Practical Dermatology
Reconstruction Techniques of Choice for the Facial Cosmetic Units
Técnicas reconstructivas de elección por unidades estéticas faciales
F. Russoa,
, M. Linaresb, M.E. Iglesiasc, J.L. Martínez-Amod, F. Caboe, J. Tercedorf, R. Costa-Vieirag, T. Toledo-Pastranah, J.M. Ródenasi, V. Leisj
Corresponding author
a Servicio de Dermatología, Hospital Punta de Europa, Algeciras, Cádiz, Spain
b Servicio de Dermatología, Hospital Puerta del Mar, Cádiz, Spain
c Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Spain
d Servicio de Dermatología, Hospital de Poniente, El Ejido, Almería, Spain
e Servicio de Dermatología, Complexo Hospitalario Universitario de Ourense, Orense, Spain
f Servicio de Dermatología, Complejo Hospitalario de Granada, Granada, Spain
g Servicio de Dermatología, Centro Hospitalario e Universitário de Coimbra, Coimbra, Portugal
h Servicio de Dermatología. Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
i Servicio de Dermatología, Hospital General Universitario Morales Meseguer, Murcia, Spain
j Servicio de Dermatología, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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"apellidos" => "Leis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] ] "afiliaciones" => array:10 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Punta de Europa, Algeciras, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Puerta del Mar, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de Poniente, El Ejido, Almería, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Dermatología, Complexo Hospitalario Universitario de Ourense, Orense, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario de Granada, Granada, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Dermatología, Centro Hospitalario e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Dermatología. Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Morales Meseguer, Murcia, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Técnicas reconstructivas de elección por unidades estéticas faciales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 1600 "Tamanyo" => 260985 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A, The flag flap was chosen as the flap of choice for the forehead. B, The Limberg flap was the flap of choice for the lateral forehead. C, The subcutaneous island pedicle flap was the flap of choice for the brow.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Photographs courtesy of Dr. Donis Muñoz Borras.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The reconstruction of large surgical defects after the surgical excision of skin tumors usually requires the use of skin flaps. For optimal results, it is important to take into account the concept of facial cosmetic units.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> These units consist of areas limited by natural folds and borders, such as the nasolabial fold, mental crease, vermilion, brow, and hairline, and have a relatively uniform skin color, texture, and thickness, quantity of subcutaneous fat, mobility, and hair distribution, among other common characteristics. The main cosmetic units are in turn subdivided into various subunits because of the anatomic complexity of some regions, such as the nose and the auricles of the ear (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Certain fundamental norms based on these cosmetic units exist to help us achieve minimally visible scars. A flap must be designed within the limits of the cosmetic unit in which the primary defect is located, and the incisions should preferably be placed along the borders of the units, without crossing them. It should also be noted that best results are obtained with the reconstruction of complete cosmetic units, even if the defect affects less than the whole unit, and that the reconstruction of defects that affect various cosmetic units should be undertaken considering each individual unit, compartmentalizing the repair. However, there is considerable variability in the choice of the best flap for each site. Although general recommendations exist according to the topographic site,<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2–5</span></a> no consensus guidelines have been published to specify which flap should be used in each cosmetic unit. In order to draw up a practical guideline on the most useful flaps for each one the distinct facial cosmetic units, we undertook a study with the participation of 10 dermatologists with extensive experience in reconstructive surgery, who stated their preferred flaps for each site. We have found no evidence that any study of these characteristics has yet been performed in Spain.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">Ten dermatologists were selected from different surgical schools across the Iberian Peninsula (9 Spanish and 1 Portuguese). All had between 10 and 30 years’ experience in dermatologic surgery and performed at least 300 complex operations per year. They were sent a questionnaire with a diagram of all the facial cosmetic subunits and they were asked to choose 2 flaps, in order of preference, for each subunit.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The choice of flaps was based on each dermatologist's personal experience. The suitability of a flap depended on factors such as the objective adaptation of flap design to the site of the defect, final cosmetic result, surgical complexity, and risk of complications.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To unify flap classification criteria, we decided to use the concept of the main movement performed during movement of the flap—rotation, transposition, or advancement—and the participating dermatologists were sent a detailed classification so that the same terminology was used in all cases. Among the rotation flaps we included classic variants such as the Mustardé, O-Z, and Rieger flaps. Transposition flaps were subdivided into rhomboidal (Limberg, Dufourmentel), bilobar, and interpolation (nasolabial, paramedian forehead) flaps.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Advancement flaps were subdivided into unilateral, bilateral (flag), A-T, V-Y, crescentic, and island.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first flap chosen was assigned 10 points and the second 5. The 3 best flaps for each site were thus determined according to the sum of the scores obtained from each participating dermatologist.