Case and Research Letter
Combined Double Rotation Flap on the Cheek
Doble colgajo combinado de rotación en la mejilla
M.M. Otero-Rivas
, G. Pérez-Paredes, L.M. Valladares-Narganes, M.A. Rodríguez-Prieto
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Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain
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Otero-Rivas, G. Pérez-Paredes, L.M. Valladares-Narganes, M.A. Rodríguez-Prieto" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.M." "apellidos" => "Otero-Rivas" "email" => array:2 [ 0 => "motero@aedv.es" 1 => "acuviel@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Pérez-Paredes" ] 2 => array:2 [ "nombre" => "L.M." "apellidos" => "Valladares-Narganes" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Rodríguez-Prieto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Doble colgajo combinado de rotación en la mejilla" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1000 "Ancho" => 788 "Tamanyo" => 155984 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Result 24 months after surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Basal cell carcinoma is the most common skin tumor in white individuals.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It arises mainly in sun-exposed areas and is usually a nonaggressive, slow-growing tumor. However, in the office it is not uncommon to see large tumors that require complex reconstruction techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Reconstruction of the cheek is a particular challenge, as functionality must be preserved while minimizing the cosmetic impact of the resulting scar and without distorting the mandibular or nasal sulci or the palpebral fold.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe the case of an 83-year-old man with no past medical or surgical history of interest who was seen for a lesion that had been present for 3 years on the right side of the face, at the union of the superolateral border of the cheek with the area of the zygomatic arch.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The tumor had a sclerodermiform appearance, with well-defined pearly borders, and measured 2.5<span class="elsevierStyleHsp" style=""></span>cm in its largest diameter (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Telangiectasias were visible over most of the surface of the tumor and there were small ulcers with blood-stained crusts.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Based on a clinical suspicion of morpheaform basal cell carcinoma, the patient was scheduled for surgical excision of the tumor under local anesthesia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After palpation of the lesion and of the surrounding donor site, we designed a rotation flap with its base oriented inferiorly and a Burow triangle positioned superiorly to reduce tension (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An M-plasty was designed in the skin inferior to the lesion to close the defect.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Local anesthesia was infiltrated around the lesion and in the area of the flap. However, after excision of the tumor with an adequate margin and incision of the flap, the tissue was found to be difficult to mobilize and it was decided to create an additional preauricular rotation flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The Burow triangle shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> was not excised.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Both flaps were dissected in a plane immediately superior to the superficial musculoaponeurotic system, making the procedure easier and less time-consuming as there is less bleeding. This technique also achieves better cosmetic and functional results as it does not affect the innervation of the area.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The 2 flaps were sutured with interrupted 4-0 silk sutures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0050" class="elsevierStylePara elsevierViewall">The immediate postoperative period was satisfactory, with no hematoma or infection of the surgical wound. At 24 months, the patient presented no signs of recurrence, and the functional and cosmetic results were excellent (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">This case demonstrates the difficulty of reconstructing large areas such as the cheek. Although there is usually sufficient donor tissue, large flaps may sometimes be required, and we must be aware of the existence of critical points due to the presence of nerves and blood vessels. The best possible cosmetic result must be sought while ensuring an adequate oncologic surgery.