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We evaluate a number of reconstruction techniques in patients with tumors situated in the medial and zygomatic regions&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the medial subunit we must take into account that the union of the cheek with the eyelid forms its own subunit&#44; and we must also therefore respect the position and function of the lower eyelid&#44; as well as the morphology of this subunit and the gradual change that occurs from the malar to the palpebral regions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The zygomatic ligament fixes the skin of the zygomatic subunit&#44; and it must be remembered during surgery that the temporal branch of the facial nerve is in a very superficial plane in this region&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Reconstruction of the malar eminence must respect the fat pad&#44; which creates the convexity of this area and gives it volume&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The blood supply is derived from the facial artery and its branches&#44; motor innervation is via the facial nerve&#44; and the sensory supply is from the maxillary nerve&#44; a branch of the fifth cranial nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 75-year-old woman with a lentigo maligna melanoma of 2&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>cm&#46; After resection of the lesion&#44; an advancement-rotation flap was designed above the zygomatic arch&#44; extending to tragus&#46; The inferior border of the defect was triangulated and a Z-plasty was used in the preauricular region to allow greater advancement of the flap&#46; The subcutaneous tissue was sutured with Vicryl and the skin was closed with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0035" class="elsevierStylePara elsevierViewall">A man aged 78 years presented a basal cell carcinoma of 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>cm on the lateral third of the upper left eyelid and a lentigo maligna melanoma of 3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm on the left cheek&#46; After excision of the cheek lesion&#44; an advancement flap was designed in the temporal region&#46; The superomedial border of the defect was triangulated&#44; the inferior border was undermined&#44; and the eyelid tumor was excised using a triangular incision&#44; which served as a tension-releasing triangle for advancement of the flap&#46; The skin was sutured with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0040" class="elsevierStylePara elsevierViewall">This patient was a 72-year-old man who presented a solid sclerodermiform basal cell carcinoma of 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>cm in the malar region&#46; After excision&#44; an advancement-rotation flap was designed&#44; respecting the tension lines of the cheek&#46; The inferior part of the defect was triangulated and a semicircle of healthy skin was excised along the superolateral border to facilitate positioning of the flap&#46; The borders of the flap were sutured with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 4</span><p id="par0045" class="elsevierStylePara elsevierViewall">This patient was a man aged 77 years with a basosquamous carcinoma of 4&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the area of the right lateral canthus and right malar region&#46; After excision of the lesion&#44; the defect was covered by a transposition flap taken from the frontotemporal region&#44; above the ipsilateral eyebrow&#46; The skin was sutured with 4&#47;0 and 5&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Case 5</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 79-year-old man presented a lentigo maligna with a diameter of approximately 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm situated on the lateral half of the right palpebromalar region&#46; The surgical defect left by the excision was closed using a Limberg flap from the temporal region &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The skin was sutured with 4&#47;0 silk&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Good clinical&#44; functional&#44; and cosmetic outcomes were achieved in all the cases presented&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The choice of surgical technique will depend on the site&#44; size&#44; thickness&#44; and histological characteristics of the tumor&#46; We must also take into account the age and general state of health of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The main objective&#44; as in any oncologic surgery&#44; is radical excision of the tumor&#59; prevention of the distortion of local structures and achieving the best cosmetic outcome are secondary objectives&#46; To obtain the best cosmetic outcome&#44; we must locate the donor site with the greatest tissue reserve and choose the best reconstruction technique&#46; This is important in the medial zygomatic area&#44; where an inappropriate choice can lead to ectropion and a very visible scar&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A number of reconstruction techniques are available for use at this site&#46; Whenever size permits&#44; primary closure should be chosen&#46; Second-intention healing is not to be recommended&#44; as scar retraction will lead to ectropion&#46; Grafts enable us to cover large defects&#44; but apart from the typically poor cosmetic result in this region&#44; graft retraction can lead to deformities of the adjacent facial subunits&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In our first case&#44; with a medium-sized tumor&#44; the largest tissue reservoir was in the lateral subunit&#46; We decided to use an advancement-rotation flap from the cheek that required a Z-plasty in the preauricular region to allow greater