Invited discussion: Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander

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    L. SCOTT LEVIN, M.D., F.A.C.S.*

    This article from the Ninth Peoples Hospital in Chinademonstrates forward thinking and brings us to the edge

    of an era in which composite tissue allotransplantation to

    reconstruct faces may replace such techniques. The

    authors are to be congratulated for their innovation and

    integration of multiple techniques that include conven-

    tional principles of ap rotation in the head and neck,

    pre-expansion, prefabrication, and knowledge of the

    descending branch of the lateral circumex system as a

    fascia carrier to produce a Matching, Large size, and

    Thinner thickness (MLT) ap. The authors have been

    completely forthright the venous problems of expanded

    aps, and I have encountered this on my own cases in

    which I have attempted to pre-expand a scapular ap for

    forehead reconstruction. This required the use of leeches

    and ultimately the majority of the ap lived, but it was

    not without trepidation. The patients in cases like this are

    devastated by their original injury, they subsequently

    have to go through a series of steps to produce, in some

    cases spectacular results, such as in Case 1, but in other

    cases, less optimal results despite the neck releases and

    resurfacing of a better textured skin, the ravages of the

    burns still remain in other areas of the facial surface.

    This is not a criticism of the authors by any stretch; it is

    to say that despite our best techniques with the most

    innovative conventional means, we still fall short in terms

    of reconstruction of the total burned face. We should def-

    initely not abandon these techniques in that they can be

    used for a variety of patients with effective results and

    certainly with an improved cosmesis. I have no disagree-

    ments with the authors principles of their efforts and

    compliment them for taking on such a challenging patient

    group. I am well familiar with the excellence in recon-

    structive plastic surgery from the Ninth Peoples Hospital

    in China. Dr. QingFeng Li and his coauthors have also

    done laboratory research in facial allotransplantation

    using a dog model. Im interested in whether or not with

    safer immunmodulation when they will consider in the

    totally burned face, a CTA compared with these techni-

    ques. Clearly, donor patients for total facial resurfacing

    in CTA eld will be difcult to obtain, especially with

    some of the cultural issues that Im sure exist in China,

    as in other cultures around the world. The authors

    commented on the concept of delay, but Im wondering

    why they did not use this to redirect the angiosomes for

    their new vascularized pedicle. Perhaps, the delay of

    these expanded aps would decrease the propensity to-

    ward venous engorgement. I did this in the case that I

    described forehead reconstruction using a preexpanded

    scapular ap and yet it did not prevent the venous com-

    promise that Id hoped to avoid. I think this article raises

    the question as to the future of SVCN surgery with CTA

    and safe immunomodulation on the horizon to composite

    tissue allotransplantion.

    Department of Orthopaedic Surgery, Hospital of the University of Pennsylva-nia, Philadelphia, PA

    *Correspondence to: L. Scott Levin, M.D., F.A.C.S., Department of Orthopae-dic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street,2 Silverstein, Philadelphia, PA 19104-4283. E-mail:

    Received 16 June 2009; Accepted 17 June 2009Published online 24 August 2009 in Wiley InterScience ( DOI 10.1002/micr.20690

    VVC 2009 Wiley-Liss, Inc.


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