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Surgical Treatment of Facial Soft-Tissue Deformities in Postburn Patients: A Proposed Classification Based on a Retrospective Study

Fang, Lin M.D.; Zhang, Chen B.S.; Wang, Lianzhao M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 489e–491e
doi: 10.1097/PRS.0000000000000479
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Microinvasive Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People’s Republic of China

Correspondence to Dr. Wang, Microinvasive Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 33, Ba-Da-Chu Road, Beijing 100144, People’s Republic of China, sarayfanglin@163.com

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Sir:

In the article reported by Zan et al., “Surgical Treatment of Facial Soft-Tissue Deformities in Postburn Patients: A Proposed Classification Based on a Retrospective Study,”1 the authors developed a classification system and proposed an aesthetic reconstructive ladder (Table 6). We agree with the authors that this system is a versatile option for reconstructing the four types of defects; however, we would like to provide a description of other common techniques that were not mentioned in the article.

For large type 2 and type 3 deformities, expanded flaps from the supraclavicular and anterior chest area were recommended as better donor sites if the entire neck skin is not intact; expanded forehead flaps were only mentioned for partial forehead, nasal, or upper cheek repair in the article. Actually, expanded forehead flaps are considered to be common techniques for reconstructing larger facial defects, even subtotal face type 4 deformities in our center. With our experiences in nine patients using the bilateral pedicled expanded forehead flaps for perioral, cheek, lower third of the face, submental, and cervical lesion repair, the flap could be formed as large as 20 × 25 cm across the midline of the forehead without flap necrosis and problems with donor-site closure (Fig. 1). The scars in the forehead were inconspicuous and were concealed in the hairline or covered with hair. In male patients with a demand for moustache restoration, the flap should also be designed with a certain amount of hair-bearing scalp. The expanded forehead flap is usually developed as a versatile and useful surgical option for larger facial soft-tissue deformities rather than only for nasal or upper cheek reconstruction.2,3 Gan et al.3 reported the reconstruction of unilateral hemifacial scar contractures with supercharged expanded forehead flaps measuring from 20 × 8 cm to 30 × 11 cm. This technique could provide ample, thin, color-matched tissue for subtotal facial deformity with minimal donor-site morbidity, especially for the supraclavicular area, and the anterior chest cannot be chosen as the donor site. The versatility of these flaps is summarized in Figure 2. In addition, we would like to present other techniques for repairing these corresponding defects according to literature review. The origin and distribution of the perforator arteries in the medial upper arm area were investigated for face and cervical reconstruction.4 The traditional donor site for nasal reconstruction is also chosen for large facial defect reconstruction. In addition, some pedicled perforator flaps in the head and neck, such as the submental artery perforator flap and the facial artery perforator flap, have also been described for facial defects.5 The submental flap, reported with a size of 18 × 8 cm, is a viable option for nearly total lip defects, the nasal or perioral area, and cheek reconstruction.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

We believe that techniques common in many centers must be fully described; for some defects, the techniques mentioned above could be used appropriately. We describe these additional techniques in order to optimize management and to provide more donor-site choices that are not based on surgeon preference.

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PATIENT CONSENT

The patient provided written consent for use of the patient’s image.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Lin Fang, M.D.

Chen Zhang, B.S.

Lianzhao Wang, M.D.

Microinvasive Department of Plastic Surgery

Plastic Surgery Hospital

Chinese Academy of Medical Sciences

Peking Union Medical College

Beijing, People’s Republic of China

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REFERENCES

1. Zan T, Li H, Bu B, et al. Surgical treatment of facial soft-tissue deformities in postburn patients: A proposed classification based on a retrospective study. Plast Reconstr Surg. 2013;132:1001e–1004e
2. Margulis A, Amar D, Billig A, Adler N. Periorbital reconstruction with the expanded pedicled forehead flap. Ann Plast Surg. ePub ahead of print; July 30, 2013:doi:10.1097/SAP.0b013e3182978a29
3. Gan C, Fan J, Liu L, et al. Reconstruction of large unilateral hemi-facial scar contractures with supercharged expanded forehead flaps based on the anterofrontal superficial temporal vessels. J Plast Reconstr Aesthet Surg. 2013;66:1470–1476
4. Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: Anatomical basis of a new flap donor site. Surg Radiol Anat. 2013;35:39–48
5. Hofer SO, Mureau MA. Pedicled perforator flaps in the head and neck. Clin Plast Surg. 2010;37:627–640, vi
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