Comment on “Reconstruction of a Large Oncologic Defect Involving Lower Eyelid and Infraorbital Cheek Using MSTAFI Flap”

Dear Editors,

The supratrochlear artery forehead island flap (STAFI) and its modifications have been widely used in reconstructing facial defects from congenital anomalies, trauma, and tumor excision, with consistently reliable outcomes. Of particular note is the case reported by Lian et al., ¹ in which a modified STAFI (MSTAFI) flap was combined with a cheek advancement-rotation flap to repair a large facial defect in a female patient with systemic lupus erythematosus (SLE) and secondary cutaneous squamous cell carcinoma (cSCC). This approach successfully reconstructs a complex defect involving the lower eyelid and infraorbital-cheek region, achieving a favorable aesthetic result. Compared to conventional techniques, the MSTAFI flap provides greater mobility, a broader arc of rotation, and avoids brow deformity as well as the need for secondary procedures, offering clear advantages. We commend the authors for their innovative use of the MSTAFI flap in a one-stage reconstruction of a large lower eyelid and infraorbital oncologic defect. However, several issues warrant further discussion.

First, patients with SLE are predisposed to coagulation disturbances due to autoantibody-mediated disruption of hemostasis and inflammation-induced endothelial injury. These factors compromise flap viability by increasing the risk of intraoperative thrombosis, hemorrhage, ² and ischemia secondary to vasculopathy and vascular calcification. ³ In addition, immunosuppression, whether due to the disease itself or long-term immunosuppressive therapy, increases the risk of postoperative infection and delays wound healing. ⁴ Surgical stress may also provoke lupus flares, underscoring the need for careful risk-benefit evaluation.^3,5 SLE is therefore considered a relative, but not absolute, contraindication to flap reconstruction. ⁶ Further insight from the authors regarding patient selection, perioperative management, and intraoperative strategies would offer valuable guidance for reconstructive surgery in similarly high-risk cases.

Second, studies indicate that cSCC in patients with SLE may demonstrate increased malignancy, ⁷ particularly when associated with chronic inflammation in discoid lupus erythematosus, resulting in more aggressive tumors and poorer prognosis. ⁸ Prolonged immunosuppression and ultraviolet (UV) exposure are potential factors promoting malignant transformation. ⁷ Preoperative assessment should include imaging such as positron emission tomography-computed tomography (PET-CT) or high-frequency ultrasound to evaluate tumor depth and regional lymph nodes, alongside biopsy to determine differentiation and invasiveness. For high-risk lesions, wider excision margins (>6 mm or to the fascial layer) are recommended, ⁹ with lymphadenectomy or neoadjuvant therapy considered based on staging. Long-term postoperative surveillance with a multidisciplinary approach involving dermatology, rheumatology, and surgical oncology is crucial to monitor for recurrence and systemic disease activity.

Third, regarding surgical technique, the original authors used a supratrochlear forehead island flap combined with a Schrudde flap. Although feasible, this method is complex and technically demanding. We suggest that for limited defects with adequate tissue laxity, reconstruction using a Schrudde flap alone or combined with a nasolabial flap can provide satisfactory functional and aesthetic results. Simplifying the procedure may reduce surgical difficulty, increase success rates, and lower complication risks. Ultimately, the choice of technique should be guided by careful evaluation of donor site tension, vascular supply, and potential scarring.

In conclusion, MSTAFI offers a promising alternative for reconstructing large facial oncologic defects. We look forward to the authors’ further insights on the issues raised, which will help promote the safe application of this technique in special patient populations.

Jing-Jing Guo, MMDepartment of Plastic Surgery, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China Ze-Tao Qian, MDDepartment of Orthopedics, The First Hospital of Lanzhou University, Lanzhou, Gansu, China Xuan-Fen Zhang, MDDepartment of Plastic Surgery, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, Gansu, China