movement&#46; If further tissue mobilization had been necessary&#44; we could have prolonged the zygomatic incision along the preauricular sulcus&#44; even onto the neck&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Belmahi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> described a flap that combined the classic Mustard&#233; flap with a temporoparietal rotation flap that is used to cover the secondary defect left by the Mustard&#233; flap&#46; This technique can be used for defects of up to 7<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other&#44; less desirable alternatives include use of the skin from the medial melolabial area or interpolation flaps&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the second patient&#44; the largest diameter of the surgical defect ran obliquely&#46; The main tissue reservoirs were in the temporal&#44; lateral&#44; and medial buccal subunits&#46; We could therefore have created a preauricular or melolabial advancement-rotation flap or a combination of the two&#46; The existence of a second tumor on the upper eyelid and our evaluation of the elasticity of the skin led us to choose an advancement flap from the temporal subunit&#46; The excision of the tumor on the eyelid served as a tension-relieving triangle for mobilization of the flap&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The third patient presented a small tumor&#46; Primary suture would have been the treatment of choice&#44; but the patient&#39;s skin was difficult to mobilize&#44; which would have led to a high risk of ectropion&#46; The main skin reservoirs were in the zygomatic and upper medial subunits&#46; We decided to use a rotation-advancement plasty from the cheek&#44; following the skin tension lines&#46; A medial plasty would have required incision of the eyelid&#44; which often provokes persistent edema&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The tumor in the fourth patient&#44; in contact with the lateral canthus&#44; affected part of both eyelids and the cheek&#46; The main skin reservoirs were the lateral cheek and the temporal region&#46; We rejected the lateral cheek option because the skin is hairy&#46; Instead we chose a supraciliary transposition flap&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The final patient presented a smaller lesion than the previous patient&#44; but it was at a similar site and the decisions were therefore very similar&#46; The possible tissue reservoirs were the upper medial and the temporal subunits&#46; From the medial area we could fashion a transposition flap with a superior base or a rotation flap with an incision along the melolabial fold&#46; In the temporal region we could use transposition plasties&#44; as above&#44; or a Limberg flap&#46; This patient had sufficient skin in the temporal region and even more close to the lateral canthus&#44; and we thus considered a rhomboidal flap to be a good choice&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It may sometimes be necessary to use combinations of flaps to repair defects in this area&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The main disadvantage of advancement-rotation plasties in the medial zygomatic region of the cheek &#40;cases 1&#44; 2&#44; and<span class="elsevierStyleHsp" style=""></span>3&#41; is the risk of postsurgical ectropion if the flap is not correctly designed&#46; The major complication of transposition flaps &#40;cases 4 and<span class="elsevierStyleHsp" style=""></span>5&#41;&#44; on the other hand&#44; is displacement of the lateral canthus&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When the tension vectors are vertical or horizontal&#44; it may be necessary to anchor the flap to the periostium of the orbital rim to avoid traction on the lower eyelid&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Reconstruction of the medial zygomatic subunit&#44; one of the subunits of the cheek&#44; is particularly complicated&#46; We have described 5 possible reconstruction techniques for this area&#44; discussing other alternatives and explaining the reasons for which we chose each of the options used&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical Disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information and that written informed consent for voluntary participation was obtained for all patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The cheek is the largest anatomical subunit of the face&#46; It is a bilateral structure and symmetry must therefore be preserved&#46; Peripherally it is related to important natural orifices whose location must also be maintained during surgical reconstructions&#46; This is particularly important in the medial zygomatic subunit&#44; whose delicate junction with the lower eyelid means that care must be taken to avoid ectropion&#46; We present 5 options for the reconstruction of surgical defects secondary to the excision of tumors in this region&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La mejilla es la subunidad anat&#243;mica mayor de la cara&#46; Es una estructura bilateral&#44; por lo que es necesario respetar la simetr&#237;a&#46; Por otra parte contacta perif&#233;ricamente con importantes orificios naturales cuya localizaci&#243;n debemos respetar en la reconstrucci&#243;n quir&#250;rgica&#46; Esto es particularmente importante en la subunidad cigom&#225;tico-medial&#44; cuya delicada uni&#243;n con el p&#225;rpado inferior hace que tengamos que ser cuidadosos para evitar un ectropi&#243;n&#46; Presentamos 5 opciones reconstructivas de defectos quir&#250;rgicos secundarios a la extirpaci&#243;n de otros tantos tumores en esta localizaci&#243;n&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-Paredes M&#44; Gonz&#225;lez-Sixto B&#44; Otero-Rivas MM&#44; Rodr&#237;guez-Prieto MA&#46; Cirug&#237;a reconstructiva de la regi&#243;n cigom&#225;tica-medial de la mejilla&#58; Presentaci&#243;n de 5 casos&#46; Actas Dermosifiliogr&#46; 2014&#59;105&#58;e27&#8211;e31&#46;</p>"
