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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 6 | 17 |
| 2024 Octubre | 98 | 55 | 153 |
| 2024 Septiembre | 95 | 30 | 125 |
| 2024 Agosto | 116 | 56 | 172 |
| 2024 Julio | 136 | 30 | 166 |
| 2024 Junio | 129 | 32 | 161 |
| 2024 Mayo | 120 | 37 | 157 |
| 2024 Abril | 85 | 32 | 117 |
| 2024 Marzo | 90 | 24 | 114 |
| 2024 Febrero | 90 | 34 | 124 |
| 2024 Enero | 59 | 32 | 91 |
| 2023 Diciembre | 61 | 13 | 74 |
| 2023 Noviembre | 104 | 43 | 147 |
| 2023 Octubre | 80 | 26 | 106 |
| 2023 Septiembre | 78 | 31 | 109 |
| 2023 Agosto | 77 | 20 | 97 |
| 2023 Julio | 87 | 33 | 120 |
| 2023 Junio | 80 | 26 | 106 |
| 2023 Mayo | 81 | 34 | 115 |
| 2023 Abril | 74 | 21 | 95 |
| 2023 Marzo | 56 | 31 | 87 |
| 2023 Febrero | 60 | 27 | 87 |
| 2023 Enero | 45 | 25 | 70 |
| 2022 Diciembre | 50 | 33 | 83 |
| 2022 Noviembre | 42 | 37 | 79 |
| 2022 Octubre | 45 | 26 | 71 |
| 2022 Septiembre | 41 | 37 | 78 |
| 2022 Agosto | 36 | 38 | 74 |
| 2022 Julio | 26 | 34 | 60 |
| 2022 Junio | 30 | 23 | 53 |
| 2022 Mayo | 40 | 49 | 89 |
| 2022 Abril | 54 | 35 | 89 |
| 2022 Marzo | 51 | 58 | 109 |
| 2022 Febrero | 39 | 22 | 61 |
| 2022 Enero | 98 | 49 | 147 |
| 2021 Diciembre | 52 | 38 | 90 |
| 2021 Noviembre | 58 | 58 | 116 |
| 2021 Octubre | 61 | 67 | 128 |
| 2021 Septiembre | 47 | 47 | 94 |
| 2021 Agosto | 44 | 37 | 81 |
| 2021 Julio | 36 | 32 | 68 |
| 2021 Junio | 38 | 33 | 71 |
| 2021 Mayo | 43 | 50 | 93 |
| 2021 Abril | 66 | 95 | 161 |
| 2021 Marzo | 71 | 39 | 110 |
| 2021 Febrero | 70 | 36 | 106 |
| 2021 Enero | 35 | 32 | 67 |
| 2020 Diciembre | 37 | 29 | 66 |
| 2020 Noviembre | 36 | 26 | 62 |
| 2020 Octubre | 53 | 14 | 67 |
| 2020 Septiembre | 41 | 24 | 65 |
| 2020 Agosto | 45 | 31 | 76 |
| 2020 Julio | 27 | 23 | 50 |
| 2020 Junio | 35 | 33 | 68 |
| 2020 Mayo | 44 | 20 | 64 |
| 2020 Abril | 53 | 11 | 64 |
| 2020 Marzo | 27 | 8 | 35 |
| 2020 Febrero | 2 | 0 | 2 |
| 2019 Febrero | 1 | 0 | 1 |
| 2018 Noviembre | 23 | 0 | 23 |
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