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">All the reconstruction techniques chosen by each dermatologist for each facial cosmetic subunit are listed in order of preference in the <a class="elsevierStyleCrossRef" href="#sec0035">Additional Material</a>, together with the final score obtained for each reconstruction technique in each cosmetic subunit.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dermatologic surgical practice varies considerably in Spain depending on the surgical school in which a surgeon has trained. This data compilation has enabled us to draw certain conclusions that represent an interesting common viewpoint on the choice of reconstructive technique.</p><p id="par0045" class="elsevierStylePara elsevierViewall">First, the flap with the highest score was the glabellar flap for defects of the medial canthus of the eye. This flap achieved the maximum score of 100 points, reflecting unanimity of all the participating dermatologists for this cosmetic unit. The flaps with the following highest scores were the bilateral advancement flag flap or H flap for the forehead (95 points), the revolving-door flap for the auricle of the ear (85 points), the Mustardé flap for the infraorbital cheek (85 points), the O-Z rotation flap for the scalp (80 points), the Tenzel flap for the lower eyelid (75 points), and the island flap for the upper lip (75 points). The agreement on the use of these flaps as best option in these cosmetic units, supported by the extensive surgical experience of the participating dermatologists, allows us to confirm them as the flaps of first choice for each of these sites.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the analysis of the cosmetic units that generated fewest different repair options, the parotid-masseteric subunit of the cheek stood out for having only 2 flaps nominated: the rhomboid transposition (Limberg) flap and the lateral rotation flap. This finding also confirmed unanimity of criteria in this cosmetic subunit.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In contrast, the sites for which the largest number of different flaps were proposed were the antihelix of the auricle of the ear and 3 subunits of the external nose: the lateral wall, the tip, and the dorsum of the nose. This diversity of flaps suggests a lack of unanimity of criteria between participants; this can be explained by the surgical complexity of these areas. Another possible cause is the use of different flaps depending on the size of the defect within a single cosmetic subunit.</p><p id="par0060" class="elsevierStylePara elsevierViewall">With respect to the most frequently chosen flaps according to the main movement to be made, advancement flaps came at the top of the list, followed by transposition flaps and, finally, rotation flaps. However, the individual flap most widely used in the overall group of facial cosmetic units was the Limberg flap. This flap can therefore be considered the most versatile flap for use in almost all the cosmetic subunits. But perhaps the most important outcome of the analysis of these data is the elaboration of a practical guideline to choose the ideal flap in each cosmetic subunit (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the central subunit of the forehead, the flap of choice was the bilateral advancement flag flap or H flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A),<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> followed by the A-T advancement flap and the O-Z rotation flap.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the lateral subunit of the forehead, the flap of choice was the Limberg flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B), followed by the rotation flap from an inferior position and, in third place, the A-T flap.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">In the brow, the preferred flap was the island flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a><span class="elsevierStyleHsp" style=""></span>C), followed by the flag flap and, finally, the O-Z rotation flap.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0080" class="elsevierStylePara elsevierViewall">For the dorsum of the nose, the flap of choice was the Rieger flap (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A),<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> followed by the Limberg flap and the A-T flap.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0085" class="elsevierStylePara elsevierViewall">On the lateral wall of the nose, the first choice of flap was the Limberg flap,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> followed by the lateral advancement flap and, in third place, the lateral advancement flap with a double Burow or Webster triangle.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0090" class="elsevierStylePara elsevierViewall">The majority of participants in the survey most commonly used a nasolabial transposition flap to reconstruct the nasal ala (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B),<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> with the Limberg flap in second place and spiral rotation flap in third.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0095" class="elsevierStylePara elsevierViewall">There was considerable variability in the choice of flap for the repair of defects on the tip of the nose, but the bilobar flap (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a><span class="elsevierStyleHsp" style=""></span>C) was preferred, followed by the horizontal advancement flap after the excision of 2 opposing Burow triangles (east-west advancement flap<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a>), and in third place the Rieger flap.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0100" class="elsevierStylePara elsevierViewall">The columella was also a cosmetic subunit in which it was difficult to reach consensus because few cases affect this site.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> In the end, the first choice was the upper lip double transposition flap, second was Burow triangles, and third the nasolabial flap.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0105" class="elsevierStylePara elsevierViewall">With respect to the upper eyelid,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> few defects cannot be closed by direct suture. When a flap is required, the lateral advancement flap gained the highest score, followed by the reverse Tripier flap and the reverse Tenzel flap.