Sir: Dr. Durrani reveals an impressive and respectable experience of over 4000 instances of hyperbaric oxygen therapy in his recent letter. Admittedly, we as surgeons at our institution do not personally use this modality; rather, our interaction is one where we either refer patients for this hyperbaric oxygen therapy or they are referred to us because of lack of success with hyperbaric oxygen therapy or because of reconstructive needs. One of the motivating factors for us writing our recent article1 is that osteoradionecrosis of the mandible is a rare but devastating complication of radiotherapy to the craniofacial skeleton for head and neck cancers, and we were curious as to whether or not hyperbaric oxygen therapy was the modality of choice for advanced disease. As shown in our work, we feel that a more aggressive approach for such severe illness is overall more cost-effective, more successful, and less psychologically painful, as the patient is subject to one large procedure that is effective rather than many treatments that are prolonged, expensive, and have trended to be futile in our institution’s hyperbaric oxygen therapy experience for such extensive disease. Dr. Durrani raises an interesting point by suggesting that we should refer to this disease process as “radiopathy,” because he has found that radiation-induced injury does not always involve necrosis of the bone. Our expertise lies in performing a satisfactory microvascular free flap reconstruction in an area where tissue is devitalized and healing is impaired unless viable, healthy tissue is transferred to the area. Our goal was not to redefine that which others had already described. In fact, our goal was to (1) relay our success in treating osteoradionecrosis of the craniofacial skeleton using microvascular free tissue transfer and (2) show that this treatment regimen can be cost-effective. The cases that we mentioned were patients with extensive and/or intractable osteoradionecrosis of the craniofacial skeleton presenting with either exposed bone or pathologic fracture after radiation injury. Such disease had been described previously by many others before us as “osteoradionecrosis,” where the disease is so severe that there is not only variable soft-tissue damage but also bone necrosis.2–9 Our case series involved patients who suffered from this most severe form of radiation injury to the craniofacial skeleton where there indeed was necrosis of previously healthy bone tissue presenting as either pathologic fracture or exposed bone. Dr. Durrani’s extensive experience with hyperbaric oxygen therapy and radiation injury puts him at an advantageous position where he may define scientifically with pathologic grading the term “radiopathy” as a less severe form of osteoradionecrosis because this term has not been described as such and thus is not found when searched for on PubMed or Google. With respect to our patients receiving prior hyperbaric oxygen therapy, this is true for close to 50 percent of our patients, but not true for the rest that were sent to us. The benefits of hyperbaric oxygen therapy are not disputed by us and in fact are mentioned in our recent article. However, for advanced osteoradionecrosis of the craniofacial skeleton, the “upgrades” provided to the damaged tissue with hyperbaric oxygen therapy is in our experience not sufficient to overcome the effects of such severe disease. We instead recommend replacing this nonhealing ischemic tissue host environment with uninjured tissue that is rich in vascular supply. We mention that our study had limitations, especially with respect to sample size, and we agree with Dr. Durrani that a future prospective study comparing microvascular free flap reconstruction for osteoradionecrosis of the craniofacial skeleton with and without adjunct hyperbaric oxygen therapy is worth investigating. Although two of our patients did have slight complications, it is impossible to predict based on the literature at hand whether adjunct hyperbaric oxygen therapy would have prevented such complications—the reality is that all surgical procedures suffer from a percentage of complications, and our complication rate was still pretty low with respect to similar models mentioned in our study. With regard to financial benefit of free tissue transfer versus hyperbaric oxygen therapy in advanced osteoradionecrosis, this topic is fully addressed in the Discussion and Conclusions sections of our recent publication. In our view, for advanced osteoradionecrosis of the craniofacial skeleton, it appears that conservative therapy provides a false sense of security and added burden by obligating additional hospital visits, financial and scheduling burdens and, at times, disappointment from failure. Advanced or intractable osteoradionecrosis should be treated surgically because it is ultimately more cost-effective. Shahrooz S. Kelishadi, M.D. Eduardo D. Rodriguez, M.D., D.D.S. Division of Plastic, Reconstructive, and Maxillofacial Surgery R Adams Cowley Shock Trauma Center University of Maryland School of Medicine and Johns Hopkins School of Medicine Baltimore, Md. DISCLOSURE Neither of the authors has a financial interest to declare in relation to the content of this communication.