Reply

Abstract

Sir: Thank you for the opportunity to reply to the letter by Dr. Freshwater. Dr. Freshwater has asked some questions regarding our recent report in the April of 2010 issue of Plastic and Reconstructive Surgery in which we present a unique series of buried deep inferior epigastric perforator flaps for breast reconstruction in which there was no cutaneous paddle for flap monitoring,1 a technique that can be achieved safely only with the use of a technique for flap monitoring such as the implantable Doppler probe. No similar series of buried deep inferior epigastric perforator flaps for breast reconstruction has been previously published to our knowledge. Dr. Freshwater has written to us previously, echoing the suggestion made here that some of our data may be misleading or duplicated—this ignores the fact that this article underwent extensive peer review by multiple reviewers, including a biostatistician, as did the Journal of Plastic, Reconstructive & Aesthetic Surgery article he mentions. The first question raised pertains to a reference to some of our other experience with the implantable Doppler probe. This reference was suitably made to demonstrate our broader experience with breast reconstruction and with the implantable Doppler probe, and to allow readers to identify any perceived connections between the works. This was not to highlight our only experience. The use of appropriate referencing and specific titles in the two articles clearly demonstrates this. The letter by Dr. Freshwater also brings up some fallacies that are often entertained about the use of new or advanced techniques for postoperative flap monitoring. Each technique for flap monitoring has an intrinsic rate of false-positive and false-negative results, and this holds true for clinical monitoring as well. This was highlighted in a separate article in the same April issue of Plastic and Reconstructive Surgery,2 of which we were also authors, which demonstrated that clinical monitoring is indeed associated with false-positives and false-negatives, and that other monitoring techniques should be evaluated in the context of this. These figures are simply the statistical outcomes of any screening test, and although certainly these should be quoted in any study of a monitoring technique, they are not complications. In terms of the remainder of the questions raised: Six of the eight buried flaps were included in the Journal of Plastic, Reconstructive & Aesthetic Surgery study. Although 121 cases were included in the Journal of Plastic, Reconstructive & Aesthetic Surgery study, 30 more cases had been performed by the time of writing the current study and over 100 more by today. Buried flaps with suspicious Doppler signals are taken to the operating room, whereas flaps with a cutaneous paddle are either taken back to the operating room immediately or compared with clinical monitoring findings (surgeon preference). The Traveling Fellowship was a one-off educational grant to cover transport and accommodation costs to allow Mr. Iain S. Whitaker to gain further experience in microsurgical reconstruction. There were “no strings” attached and this award has certainly had no impact on the presentation or publication of work. This has been clearly declared previously. The authors have no competing interests: financial, editorial, or otherwise. Rafael Acosta, M.D. Department of Plastic Surgery Uppsala Clinic Hospital Uppsala, Sweden Warren M. Rozen, M.B.B.S., P.G.Dip.Surg.Anat., Ph.D. Jack Brockhoff Reconstructive Plastic Surgery Research Unit Department of Anatomy and Cell Biology University of Melbourne Parkville, Victoria, Australia Iain S. Whitaker, M.A.(Cantab.), M.R.C.S. Department of Plastic, Reconstructive, and Burns Surgery The Welsh National Plastic Surgery Unit The Morriston Hospital Swansea, United Kingdom