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In Reference to The Submental Flap for Head and Neck Reconstruction: Comparison of Outcomes to the Radial Forearm Free Flap

We read with great interest the article by Urjeet Patel titled “The Submental Flap for Head and Neck Reconstruction: Comparison of Outcomes to the Radial Forearm Free Flap.” The operative time in aheadandneck surgical procedure depends on the extent of resection, the site involved, the expertise of the surgeon, bilaterality, previous adjuvant treatment, and the complexity of reconstruction. Free flap reconstruction is challenging and time consuming compared to a local flap. In the current study, themean area of the submental flap (SMF) was smaller at 28 cm compared to 48 cm for the radial forearm free flap (RFFF), which suggests that the RFFFwould be the preferred choice for larger defects. The complexity of reconstruction with these larger defects and bilateral neck treatment when the tumors cross midline, could be a confounding factor for the longer operative time. An advanced T stage, invariably would involve resection of the gingivo-glossal sulcus (GGS) and a more complex anatomical defect. The flaps used for reconstruction are adynamic and dependent on the residual tongue for movement. When the GGS is resected, the reconstruction, irrespective of the flap, can impair movement. In the current study, a RFFF was used for the majority of the T3 tumors, which may have involved resection of the GGS. Despite this, the voice outcome were comparable between the free flap and local flap group. The type of resection based on the primary site should be the determining factor for a postoperative tracheostomy. The RFFF was the flap of choice for patients with oropharyngeal primaries, and this could explain the higher rates of tracheostomy in the RFFF group. In one of the largest series of SMFs by Thomas et al, 32.3% of all patients recruited had N+ disease, and 12.2% of patients had involvement at nodal station IB. Of these patients, 3.9% had a local recurrence at the site of the flap and 5.2% away from it, with a total local recurrence rate of 9.1%. Pathological node positivity on multivariate analysis was a significant predictor for recurrence. Positive nodes at level I raise concerns for oncological safety. Several larger studies concerning the RFFF have reported minimal morbidity and excellent functional outcomes. Nonetheless, we congratulate the author on his wellstructured retrospective study, but a subset analysis comparing similar resections and reconstruction dimensions would be more comparable.