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0110" class="elsevierStylePara elsevierViewall">The lower eyelid, on the other hand, is an area that requires flaps even for small defects due to the risk of ectropion.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> The first choice of flap for this subunit was the lateral advancement or Tenzel flap (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A), followed by the classic Tripier or myocutaneous transposition flap from the upper eyelid and, in third place, the Imre flap, which is a rotation flap using skin from the infraorbital cheek adjacent to the defect.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0115" class="elsevierStylePara elsevierViewall">For defects of the lateral canthus of the eye, the Limberg flap (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B) received the highest score, followed by the lateral advancement flap with 2 Burow triangles (the puzzle flap),<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> and the M-plasty.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0120" class="elsevierStylePara elsevierViewall">The glabellar flap (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a><span class="elsevierStyleHsp" style=""></span>C) received by far the highest score for defects of the medial canthus of the eye,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> followed by the island flap, and, in third place, the A-T flap.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0125" class="elsevierStylePara elsevierViewall">In the majority of cases, the infraorbital cheek was reconstructed using the Mustardé flap (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A), followed by the rotation flap from lower areas of the cheek (the Blascovicz flap), and the Limberg flap in third place.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">–</span><p id="par0130" class="elsevierStylePara elsevierViewall">The Limberg flap was preferred for the zygomatic region of the cheek (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B), followed by the lateral rotation flap, and the M-plasty in third place.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">–</span><p id="par0135" class="elsevierStylePara elsevierViewall">The Limberg flap was also the most voted for the buccal cheek, followed by the crescentic flap and the lateral advancement flap.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">–</span><p id="par0140" class="elsevierStylePara elsevierViewall">Curiously, only 2 flaps were nominated for the parotid-masseteric region of the cheek, the Limberg flap in first place, and the lateral rotation flap in second.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">–</span><p id="par0145" class="elsevierStylePara elsevierViewall">The central area (philtrum) of the upper lip was reconstructed by the majority of participants using the A-T flap (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>A).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> In second place was the flag flap and, in third, the island flap.</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">–</span><p id="par0150" class="elsevierStylePara elsevierViewall">In the lateral zones of the upper lip, the island flap (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>B) was the flap of choice, followed by the A-T flap and the Bernard-Webster flap.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">–</span><p id="par0155" class="elsevierStylePara elsevierViewall">When a simple wedge is insufficient to repair a full-thickness defect of the vermilion of upper lip and a flap must be used, the bilateral perialar horizontal advancement flap described by Celsus (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a><span class="elsevierStyleHsp" style=""></span>C) was the most widely used, followed by the pedicled rotation flap in 2 stages from the lower lip (the lip switch or Abbe flap), and in third place the inverted Karapandzic flap, which is a rotation-advancement flap of skin from the upper lip, following the nasolabial sulcus.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">–</span><p id="par0160" class="elsevierStylePara elsevierViewall">The most widely used flap in the vermilion of lower lip was the advancement flap with double crescents from the chin, proposed by Turgut<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>), followed by the rotation-advancement flap from the skin of the lower lip and nasolabial sulcus (the classic Karapandzic) and the Abbe pedicled rotation flap from the upper lip.</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">–</span><p id="par0165" class="elsevierStylePara elsevierViewall">In the central region of the lower lip, the flap of choice was the A-T flap, followed by the flag flap and the M-plasty.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">–</span><p id="par0170" class="elsevierStylePara elsevierViewall">The majority of participants reconstructed the chin using an A-T flap (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>),<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> with a rotation flap along the labiomental fold in second place, and the lateral advancement flap in third.</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">–</span><p id="par0175" class="elsevierStylePara elsevierViewall">The flap that received most votes for the helix of the ears was the helical advancement flap (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>A),<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> followed by the retroauricular advancement flap and the Trendelenburg reduction plasty.</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">–</span><p id="par0180" class="elsevierStylePara elsevierViewall">The Limberg flap was the flap of choice for the antihelix, followed by the single or double (O-Z) rotation flap and the A-T flap in third place.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">–</span><p id="par0185" class="elsevierStylePara elsevierViewall">The majority of participating surgeons used a revolving-door flap to repair the concha of the ear (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>B). Healing by second intention was considered a very useful alternative to flaps in this region. In third place, the preauricular transposition flap in 2 stages.