Videos of Surgical Procedures in Dermatology
Using a “Mutaf Triangular Flap” for Lower Eyelid Reconstruction
Reconstrucción palpebral inferior mediante «colgajo triangular de Mutaf»
P. Fernández Canga
, E. Varas Meis, J. Castiñeiras González, M. Espasandín Arias, M.Á. Rodríguez Prieto
Corresponding author
Servicio de Dermatología, Complejo Asistencial Universitario de León, León, España
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A. Defecto primario triangulado. B. Colgajo disecado compuesto por 2 triángulos opuestos. C. Posicionamiento final del colgajo. D y E. Posoperatorio inmediato y tardío (8 semanas). Visión frontal y lateral.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Fernández Canga, E. Varas Meis, J. Castiñeiras González, M. Espasandín Arias, M.Á. Rodríguez Prieto" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Fernández Canga" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Varas Meis" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Castiñeiras González" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Espasandín Arias" ] 4 => array:2 [ "nombre" => "M.Á." 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Fernández Canga, E. Varas Meis, J. Castiñeiras González, M. Espasandín Arias, M.Á. Rodríguez Prieto" "autores" => array:5 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Fernández Canga" "email" => array:1 [ 0 => "paulafcanga@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Varas Meis" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Castiñeiras González" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Espasandín Arias" ] 4 => array:2 [ "nombre" => "M.Á." "apellidos" => "Rodríguez Prieto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Asistencial Universitario de León, León, España" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reconstrucción palpebral inferior mediante «colgajo triangular de Mutaf»" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 431 "Ancho" => 1700 "Tamanyo" => 112808 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examination of palpebral laxity. A, Snap test: slow repositioning of the eyelid. B, Medial traction: examination of lateral canthal laxity based on increase in the external angle. C, Lateral traction: assessment of medial canthal laxity based on the degree of movement of the tear duct.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The infraorbital region is a unique anatomic subunit, close to structures of functional and esthetic importance, such as the lower eyelid, nasal ala and oral commissure, which should be taken into consideration during reconstructive surgery. The main cause of distortion is traction secondary to closure with excessive tension or to scar contraction. The absence of folds in which to hide scars is an added difficulty.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the principal complications when reconstructing infraorbital defects is postoperative ectropion. A thorough examination of the eyelid prior to surgery is therefore required to identify signs of excessive laxity (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the event of muscle wasting that may favor ectropion, the need for an associated eyelid-suspension technique (e.g., canthopexy associated with the flap chosen to close the defect) should be considered.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The Mutaf triangular flap technique was described in 2011 by Mutaf et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> for the reconstruction of infraorbital defects. It is based on 2 triangular transposition flaps treated as an unequal Z-plasty.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Technical Description</span><p id="par0020" class="elsevierStylePara elsevierViewall">The technique requires converting the surgical defect into an isosceles triangle with the base superior (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Based on this triangle and its dimensions, 2 opposing triangles are then traced (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D-F). One triangle is transposed to cover the original defect and the second triangle will cover the defect of the donor region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B and <span class="elsevierStyleSmallCaps">C</span>). The suture line and, therefore, the resulting scar will follow the tension lines of the cheek.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">2,3</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We report our experience in performing the Mutaf flap in a patient with a large defect in the palpebromalar region following Mohs surgery for basal cell carcinoma (<span class="elsevierStyleItalic">see video</span>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was placed under general anesthesia and we began the incision and dissection of the tissue to convert the primary defect into a triangle. When this triangle had been defined, the first part of the flap was incised and the flap was dissected superficially in a subcutaneous plane. The second triangle was then raised and the final positioning of both flaps was verified (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A-C).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Before commencing suturing, careful hemostasis was performed, the uppermost part of the flap was thinned to ensure it was as similar as possible to the palpebral skin, and the lateral orbital edge was attached by means of an anchor stitch using a 3-0 absorbable braided suture (Vicryl<span class="elsevierStyleSup">®</span>) to prevent retraction. Finally, continuous suture of the flap was performed using 4-0 silk and the dog-ears at the distal end were corrected (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D and E).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indication</span><p id="par0040" class="elsevierStylePara elsevierViewall">Medium and large infraorbital skin defects, for which other, simpler, reconstructive techniques are scheduled may give rise to postoperative ectropion or poor esthetic results.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Contraindications</span><p id="par0045" class="elsevierStylePara elsevierViewall">No absolute contraindications are known. Abnormal coagulation and factors that predispose the patient to cutaneous ischemia (smoking, prior radiation therapy, diabetic foot, etc.), which may compromise the viability of the flap, may be considered relative contraindications.