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                      "titulo" => "Reconstruction of cheek defects&#58; A review of current techniques"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "N&#46; Jowett"
                            1 => "A&#46;M&#46; Mlynarek"
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                    0 => array:2 [
                      "doi" => "10.1097/MOO.0b013e32833a6d7f"
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                        "fecha" => "2010"
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                      "titulo" => "Reconstruction of cheek skin defects by the &#8220;Yin-Yang&#8221; rotation of the Mustard&#233; flap and the temporoparietal scalp"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Belmahi"
                            1 => "A&#46; Oufkir"
                            2 => "T&#46; Bron"
                            3 => "S&#46; Ouezzani"
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                      "titulo" => "Maximizing results in reconstruction of cheek defects&#46; Algorithm for the repair of cheek defects"
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                          "etal" => false
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                            0 => "M&#46;A&#46;M&#46; Mureau"
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                    0 => array:2 [
                      "titulo" => "Monograf&#237;as de dermatolog&#237;a quir&#250;rgica&#46; Escisiones fusiformes&#46; Colgajos cut&#225;neos locales"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:1 [
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                        "fecha" => "2009"
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                        "editorialLocalizacion" => "Barcelona"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Cirug&#237;a de la mejilla"
                      "autores" => array:1 [
                        0 => array:2 [
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Case report
Reconstructive Surgery of the Medial Zygomatic Region of the Cheek: Presentation of 5 Cases
Cirugía reconstructiva de la región cigomática-medial de la mejilla: Presentación de 5 casos
M.G. Pérez-Paredes
Autor para correspondencia
pegemina@yahoo.es

Corresponding author.
, B. González-Sixto, M.M. Otero-Rivas, M.Á. Rodríguez-Prieto
Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The cheek is the largest cosmetic unit of the face&#46; It has clear limits defined by the zygomatic arch and the infraorbital rim superiorly&#44; the nasolabial and melolabial folds medially&#44; the mandibular border inferiorly&#44; and the preauricular region laterally&#46; For educational purposes&#44; it is classically divided into 4 cosmetic subunits&#58; medial&#44; zygomatic&#44; buccal&#44; and lateral&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Each of these subunits has specific characteristics that the surgeon must take into account during reconstruction procedures in order to achieve the best functional and cosmetic outcome&#46; Ideally&#44; incisions and borders of flaps should be situated within these subunits to best camouflage the resulting scars&#46; We evaluate a number of reconstruction techniques in patients with tumors situated in the medial and zygomatic regions&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the medial subunit we must take into account that the union of the cheek with the eyelid forms its own subunit&#44; and we must also therefore respect the position and function of the lower eyelid&#44; as well as the morphology of this subunit and the gradual change that occurs from the malar to the palpebral regions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The zygomatic ligament fixes the skin of the zygomatic subunit&#44; and it must be remembered during surgery that the temporal branch of the facial nerve is in a very superficial plane in this region&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Reconstruction of the malar eminence must respect the fat pad&#44; which creates the convexity of this area and gives it volume&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The blood supply is derived from the facial artery and its branches&#44; motor innervation is via the facial nerve&#44; and the sensory supply is from the maxillary nerve&#44; a branch of the fifth cranial nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 75-year-old woman with a lentigo maligna melanoma of 2&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;2<span class="elsevierStyleHsp" style=""></span>cm&#46; After resection of the lesion&#44; an advancement-rotation flap was designed above the zygomatic arch&#44; extending to tragus&#46; The inferior border of the defect was triangulated and a Z-plasty was used in the preauricular region to allow greater advancement of the flap&#46; The subcutaneous tissue was sutured with Vicryl and the skin was closed with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0035" class="elsevierStylePara elsevierViewall">A man aged 78 years presented a basal cell carcinoma of 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>cm on the lateral third of the upper left eyelid and a lentigo maligna melanoma of 3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm on the left cheek&#46; After excision of the cheek lesion&#44; an advancement flap was designed in the temporal region&#46; The superomedial border of the defect was triangulated&#44; the inferior border was undermined&#44; and the eyelid tumor was excised using a triangular incision&#44; which