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">–</span><p id="par0190" class="elsevierStylePara elsevierViewall">The Limberg flap was the flap of choice for the earlobe (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a><span class="elsevierStyleHsp" style=""></span>C), followed by the modified bilobar flap using retro- and infra-auricular skin (the Gavello flap),<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> and an advancement flap in third place.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">–</span><p id="par0195" class="elsevierStylePara elsevierViewall">The retroauricular area was repaired by the majority of participating dermatologists using a Limberg flap (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>D), followed by rotation flaps, and an advancement flap in third place.</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">–</span><p id="par0200" class="elsevierStylePara elsevierViewall">And finally the scalp cosmetic unit, which was reconstructed by the majority of participants using an O-Z rotation flap (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>), followed by the triple Limberg flap and healing by second intention.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">The list of the best 3 skin flaps for each one of the 28 facial cosmetic subunits is a practical guideline that can help dermatologists to choose the best reconstruction technique in specific cases.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The availability of digital devices with wi-fi connection in the majority of operating rooms will make it possible to perform online searches for surgical solutions when repairing surgical defects, with the advantage of an immediate search result. For this reason, and to facilitate access, a schematic version of these guidelines has been included on the online atlas of dermatologic surgery (<a href="http://www.cirugiaderma.es/">www.cirugiaderma.es</a>) in the section on flaps of choice (<a href="http://www.cirugiaderma.es/colgajos%20de%20eleccion.htm">http://www.cirugiaderma.es/colgajos%20de%20eleccion.htm</a>).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres908291" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec888214" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres908290" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec888215" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-03" "fechaAceptado" => "2017-02-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec888214" "palabras" => array:4 [ 0 => "Flaps" 1 => "Cosmetic unit" 2 => "Practical guideline" 3 => "Reconstructive surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec888215" "palabras" => array:4 [ 0 => "Colgajos" 1 => "Unidad estética" 2 => "Guía práctica" 3 => "Cirugía reconstructiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A broad range of skin flaps can be used to repair facial surgical defects after the excision of a tumor. The aim of our study was to develop a practical guideline covering the most useful skin grafts for each of the distinct facial cosmetic units.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a multicenter study in which 10 dermatologists with extensive experience in reconstructive surgery chose their preferred technique for each cosmetic unit. The choice of flaps was based on personal experience, taking into account factors such as suitability of the reconstruction technique for the specific defect, the final cosmetic result, surgical difficulty, and risk of complications. Each dermatologist proposed 2 flaps in order of preference for each cosmetic subunit. A score of 10 was given to the first flap and a score of 5 to the second.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The total score obtained for each of the options proposed by the participating dermatologists was used to draw up a list of the 3 best grafts for each site. There was notable unanimity of criteria among most of the dermatologists for reconstructive techniques such as the glabellar flap for defects of the medial canthus of the eye, the bilateral advancement flag flap or H flap for the forehead, the rotary door flap for the auricle of the ear, the Mustarde flap for the infraorbital cheek, the O-Z rotation flap for the scalp, the Tenzel flap for the lower eyelid, and the island flap for the upper lip.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results of this study will be useful as a practical guide to choosing the best reconstruction technique for each of the facial cosmetic units.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existe una enorme variedad de colgajos cutáneos empleados para la reparación de defectos quirúrgicos faciales tras la extirpación de tumores. El objetivo del estudio fue consensuar una guía práctica de los colgajos más útiles para cada una de las distintas unidades estéticas faciales.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio multicéntrico donde 10 dermatólogos de larga experiencia quirúrgica reconstructiva eligieron sus técnicas preferidas para cada unidad estética. La elección de estos colgajos se fundamentó en la experiencia personal de cada dermatólogo basándose en factores como la idoneidad de la técnica reconstructiva para ese defecto, el resultado estético final, la facilidad de ejecución y la baja probabilidad de complicaciones, entre otros. Eligieron 2 colgajos por orden de preferencia para cada subunidad estética y se le asignaron 10 puntos al primer colgajo y 5 al segundo.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Con la suma obtenida de todas las opciones aportadas por los dermatólogos encuestados se obtuvo una relación de los 3 mejores colgajos para cada localización. Destacar la unanimidad de criterio por parte de la mayoría de los dermatólogos para técnicas reconstructivas como el colgajo glabelar para defectos de canto interno del ojo, el colgajo de avance bilateral en bandera o H para frente, el colgajo en puerta giratoria para concha auricular, el colgajo pangeniano para mejilla infraorbitaria, el colgajo de rotación O-Z para cuero cabelludo, el colgajo de Tenzel para párpado inferior y el colgajo en isla para labio superior.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los resultados de este estudio son de utilidad para ofrecer una guía práctica para la elección de las mejores técnicas reconstructivas en cada una de las distintas subunidades estéticas faciales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Russo F, Linares M, Iglesias ME, Martínez-Amo JL, Cabo F, Tercedor J, et al. Técnicas reconstructivas de elección por unidades estéticas faciales. Actas Dermosifiliogr. 