073-8. 5. Mücke T, Wagenpfeil S, Kesting MR, Hölzle F, Wolff KD. Recurrence interval affects survival after local relapse of oral cancer. Oral Oncol 2009;45:687-91. 6. Mücke T, Wolff KD, Wagenpfeil S, Mitchell DA, Hölzle F. Immediate microsurgical reconstruction after tumor ablation predicts survival among patients with head and neck carcinoma. Ann Surg Oncol 2010;17:287-95. 7. Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002;128:161-6. 8. Triana RJ Jr, Uglesic V, Virag M, Varga SG, Knezevic P, Milenovic A, et al. Microvascular free flap reconstructive options
Letters to the Editor 7 in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2:91-101. 9. Chen HC, Coskunfirat OK, Ozkan O, Mardini S, Cigna E, Salgado CJ, et al. Guidelines for the optimization of microsurgery in atherosclerotic patients. Microsurgery 2006;26:356-62. 10. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the previously operated and irradiated neck. Microsurgery 2009;29:1-7. doi:10.1016/j.tripleo.2010.08.024
A histopathologic comparison between synchronous and single primary oral squamous cell carcinomas To the Editor: We have read with great interest and would like to take the opportunity to comment on the recently published article by Dissanayaka et al.,1 “A histopathologic comparison between synchronous and single primary oral squamous cell carcinomas.” It is hypothesized that synchronous oral squamous cell carcinomas (OSCCs) may present with more aggressive histologic behavior. Hence, the authors compared histologic parameters with known prognostic significance between synchronous and single primary OSCCs. The unexpected results showed that synchronous OSCCs have more aggressive histologic features than single primary OSCC. It is a known fact that OSCCs in 2 different individuals will have different histologic features even if they are age, gender, and site matched, which in turn largely depends on biological behavior and degree of differentiation of OSCC.2 Thus, making it very obvious that the prognosis and survival of patients of the same age and sex with OSCC of the same location will also vary. The same result is expected when comparing histologic features of synchronous with single primary OSCCs. The results of the present study showed a significantly higher number of mitosis, tumor-induced stroma, lymph node metastasis, extracapsular invasion, and more tumor thickness and invasion into deeper areas in single primary OSCC as compared with synchronous OSCCs. We strongly posit that these results could be because of unintentional inclusion of control cases (selection bias) showing more aggressive histologic features. We would also like to question the authors’ selection of only 1 case of primary OSCC showing a verrucous appearance (micro and microscopic) in comparison with 6 cases of synchronous OSCCs. The verrucous appearance is known to have less aggressive histologic features and this must have further exacerbated the bias. Although the authors have made a genuine attempt to shed some light on the behavior of synchronous OSCCs, the results seem to be misleading,