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Knowledge of the different surgical techniques is essential in order to rapidly resolve those cases in which the initially designed flap does not adequately close the defect. Such problems can often be avoided by detailed presurgical examination of the donor site, as was performed in our patient, but the distensibility of the skin and the mobility of the flap can only be definitively evaluated after the flap is created, especially in large defects. In our patient, the tumor type was an additional factor that led to greater tissue loss than was expected.</p><p id="par0065" class="elsevierStylePara elsevierViewall">As in dermatologic surgery in other anatomical areas, during reconstruction of the cheek we must aim to obtain tissue with a similar color and texture. In the majority of cases this is sufficient to achieve adequate symmetry and cosmetic results. However, it is not essential to follow the general principles applicable to the reconstruction of central structures (nose, eyes, lips, etc.) proposed by Burget and Menick,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> who favor the reconstruction of complete units.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the large size of the final defect, one of the alternatives considered in this case was to combine the initial plasty with a graft. The majority of authors do not recommend this option because of its poor cosmetic result, although they may consider it in patients with comorbid conditions that contraindicate more complex flaps.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Converting the reconstruction to a standard or modified Limberg flap would leave a more visible scar. Roth et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> recommend avoiding incisions anterior to the Z-line unless they can be hidden in a natural fold. The Z-line is an imaginary vertical line that runs perpendicularly down from the lateral canthus of the eye to the mandibular border. Geometric plasties on the cheek do not usually achieve a fully satisfactory cosmetic result.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Another option in the zygomatic region and midcheek, where the defect was located in our patient, is the use of advancement-rotation flaps with a base that may be lateral or medial.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The complications that can arise in the reconstruction of the cheek include those specific to large flaps, such as flap necrosis or the trap-door effect due to incorrect fat removal from the donor tissue, and the possibility of ectropion or a change in the distribution of facial hair and of the line of implantation of the hair.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A useful maneuver that is frequently employed to prevent ectropion is to anchor the flap to the periosteum of the inferior border of the orbit with a reabsorbable suture. This was not necessary in our patient as the design of a second flap provided sufficient tissue. Some authors believe this technique, though widely described in the literature,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> can contribute to distal necrosis of the flap.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">We have presented an original combination of flaps performed in a single operation, with excellent functional and cosmetic results. This case also illustrates other possibilities of surgical reconstruction that avoid the need to use less suitable techniques, such as grafts or geometric flaps.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In daily dermatologic surgery practice we must always be prepared for the great variability in the characteristics of the skin of each patient and of the lesions. We stress the need for adequate presurgical design and planning, as this will enable us to resolve situations that may arise during an intervention.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Otero-Rivas M, Pérez-Paredes G, Valladares-Narganes L, Rodríguez-Prieto M. Doble colgajo combinado de rotación en la mejilla. Actas Dermosifiliogr. 2014;105:101–103.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 822 "Tamanyo" => 187397 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Morpheaform basal cell carcinoma over the right zygomatic arch, with a largest diameter of 2.5<span class="elsevierStyleHsp" style=""></span>cm. Design of the original plasty: a rotation flap with an inferior M-plasty and a superolateral triangle to reduce tension.</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" => 635 "Ancho" => 1300 "Tamanyo" => 221577 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Design of the preauricular rotation flap with its base oriented anteriorly. Suture with interrupted 4-0 silk sutures. Mild edema and a small hematoma in the immediate postoperative period.</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" => 1000 "Ancho" => 788 "Tamanyo" => 155984 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Result 24 months after surgery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of basal cell carcinoma" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "British Association of Dermatologists" "etal" => false "autores" => array:3 [ 0 => "N.R. 