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

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<ul><li><p>INVITED DISCUSSION: FACE RESURFACING USING ACERVICOTHORACIC SKIN FLAP PREFABRICATED BYLATERAL THIGH FASCIAL FLAP AND TISSUE EXPANDER</p><p>L. SCOTT LEVIN, M.D., F.A.C.S.*</p><p>This article from the Ninth Peoples Hospital in Chinademonstrates forward thinking and brings us to the edge</p><p>of an era in which composite tissue allotransplantation to</p><p>reconstruct faces may replace such techniques. The</p><p>authors are to be congratulated for their innovation and</p><p>integration of multiple techniques that include conven-</p><p>tional principles of ap rotation in the head and neck,</p><p>pre-expansion, prefabrication, and knowledge of the</p><p>descending branch of the lateral circumex system as a</p><p>fascia carrier to produce a Matching, Large size, and</p><p>Thinner thickness (MLT) ap. The authors have been</p><p>completely forthright the venous problems of expanded</p><p>aps, and I have encountered this on my own cases in</p><p>which I have attempted to pre-expand a scapular ap for</p><p>forehead reconstruction. This required the use of leeches</p><p>and ultimately the majority of the ap lived, but it was</p><p>not without trepidation. The patients in cases like this are</p><p>devastated by their original injury, they subsequently</p><p>have to go through a series of steps to produce, in some</p><p>cases spectacular results, such as in Case 1, but in other</p><p>cases, less optimal results despite the neck releases and</p><p>resurfacing of a better textured skin, the ravages of the</p><p>burns still remain in other areas of the facial surface.</p><p>This is not a criticism of the authors by any stretch; it is</p><p>to say that despite our best techniques with the most</p><p>innovative conventional means, we still fall short in terms</p><p>of reconstruction of the total burned face. We should def-</p><p>initely not abandon these techniques in that they can be</p><p>used for a variety of patients with effective results and</p><p>certainly with an improved cosmesis. I have no disagree-</p><p>ments with the authors principles of their efforts and</p><p>compliment them for taking on such a challenging patient</p><p>group. I am well familiar with the excellence in recon-</p><p>structive plastic surgery from the Ninth Peoples Hospital</p><p>in China. Dr. QingFeng Li and his coauthors have also</p><p>done laboratory research in facial allotransplantation</p><p>using a dog model. Im interested in whether or not with</p><p>safer immunmodulation when they will consider in the</p><p>totally burned face, a CTA compared with these techni-</p><p>ques. Clearly, donor patients for total facial resurfacing</p><p>in CTA eld will be difcult to obtain, especially with</p><p>some of the cultural issues that Im sure exist in China,</p><p>as in other cultures around the world. The authors</p><p>commented on the concept of delay, but Im wondering</p><p>why they did not use this to redirect the angiosomes for</p><p>their new vascularized pedicle. Perhaps, the delay of</p><p>these expanded aps would decrease the propensity to-</p><p>ward venous engorgement. I did this in the case that I</p><p>described forehead reconstruction using a preexpanded</p><p>scapular ap and yet it did not prevent the venous com-</p><p>promise that Id hoped to avoid. I think this article raises</p><p>the question as to the future of SVCN surgery with CTA</p><p>and safe immunomodulation on the horizon to composite</p><p>tissue allotransplantion.</p><p>Department of Orthopaedic Surgery, Hospital of the University of Pennsylva-nia, Philadelphia, PA</p><p>*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: levin001@mc.duke.edu</p><p>Received 16 June 2009; Accepted 17 June 2009Published online 24 August 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20690</p><p>VVC 2009 Wiley-Liss, Inc.</p></li></ul>

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