Reply to the Comments on “Reconstruction of a Large Oncologic Defect Involving the Lower Eyelid and Infraorbital Cheek Using the MSTAFI Flap”

Dear Editors,

We sincerely appreciate the insightful and constructive comments from the reader regarding our case report entitled “Reconstruction of a Large Oncologic Defect Involving Lower Eyelid and Infraorbital Cheek Using modified supratrochlear artery forehead island flap (MSTAFI) Flap.” ¹ We fully acknowledge and respect the concerns raised about flap reconstruction in the context of systemic lupus erythematosus (SLE) complicated by cutaneous squamous cell carcinoma (cSCC).

First, concerning perioperative management of SLE patients, we concur with the reader’s emphasis on the risks of coagulopathy, vasculopathy, and immunosuppression. A thorough preoperative evaluation was conducted in collaboration with rheumatology specialists, and immunosuppressive therapy was optimized accordingly. Intraoperatively, we minimized flap tension and ensured adequate vascularization. Postoperative care included individualized monitoring tailored to the patient’s risk profile. The patient recovered uneventfully without lupus flare or flap-related complications. While SLE remains a relative contraindication for flap reconstruction, we believe that with careful multidisciplinary evaluation and management, successful outcomes can be achieved in selected patients.^2,3

Second, regarding the malignant potential of cSCC in SLE patients, we agree with the reader’s concerns. ⁴ The tumor was excised with clear oncologic margins confirmed by intraoperative frozen sections. Given the absence of clinical or radiological lymphadenopathy and stable systemic status, positron emission tomography-computed tomography (PET-CT) was not performed. The patient has been enrolled in a long-term surveillance program to monitor for recurrence.

Regarding the choice of reconstruction technique, although Schrudde flap (alone or combined with nasolabial flap) was initially considered, the large size and anatomical location of the defect adjacent to the lower eyelid rendered this option suboptimal due to the high risk of tension-related complications such as lower eyelid ectropion.^{5 -7} Instead, we selected a MSTAFI combined with a cheek advancement-rotation flap, which provided effective defect coverage, tension reduction, and satisfactory aesthetic outcome in a single-stage procedure. ⁸

We emphasize that reconstructive strategy should be based on a comprehensive assessment of defect size, location, tissue tension, complication risk, and aesthetic considerations rather than solely on the feasibility of primary closure. Further studies are warranted to validate the MSTAFI flap in similar complex reconstructions. We hope this case provides useful insights for managing challenging oncologic defects in patients with autoimmune comorbidities.

Chao Lian, MD Department of Plastic and Aesthetic Surgery, Affiliated Changzhi People’s Hospital of Changzhi Medical University, Changzhi, Shanxi, China Xue-Lei Li, MD* Department of Plastic and Aesthetic Surgery, Affiliated Changzhi People’s Hospital of Changzhi Medical University, Changzhi, Shanxi, China Xiao-Jun Liu, MD* Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong, China *Corresponding authors.