Re: 'Osmotic tissue expanders in cleft lip and palate surgery: a cautionary tale'.

We read with some concern the letter from Rees et al. The authors report the disastrous complication of complete nasal soft tissue envelope necrosis. This followed an attempt to expand an area of ‘extreme shortage of skin following multiple previous operations for a cleft lip and nose’ using an Osmed osmotic expander. We find it rather surprising that Rees et al. can point their finger at the device for such a catastrophic complication when a basic principle of tissue expansion avoidance of donor sites compromised by previous scars or trauma was clearly overlooked. In addition, when using a new device with unfamiliar characteristics, frequent review of the patient would seem sensible, particularly if the skin appears ischaemic ‘immediately following insertion’. We were therefore, rather confused by the comment that ‘once the tissue began to necrose there was no stopping the process without removing the expander’. Self-expanders herald a new era of more precise, targeted tissue expansion, and are especially useful in paediatric facial reconstruction. The final size of the device can readily be controlled by customising its initial proportions and the speed of expansion can be controlled