We thank the authors for their letter about our article, “One versus Two Venous Anastomoses in Anterolateral Thigh Flap Reconstruction after Oral Cancer Ablation.”1 We are glad to know that they also support the backup theory and have made a change to perform two venous anastomoses systemically. We also agree that the longer operative time in the two-vein group might be reduced by using a venous coupler, and that the cost-effectiveness can be balanced by the reduced risks of surgical revision and the shorter period of hospitalization. In this communication, we try to clarify the concerns they raised about the “venous congestion,” the bulk of the flap, and the thinning of the flap.
We agree that venous congestion is an end result of various causes (e.g., thrombosis, compression, or kinking). Of the 15 patients with venous thromboses in our study, 13 had venous thrombosis and two showed pedicle compression without venous thrombosis during exploration. Of the 13 patients with venous thrombosis, nine were in the one-vein group and four were in the two-vein group. In none of the patients did one venous anastomosis develop a thrombosis while the other was unobstructed. However, it is difficult to clarify the cause of venous thrombosis. Because anastomosis failure, compression, kinking, or a combination of these can cause a thrombosis, we cannot claim that there were fewer venous thromboses in the two-vein group because there were two venous anastomoses: it might have been because of the coincidence of less pedicle compression or kinking. We showed only the relevance, but not the cause and effect, between the two-vein anastomosis and less venous congestion.
We also agree that anterolateral thigh flaps are thicker in Westerners, and that the thinning procedure might be inevitable.2 We previously reported3 that flap thickness averaged 1.3 to 0.9 cm from the proximal to distal thigh and that the thinning procedure was seldom used in our hospital. We therefore believe that our results are not confounded by the bulk and the thinning of the flap. However, we might not be able to generalize our results to the anterolateral thigh flaps of Western populations, which might have thicker flaps that need primary thinning.
Nevertheless, using two venous anastomoses had no obvious adverse effects in our study, other than needing 30 additional minutes of operative time (336 minutes versus 366 minutes; p = 0.009). Thus, we recommend using two venous anastomoses in the free flap reconstruction whenever possible, unless future studies show that the procedure propagates thromboses. Similar to the point of view of Dr. Chaput’s letter, 1 year ago we too changed our practice and are now trying to use the venous coupler. We thank the authors again for their interest in our article and for their thoughtful and useful discussion.
The authors have no financial interest to declare in relation to the content of this communication.
Yao-Chou Lee, M.D.
Shyh-Jou Shieh, M.D., Ph.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
National Cheng Kung University Hospital
College of Medicine
National Cheng Kung University
1. Lee YC, Chen WC, Chen SH, et alOne versus two venous anastomoses in anterolateral thigh flap reconstruction after oral cancer ablation.Plast Reconstr Surg2016138481–489
2. Grobbelaar AODiscussion: One versus two venous anastomoses in anterolateral thigh flap reconstruction after oral cancer ablation.Plast Reconstr Surg2016138490
3. Lee YC, Chen WC, Chou TM, Shieh SJAnatomical variability of the anterolateral thigh flap perforators: Vascular anatomy and its clinical implications.Plast Reconstr Surg20151351097–1107
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