served as a tension-releasing triangle for advancement of the flap&#46; The skin was sutured with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0040" class="elsevierStylePara elsevierViewall">This patient was a 72-year-old man who presented a solid sclerodermiform basal cell carcinoma of 1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8<span class="elsevierStyleHsp" style=""></span>cm in the malar region&#46; After excision&#44; an advancement-rotation flap was designed&#44; respecting the tension lines of the cheek&#46; The inferior part of the defect was triangulated and a semicircle of healthy skin was excised along the superolateral border to facilitate positioning of the flap&#46; The borders of the flap were sutured with 4&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 4</span><p id="par0045" class="elsevierStylePara elsevierViewall">This patient was a man aged 77 years with a basosquamous carcinoma of 4&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the area of the right lateral canthus and right malar region&#46; After excision of the lesion&#44; the defect was covered by a transposition flap taken from the frontotemporal region&#44; above the ipsilateral eyebrow&#46; The skin was sutured with 4&#47;0 and 5&#47;0 silk &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Case 5</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 79-year-old man presented a lentigo maligna with a diameter of approximately 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm situated on the lateral half of the right palpebromalar region&#46; The surgical defect left by the excision was closed using a Limberg flap from the temporal region &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The skin was sutured with 4&#47;0 silk&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Good clinical&#44; functional&#44; and cosmetic outcomes were achieved in all the cases presented&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The choice of surgical technique will depend on the site&#44; size&#44; thickness&#44; and histological characteristics of the tumor&#46; We must also take into account the age and general state of health of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The main objective&#44; as in any oncologic surgery&#44; is radical excision of the tumor&#59; prevention of the distortion of local structures and achieving the best cosmetic outcome are secondary objectives&#46; To obtain the best cosmetic outcome&#44; we must locate the donor site with the greatest tissue reserve and choose the best reconstruction technique&#46; This is important in the medial zygomatic area&#44; where an inappropriate choice can lead to ectropion and a very visible scar&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A number of reconstruction techniques are available for use at this site&#46; Whenever size permits&#44; primary closure should be chosen&#46; Second-intention healing is not to be recommended&#44; as scar retraction will lead to ectropion&#46; Grafts enable us to cover large defects&#44; but apart from the typically poor cosmetic result in this region&#44; graft retraction can lead to deformities of the adjacent facial subunits&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In our first case&#44; with a medium-sized tumor&#44; the largest tissue reservoir was in the lateral subunit&#46; We decided to use an advancement-rotation flap from the cheek that required a Z-plasty in the preauricular region to allow greater movement&#46; If further tissue mobilization had been necessary&#44; we could have prolonged the zygomatic incision along the preauricular sulcus&#44; even onto the neck&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Belmahi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> described a flap that combined the classic Mustard&#233; flap with a temporoparietal rotation flap that is used to cover the secondary defect left by the Mustard&#233; flap&#46; This technique can be used for defects of up to 7<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other&#44; less desirable alternatives include use of the skin from the medial melolabial area or interpolation flaps&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the second patient&#44; the largest diameter of the surgical defect ran obliquely&#46; The main tissue reservoirs were in the temporal&#44; lateral&#44; and medial buccal subunits&#46; We could therefore have created a preauricular or melolabial advancement-rotation flap or a combination of the two&#46; The existence of a second tumor on the upper eyelid and our evaluation of the elasticity of the skin led us to choose an advancement flap from the temporal subunit&#46; The excision of the tumor on the eyelid served as a tension-relieving triangle for mobilization of the flap&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The third patient presented a small tumor&#46; Primary suture would have been the treatment of choice&#44; but the patient&#39;s skin was difficult to mobilize&#44; which would have led to a high risk of ectropion&#46; The main skin reservoirs were in the zygomatic and upper medial subunits&#46; We decided to use a rotation-advancement plasty from the cheek&#44; following the skin tension lines&#46; A medial plasty would have required incision of the eyelid&#44; which often provokes persistent edema&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The tumor in the fourth patient&#44; in contact with the lateral canthus&#44; affected part of both eyelids and the cheek&#46; The main skin reservoirs were the lateral cheek and the temporal region&#46; We rejected the lateral cheek option because the skin is hairy&#46; Instead we chose a supraciliary transposition flap&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The final patient presented a smaller