We appreciate the valuable comments provided by Dr. Longo and Dr. Santanelli in response to our article evaluating the effect of ketorolac on microvascular thrombosis in lower extremity reconstruction. There are several points raised in their letter.
First, the present study followed a retrospective design and could not compare groups with the same characteristics. This was the main limitation of the study. However, compared with other retrospective studies, relatively homogenous groups were compared in this study.1–3 Although Drs. Longo and Santanelli indicated that “relatively homogenous” could be considered either homogenous or heterogeneous, the homogeneity was not confined to the flap type. The homogeneity of recipient site, lower extremity, and operations performed by a single surgeon also deserves note, and the patient’s underlying disease, the mechanism of defect, and the recipient vessels did not show statistical differences between groups, which should make this analysis more valuable compared with other studies. Furthermore, in analyzing the total complication rates according to flap type (composed mainly of thoracodorsal artery perforator flaps), there were no statistically significant differences observed in our study population (thoracodorsal artery perforator flap group, 16.2 percent; latissimus dorsi myocutaneous flap group, 0.0 percent; deep inferior epigastric artery perforator flap group, 0.0 percent; and anterolateral thigh flap group, 16.7 percent; p = 0.552).
There were other issues raised by Longo and Santanelli that are also important. They indicated that total complications were strongly dependent on minor complications, which could be selection bias. However, they seem to underscore the importance of minor complications. We counted only vascular-related complications resulting mainly from pedicle thrombosis or impatency of the pedicle. Minor complications were composed of flap congestion and emergent exploration caused by flap congestion, not just “minor” complication such as wound dehiscence or delayed wound healing. Because of timely and adequate intervention, these minor complications did not develop into major complications. Thus, the effect of ketorolac on the prevention of minor complications should not be neglected and deserved mention.
Ketorolac is well known as an effective analgesic, and it also has an anticoagulation effect that has already been reported in several clinical studies.4,5 The present study has value as the first clinical study focusing on the prevention of microvascular thrombosis in free flap operations, although we acknowledge that the necessity for a larger, prospective study still exists for exclusion of the potential confounding factors.
The authors have no financial interest to declare in relation to the content of this communication.
Kyeong Tae Lee, M.D.
Goo-Hyun Mun, M.D.
Department of Plastic Surgery
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul, South Korea
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