2017;108:729–737.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0225" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:13 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1492 "Ancho" => 2624 "Tamanyo" => 298950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Main facial cosmetic units and subunits.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 1600 "Tamanyo" => 260985 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A, The flag flap was chosen as the flap of choice for the forehead. B, The Limberg flap was the flap of choice for the lateral forehead. C, The subcutaneous island pedicle flap was the flap of choice for the brow.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Photographs courtesy of Dr. Donis Muñoz Borras.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1383 "Ancho" => 1000 "Tamanyo" => 214200 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A, The Rieger flap for the dorsum of the nose. B, The nasolabial flap for reconstruction of the nasal ala. C, The bilobar flap for the tip of the nose.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Photographs courtesy of Dr. Ricardo Ruiz Villaverde.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1241 "Ancho" => 1600 "Tamanyo" => 286472 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">A, The Tenzel flap for the lower eyelid. B, The Limberg flap for the lateral canthus of the eye. C, The glabellar flap for the medial canthus of the eye.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 784 "Ancho" => 1600 "Tamanyo" => 193720 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A, The Mustardé flap for the infraorbital cheek. B, The Limberg flap was the flap of choice for the zygomatic, buccal, and parotid-masseteric subunits of the cheek.</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Photographs courtesy of Dr. Antonio Ramírez Andreo.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1868 "Ancho" => 975 "Tamanyo" => 221091 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">A, A-T flap for the philtrum of the lip. B, Subcutaneous island pedicle flap for the upper lip. C, The bilateral perialar horizontal advancement flap for the vermilion of the upper lip.</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Photograph A courtesy of Dr. Soledad Saénz Guirado. Photograph B courtesy of Dr. Antonio Clemente Ruiz de Almirón. Photograph C courtesy of Dr. Francisco Vilchez.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 796 "Ancho" => 975 "Tamanyo" => 156408 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">The double labiomental advancement flap for the vermilion of the lower lip.</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Photograph courtesy of Dr. Dolores Sánchez Aguilar.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 718 "Ancho" => 975 "Tamanyo" => 95826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">A-T flap for the chin.</p> <p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Photograph courtesy of Dr. Ana Miragaya.</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1530 "Ancho" => 1500 "Tamanyo" => 357950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">A, The helical advancement flap was the flap of choice for the helix of the ear. B, The revolving-door flap for defects of the concha of the ear. C, The Limberg flap for the earlobe. D, The Limberg flap for retroauricular defects.</p> <p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Photograph A courtesy of Dr. Alfonso Rodríguez Bujaldón.</p>" ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 1026 "Ancho" => 975 "Tamanyo" => 178625 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">The O-Z flap for scalp defects.</p> <p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Photograph courtesy of Dr. Alfonso Liaño.</p>" ] ] 10 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">First Choice of Flap \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Second Choice of Flap \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Third Choice of Flap \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central forehead \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flag \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O-Z \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lateral forehead \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inferior rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Island \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flag \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O-Z \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dorsum of the nose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rieger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lateral wall of the nose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral advancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bernard-Webster \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nasal ala \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nasolabial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spiral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tip of the nose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilobar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">East-west \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rieger \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Columella \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Double transposition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">East-west \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nasolabial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper eyelid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral advancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reverse Tripier \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reverse Tenzel \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower eyelid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tenzel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tripier \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Imre \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lateral