lesion than the previous patient&#44; but it was at a similar site and the decisions were therefore very similar&#46; The possible tissue reservoirs were the upper medial and the temporal subunits&#46; From the medial area we could fashion a transposition flap with a superior base or a rotation flap with an incision along the melolabial fold&#46; In the temporal region we could use transposition plasties&#44; as above&#44; or a Limberg flap&#46; This patient had sufficient skin in the temporal region and even more close to the lateral canthus&#44; and we thus considered a rhomboidal flap to be a good choice&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It may sometimes be necessary to use combinations of flaps to repair defects in this area&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The main disadvantage of advancement-rotation plasties in the medial zygomatic region of the cheek &#40;cases 1&#44; 2&#44; and<span class="elsevierStyleHsp" style=""></span>3&#41; is the risk of postsurgical ectropion if the flap is not correctly designed&#46; The major complication of transposition flaps &#40;cases 4 and<span class="elsevierStyleHsp" style=""></span>5&#41;&#44; on the other hand&#44; is displacement of the lateral canthus&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When the tension vectors are vertical or horizontal&#44; it may be necessary to anchor the flap to the periostium of the orbital rim to avoid traction on the lower eyelid&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Reconstruction of the medial zygomatic subunit&#44; one of the subunits of the cheek&#44; is particularly complicated&#46; We have described 5 possible reconstruction techniques for this area&#44; discussing other alternatives and explaining the reasons for which we chose each of the options used&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical Disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Protection of human and animal subjects&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information and that written informed consent for voluntary participation was obtained for all patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Surgical flaps"
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            0 => "Mejilla"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The cheek is the largest anatomical subunit of the face&#46; It is a bilateral structure and symmetry must therefore be preserved&#46; Peripherally it is related to important natural orifices whose location must also be maintained during surgical reconstructions&#46; This is particularly important in the medial zygomatic subunit&#44; whose delicate junction with the lower eyelid means that care must be taken to avoid ectropion&#46; We present 5 options for the reconstruction of surgical defects secondary to the excision of tumors in this region&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La mejilla es la subunidad anat&#243;mica mayor de la cara&#46; Es una estructura bilateral&#44; por lo que es necesario respetar la simetr&#237;a&#46; Por otra parte contacta perif&#233;ricamente con importantes orificios naturales cuya localizaci&#243;n debemos respetar en la reconstrucci&#243;n quir&#250;rgica&#46; Esto es particularmente importante en la subunidad cigom&#225;tico-medial&#44; cuya delicada uni&#243;n con el p&#225;rpado inferior hace que tengamos que ser cuidadosos para evitar un ectropi&#243;n&#46; Presentamos 5 opciones reconstructivas de defectos quir&#250;rgicos secundarios a la extirpaci&#243;n de otros tantos tumores en esta localizaci&#243;n&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-Paredes M&#44; Gonz&#225;lez-Sixto B&#44; Otero-Rivas MM&#44; Rodr&#237;guez-Prieto MA&#46; Cirug&#237;a reconstructiva de la regi&#243;n cigom&#225;tica-medial de la mejilla&#58; Presentaci&#243;n de 5 casos&#46; Actas Dermosifiliogr&#46; 2014&#59;105&#58;e27&#8211;e31&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Reconstruction of cheek defects&#58; A review of current techniques"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "N&#46; Jowett"
                            1 => "A&#46;M&#46; Mlynarek"
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                      "doi" => "10.1097/MOO.0b013e32833a6d7f"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Otolaryngol Head Neck Surg"
                        "fecha" => "2010"
                        "volumen" => "18"
                        "paginaInicial" => "244"
                        "paginaFinal" => "254"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20498599"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Current concepts in cheek reconstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;D&#46; Pletcher"
                            1 => "D&#46;W&#46; Kim"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Facial Plast Surg Clin N Am"
                        "fecha" => "2005"
                        "volumen" => "13"
                        "paginaInicial" => "267"
                        "paginaFinal" => "281"
                      ]
                    ]
                  ]
                ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cheek defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46;J&#46; Dobratz"
                            1 => "P&#46;A&#46; Hilger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Facial Plast Surg Clin N Am"
                        "fecha" => "2009"
                        "volumen" => "17"
                        "paginaInicial" => "455"
                        "paginaFinal" => "467"
                      ]
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            ]
            3 => array:3 [
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ISSN: 15782190
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