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Complications</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical wound infection.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hemorrhage, hematoma, and skin necrosis.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Scarring ectropion.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Temporary or permanent altered sensation owing to damage to nerve structures.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The Mutaf triangular flap technique is a good, original reconstructive option in medium and large infraorbital defects, where, owing to the risk of palpebral retraction, other flap techniques do not provide an adequate alternative and the use of grafts may compromise the esthetic results. The operation is laborious but not technically complex and, as can be seen, provides good functional and esthetic results (<a class="elsevierStyleCrossRef" href="#fig0015">Figs. 3</a>D and E). Appropriate examination of palpebral laxity is required before designing surgery of the infraorbital region.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Technical Description" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Indication" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Contraindications" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Complications" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Canga P, Varas Meis E, Castiñeiras González J, Espasandín Arias M, Rodríguez Prieto MÁ. Reconstrucción palpebral inferior mediante «colgajo triangular de Mutaf». Actas Dermosifiliogr. 2018;109:917–919.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0090" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 431 "Ancho" => 1700 "Tamanyo" => 112808 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Examination of palpebral laxity. A, Snap test: slow repositioning of the eyelid. B, Medial traction: examination of lateral canthal laxity based on increase in the external angle. C, Lateral traction: assessment of medial canthal laxity based on the degree of movement of the tear duct.</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" => 1494 "Ancho" => 2834 "Tamanyo" => 565340 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Design of the Mutaf triangular flap. A, Conversion of the primary defect into a triangle. B, Rotation of the second triangle required to cover the primary defect (arrow). C. Rotation of the third triangle required to cover the secondary defect (arrow). D, The first part of the flap is traced at the same distance as the upper line of the defect converted to a triangle (yellow dotted line). E, The length of the flap must be the same as that of the internal face of the defect (purple dotted line) it will be moved toward (arrow). F, Extension of the vertex of the defect to define the third triangle (red dotted line). Angles of the vertices of the 3 triangles.</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" => 1553 "Ancho" => 2833 "Tamanyo" => 814366 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mutaf triangular flap. A, Primary defect converted to a triangle. B, Raised flap made up of 3 opposing triangles. C, Final positioning of the flap. D and E, Immediate and later postoperative period (8 weeks). Front and side view.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 178385860 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía reconstructiva de la región cigomática-medial de la mejilla: presentación de 5 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.G. Pérez-Paredes" 1 => "B. González-Sixto" 2 => "M.M. Otero-Rivas" 3 => "M. Rodríguez-Prieto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.adengl.2012.11.029" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr." "fecha" => "2014" "volumen" => "105" "paginaInicial" => "e27" "paginaFinal" => "e31" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24718266" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A new technique for closure of infraorbital defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Mutaf" 1 => "E. Günal" 2 => "M. Temel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SAP.0b013e31820d6830" "Revista" => array:6 [ "tituloSerie" => "Ann Plast Surg." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 6 | 17 |
| 2024 October | 98 | 55 | 153 |
| 2024 September | 95 | 30 | 125 |
| 2024 August | 116 | 56 | 172 |
| 2024 July | 136 | 30 | 166 |
| 2024 June | 129 | 32 | 161 |
| 2024 May | 120 | 37 | 157 |
| 2024 April | 85 | 32 | 117 |
| 2024 March | 90 | 24 | 114 |
| 2024 February | 90 | 34 | 124 |
| 2024 January | 59 | 32 | 91 |
| 2023 December | 61 | 13 | 74 |
| 2023 November | 104 | 43 | 147 |
| 2023 October | 80 | 26 | 106 |
| 2023 September | 78 | 31 | 109 |
| 2023 August | 77 | 20 | 97 |
| 2023 July | 87 | 33 | 120 |
| 2023 June | 80 | 26 | 106 |
| 2023 May | 81 | 34 | 115 |
| 2023 April | 74 | 21 | 95 |
| 2023 March | 56 | 31 | 87 |
| 2023 February | 60 | 27 | 87 |
| 2023 January | 45 | 25 | 70 |
| 2022 December | 50 | 33 | 83 |
| 2022 November | 42 | 37 | 79 |
| 2022 October | 45 | 26 | 71 |
| 2022 September | 41 | 37 | 78 |
| 2022 August | 36 | 38 | 74 |
| 2022 July | 26 | 34 | 60 |
| 2022 June | 30 | 23 | 53 |
| 2022 May | 40 | 49 | 89 |
| 2022 April | 54 | 35 | 89 |
| 2022 March | 51 | 58 | 109 |
| 2022 February | 39 | 22 | 61 |
| 2022 January | 98 | 49 | 147 |
| 2021 December | 52 | 38 | 90 |
| 2021 November | 58 | 58 | 116 |
| 2021 October | 61 | 67 | 128 |
| 2021 September | 47 | 47 | 94 |
| 2021 August | 44 | 37 | 81 |
| 2021 July | 36 | 32 | 68 |
| 2021 June | 38 | 33 | 71 |
| 2021 May | 43 | 50 | 93 |
| 2021 April | 66 | 95 | 161 |
| 2021 March | 71 | 39 | 110 |
| 2021 February | 70 | 36 | 106 |
| 2021 January | 35 | 32 | 67 |
| 2020 December | 37 | 29 | 66 |
| 2020 November | 36 | 26 | 62 |
| 2020 October | 53 | 14 | 67 |
| 2020 September | 41 | 24 | 65 |
| 2020 August | 45 | 31 | 76 |
| 2020 July | 27 | 23 | 50 |
| 2020 June | 35 | 33 | 68 |
| 2020 May | 44 | 20 | 64 |
| 2020 April | 53 | 11 | 64 |
| 2020 March | 27 | 8 | 35 |
| 2020 February | 2 | 0 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2018 November | 23 | 0 | 23 |
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