canthus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Puzzle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M-plasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medial canthus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Glabellar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Island \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infraorbital cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mustardé \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blascovicz \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zygomatic cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mustardé \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M-plasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Buccal cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Crescentic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Burow triangle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parotid cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper lip philtrum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flag \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Island \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lateral upper lip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Island \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bernard-Webster \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vermilion of upper lip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral perialar horizontal advancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abbe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reverse Karapandzic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central lower lip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flag \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M-plasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower lip vermilion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Double crescentic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Karapandzic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abbe \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral advancement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Helix of the ear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Helical advancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Retroauricular advancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction plasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antihelix of the ear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A-T \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Concha of the ear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Revolving-door \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Second intention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Transposition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Earlobe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Modified bilobar (Gavello) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advancement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Retroauricular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rotation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advancement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O-Z \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Triple Limberg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Second intention \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1527654.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">List of the 3 Reconstruction Techniques of Choice for Each Cosmetic Subunit.</p>" ] ] 11 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 432811 ] ] 12 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc2.pdf" "ficheroTamanyo" => 469544 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regional aesthetic units of the face" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 7 | 24 |
| 2024 October | 100 | 60 | 160 |
| 2024 September | 122 | 69 | 191 |
| 2024 August | 149 | 81 | 230 |
| 2024 July | 136 | 50 | 186 |
| 2024 June | 124 | 50 | 174 |
| 2024 May | 91 | 76 | 167 |
| 2024 April | 105 | 57 | 162 |
| 2024 March | 92 | 53 | 145 |
| 2024 February | 68 | 60 | 128 |
| 2024 January | 71 | 48 | 119 |
| 2023 December | 70 | 60 | 130 |
| 2023 November | 97 | 41 | 138 |
| 2023 October | 72 | 33 | 105 |
| 2023 September | 104 | 60 | 164 |
| 2023 August | 89 | 39 | 128 |
| 2023 July | 109 | 65 | 174 |
| 2023 June | 136 | 47 | 183 |
| 2023 May | 135 | 49 | 184 |
| 2023 April | 206 | 44 | 250 |
| 2023 March | 201 | 47 | 248 |
| 2023 February | 207 | 47 | 254 |
| 2023 January | 164 | 39 | 203 |
| 2022 December | 187 | 57 | 244 |
| 2022 November | 159 | 48 | 207 |
| 2022 October | 133 | 57 | 190 |
| 2022 September | 176 | 79 | 255 |
| 2022 August | 69 | 62 | 131 |
| 2022 July | 154 | 67 | 221 |
| 2022 June | 158 | 55 | 213 |
| 2022 May | 192 | 102 | 294 |
| 2022 April | 174 | 85 | 259 |
| 2022 March | 173 | 126 | 299 |
| 2022 February | 161 | 65 | 226 |
| 2022 January | 179 | 75 | 254 |
| 2021 December | 144 | 48 | 192 |
| 2021 November | 135 | 84 | 219 |
| 2021 October | 173 | 99 | 272 |
| 2021 September | 168 | 72 | 240 |
| 2021 August | 261 | 57 | 318 |
| 2021 July | 148 | 67 | 215 |
| 2021 June | 164 | 49 | 213 |
| 2021 May | 160 | 89 | 249 |
| 2021 April | 462 | 142 | 604 |
| 2021 March | 212 | 81 | 293 |
| 2021 February | 170 | 63 | 233 |
| 2021 January | 126 | 46 | 172 |
| 2020 December | 126 | 36 | 162 |
| 2020 November | 112 | 37 | 149 |
| 2020 October | 63 | 34 | 97 |
| 2020 September | 125 | 50 | 175 |
| 2020 August | 97 | 40 | 137 |
| 2020 July | 131 | 38 | 169 |
| 2020 June | 127 | 49 | 176 |
| 2020 May | 90 | 28 | 118 |
| 2020 April | 57 | 24 | 81 |
| 2020 March | 33 | 15 | 48 |
| 2020 February | 7 | 0 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 6 | 0 | 6 |
| 2019 November | 5 | 0 | 5 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 5 | 0 | 5 |
| 2019 June | 5 | 0 | 5 |
| 2019 May | 2 | 0 | 2 |
| 2019 April | 4 | 0 | 4 |
| 2019 March | 4 | 0 | 4 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 3 | 2 | 5 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 4 | 0 | 4 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 1 | 0 | 1 |
| 2018 February | 187 | 34 | 221 |
| 2018 January | 192 | 25 | 217 |
| 2017 December | 226 | 33 | 259 |
| 2017 November | 124 | 23 | 147 |
| 2017 October | 183 | 62 | 245 |
| 2017 September | 12 | 21 | 33 |
| 2017 August | 6 | 13 | 19 |
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