Sir:FigureWe read with interest the recent article, “A Review of 32 Free Flaps in Patients with Collagen Vascular Disorders,” by Wang et al.,1 in which they reviewed their series of free flaps in patients with collagen vascular disorders. They reviewed 1251 flaps and identified 28 patients (32 flaps) that carried diagnoses of Sjögren syndrome, Raynaud phenomenon, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, or multicentric thrombocytosis. We applaud the authors' interest in this understudied population; however, we feel their study oversimplified these complex disease processes and, as a result of their excellent outcomes, it risks creating a false sense of security in other microsurgeons who choose to operate on these patients. The authors acknowledged that patients with these diseases have “a mixed degree of disease and a wide spectrum of manifestations,” and we believe this to be the most important clinical point of their article. The rheumatology community uniformly recognizes that not all patients with the same diagnosis carry the same risk of thrombosis.2,3 Risk stratification (based on antibody profile, age, systemic autoimmune diseases, and traditional cardiovascular disease or venous thrombosis risk factors) is crucial to determine an individual patient's thrombosis risk.3 For these reasons, we cannot emphasize enough the value of working with the surgical candidate's primary rheumatologist. The rheumatic diseases and their manifestations vary so widely that, except in cases of emergency, we would operate on these patients only after consultation with a physician who is intimately familiar with the patient's clinical and serologic history, medication regimen, and current disease activity status. The aim of this collaboration is to achieve the best possible flap outcome by anticipating potential thrombotic complications and optimizing perioperative immunosuppressive drug regimens in preparation for surgery. Alana B. Levine, M.D. Division of Rheumatology Hospital for Special Surgery Steven M. Levine, M.D. Institute of Reconstructive Plastic Surgery New York University Langone Medical Center New York, N.Y. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.