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Menick" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2001" "volumen" => "108" "paginaInicial" => "496" "paginaFinal" => "504" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11496195" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anchored flaps in post-Mohs reconstruction of the lower eyelid, cheek and lateral canthus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.J. Harris" 1 => "N. Perez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.IOP.0000040670.16648.8A" "Revista" => array:6 [ "tituloSerie" => "Ophthal Plast Reconstr Surg" "fecha" => "2003" "volumen" => "19" "paginaInicial" => "5" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12544788" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suspension sutures in facial reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.K. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 6 | 17 |
| 2024 Octubre | 80 | 47 | 127 |
| 2024 Septiembre | 82 | 29 | 111 |
| 2024 Agosto | 124 | 65 | 189 |
| 2024 Julio | 70 | 38 | 108 |
| 2024 Junio | 91 | 29 | 120 |
| 2024 Mayo | 84 | 29 | 113 |
| 2024 Abril | 63 | 24 | 87 |
| 2024 Marzo | 63 | 26 | 89 |
| 2024 Febrero | 72 | 35 | 107 |
| 2024 Enero | 69 | 38 | 107 |
| 2023 Diciembre | 58 | 14 | 72 |
| 2023 Noviembre | 52 | 22 | 74 |
| 2023 Octubre | 78 | 36 | 114 |
| 2023 Septiembre | 75 | 33 | 108 |
| 2023 Agosto | 58 | 18 | 76 |
| 2023 Julio | 54 | 38 | 92 |
| 2023 Junio | 67 | 26 | 93 |
| 2023 Mayo | 80 | 23 | 103 |
| 2023 Abril | 73 | 19 | 92 |
| 2023 Marzo | 75 | 26 | 101 |
| 2023 Febrero | 41 | 20 | 61 |
| 2023 Enero | 53 | 36 | 89 |
| 2022 Diciembre | 54 | 34 | 88 |
| 2022 Noviembre | 38 | 24 | 62 |
| 2022 Octubre | 32 | 15 | 47 |
| 2022 Septiembre | 29 | 36 | 65 |
| 2022 Agosto | 25 | 28 | 53 |
| 2022 Julio | 18 | 23 | 41 |
| 2022 Junio | 18 | 27 | 45 |
| 2022 Mayo | 50 | 31 | 81 |
| 2022 Abril | 63 | 29 | 92 |
| 2022 Marzo | 80 | 49 | 129 |
| 2022 Febrero | 71 | 34 | 105 |
| 2022 Enero | 86 | 32 | 118 |
| 2021 Diciembre | 125 | 39 | 164 |
| 2021 Noviembre | 104 | 53 | 157 |
| 2021 Octubre | 108 | 42 | 150 |
| 2021 Septiembre | 80 | 31 | 111 |
| 2021 Agosto | 88 | 25 | 113 |
| 2021 Julio | 112 | 22 | 134 |
| 2021 Junio | 66 | 27 | 93 |
| 2021 Mayo | 67 | 30 | 97 |
| 2021 Abril | 179 | 67 | 246 |
| 2021 Marzo | 84 | 26 | 110 |
| 2021 Febrero | 58 | 21 | 79 |
| 2021 Enero | 68 | 19 | 87 |
| 2020 Diciembre | 34 | 13 | 47 |
| 2020 Noviembre | 24 | 15 | 39 |
| 2020 Octubre | 11 | 10 | 21 |
| 2020 Septiembre | 29 | 7 | 36 |
| 2020 Agosto | 28 | 21 | 49 |
| 2020 Julio | 32 | 13 | 45 |
| 2020 Junio | 38 | 18 | 56 |
| 2020 Mayo | 25 | 17 | 42 |
| 2020 Abril | 33 | 15 | 48 |
| 2020 Marzo | 31 | 16 | 47 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 3 | 1 | 4 |
| 2019 Diciembre | 8 | 5 | 13 |
| 2019 Noviembre | 4 | 4 | 8 |
| 2019 Octubre | 0 | 3 | 3 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 3 | 7 |
| 2019 Junio | 4 | 1 | 5 |
| 2019 Mayo | 6 | 8 | 14 |
| 2019 Abril | 2 | 10 | 12 |
| 2019 Marzo | 2 | 8 | 10 |
| 2019 Febrero | 4 | 0 | 4 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 3 | 0 | 3 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Abril | 0 | 3 | 3 |
| 2018 Marzo | 2 | 6 | 8 |
| 2018 Febrero | 39 | 1 | 40 |
| 2018 Enero | 53 | 7 | 60 |
| 2017 Diciembre | 52 | 6 | 58 |
| 2017 Noviembre | 42 | 3 | 45 |
| 2017 Octubre | 48 | 6 | 54 |
| 2017 Septiembre | 40 | 7 | 47 |
| 2017 Agosto | 50 | 9 | 59 |
| 2017 Julio | 51 | 4 | 55 |
| 2017 Junio | 61 | 21 | 82 |
| 2017 Mayo | 57 | 7 | 64 |
| 2017 Abril | 66 | 20 | 86 |
| 2017 Marzo | 38 | 26 | 64 |
| 2017 Febrero | 46 | 9 | 55 |
| 2017 Enero | 17 | 14 | 31 |
| 2016 Diciembre | 47 | 10 | 57 |
| 2016 Noviembre | 53 | 12 | 65 |
| 2016 Octubre | 90 | 24 | 114 |
| 2016 Septiembre | 153 | 19 | 172 |
| 2016 Agosto | 57 | 4 | 61 |
| 2016 Julio | 32 | 5 | 37 |
| 2016 Junio | 7 | 8 | 15 |
| 2016 Mayo | 13 | 8 | 21 |
| 2016 Abril | 10 | 14 | 24 |
| 2016 Marzo | 5 | 1 | 6 |
| 2016 Febrero | 9 | 8 | 17 |
| 2016 Enero | 6 | 10 | 16 |
| 2015 Diciembre | 4 | 1 | 5 |
| 2015 Noviembre | 12 | 1 | 13 |
| 2015 Octubre | 5 | 9 | 14 |
| 2015 Septiembre | 8 | 1 | 9 |
| 2015 Agosto | 10 | 3 | 13 |
| 2015 Julio | 67 | 6 | 73 |
| 2015 Junio | 33 | 5 | 38 |
| 2015 Mayo | 47 | 4 | 51 |
| 2015 Abril | 32 | 4 | 36 |
| 2015 Marzo | 32 | 6 | 38 |
| 2015 Febrero | 34 | 3 | 37 |
| 2015 Enero | 33 | 3 | 36 |
| 2014 Diciembre | 36 | 3 | 39 |
| 2014 Noviembre | 32 | 5 | 37 |
| 2014 Octubre | 39 | 2 | 41 |
| 2014 Septiembre | 28 | 2 | 30 |
| 2014 Agosto | 23 | 2 | 25 |
| 2014 Julio | 35 | 5 | 40 |
| 2014 Junio | 37 | 2 | 39 |
| 2014 Mayo | 33 | 4 | 37 |
| 2014 Abril | 18 | 2 | 20 |
| 2014 Marzo | 14 | 1 | 15 |
| 2014 Febrero | 4 | 1 | 5 |
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