Brief Comunication
East-West Flap After Mohs Micrographic Surgery
Colgajo este-oeste después de la cirugía micrográfica de Mohs
J. Magliano, M.P. Abelenda, J. Navarrete
, C. Bazzano
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Cátedra de Dermatología, Hospital de Clínicas Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
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Magliano, M.P. Abelenda, J. Navarrete, C. Bazzano" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Magliano" ] 1 => array:2 [ "nombre" => "M.P." "apellidos" => "Abelenda" ] 2 => array:4 [ "nombre" => "J." "apellidos" => "Navarrete" "email" => array:1 [ 0 => "jnavarrete90@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Bazzano" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cátedra de Dermatología, Hospital de Clínicas Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo este-oeste después de la cirugía micrográfica de Mohs" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 551 "Ancho" => 1333 "Tamanyo" => 38442 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Repair of distal nasal defects resulting from Mohs micrographic surgery is a challenge, but surgeons can choose from a number of techniques. We present 3 cases in which an east-west flap was used to close the defect. The east-west flap is an easily conceived advancement flap that consists of a superior triangle used to cover the defect and an inferior triangle whose base is located along the advancement line. The flap results in an optimal cosmetic outcome and involves minimum movement of tissue (preserving the nasal architecture) and well-camouflaged suture lines.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0010" class="elsevierStylePara elsevierViewall">Skin cancer accounts for a third of malignant tumors in humans, and nonmelanoma tumors and basal cell carcinomas account for about 80% of skin cancers. These tumors are usually located on sun-exposed skin, especially the T-zone and in patients with low-phototype skin or chronic sun damage. The face is a high-risk zone for any size lesion. Once a lesion is removed surgically, a firm diagnosis can be reached and tumor-free margins confirmed. Mohs micrographic surgery (MMS) is able to preserve as much healthy tissue as possible, and all margins can be inspected. MMS is associated with lower recurrence rates than conventional surgery and has been shown to be effective in the treatment of nonmelanoma skin cancer.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The surgeon must choose the optimal approach for closing the post-MMS defect. Closure on the nose, where most nonmelanoma tumors are found,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> is challenging. Available techniques are direct closure, flaps, grafts, or second-intention healing. Skin flaps have the advantage of advancing skin from the surrounding area, and they provide a good blood supply.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> We describe our experience in 3 cases in which east-west flaps were used to repair defects after MMS.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The east-west advancement flap, a technique first described by Perry Robins, is often used to repair small defects of less than 1.5<span class="elsevierStyleHsp" style=""></span>cm in diameter on the nose and nearby areas.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–8</span></a> It allows skin to be advanced in a single direction and is designed by making a vertical triangle superior to the defect and another release triangle inferior to it. The base of the inferior triangle will be half the width of the primary defect and its overall size will be similar to the first triangle's.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The height of the triangles will be the same, and a larger defect will require a larger release triangle.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,8</span></a> The flaps should be undermined below the muscle and above the perichondrium so the tissue can slide horizontally toward the defect.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Three perpendicular sutures anchor the flaps (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">This study aimed to describe patient and physician assessments of the cosmetic outcomes of east-west flap repairs 6 months after MMS. Two dermatologists who did not treat the patients evaluated the results based on standardized photographs taken at the 6-month follow-up visits. Outcomes were classified as excellent, very good, good, fair, poor, or very poor.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 1</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 72-year-old man with phototype/III skin was treated for a nodular basal cell carcinoma on the nasal tip. It measured 0.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>cm on the nasal tip (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A) and had appeared 9 months earlier. The lesion was removed in a single stage of MMS, leaving a surgical defect measuring 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.9<span class="elsevierStyleHsp" style=""></span>cm that was closed with an east-west advancement flap. There were no complications and both the dermatologists and the patient evaluated the results as good (Figs 2B and 2C).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 2</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 42-year-old woman, a smoker with phototype-IV skin, was treated for an ulcerated nodular basal cell carcinoma measuring 0.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.4<span class="elsevierStyleHsp" style=""></span>cm that had appeared on the nasal tip approximately 12 months earlier (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D). The 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1-cm defect left by 2-stage MMS was repaired with an east-west flap. There were no complications. The 2 dermatologists described the outcome as good and the patient assessed it as very good (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>E and 2F).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Case 3</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 75-year-old man with phototype-III skin who had undergone several surgeries for nonmelanoma skin cancer was treated for a nodular basal cell carcinoma measuring 0.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.7<span class="elsevierStyleHsp" style=""></span>cm on the nasal tip that had appeared 6 months earlier (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>G). It was removed by MMS in a single stage. The defect, which measured 1.2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.2<span class="elsevierStyleHsp" style=""></span>cm, was repaired with an east-west flap. There were no complications and both dermatologists and the patient evaluated the results as excellent (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>H and 2I).</p><p id="par0045" class="elsevierStylePara elsevierViewall">At the 6-month follow-up visits there were no signs of recurrence. The patients continue to be followed in accordance with current protocols.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Many different flap techniques have been described for repairing nasal defects after MMS. The size of the defect and the anatomical location must be considered when selecting a technique that will preserve function and provide a cosmetically satisfactory outcome.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> We chose the east-west flap as ideal for the characteristics shared by the patients in this series.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This flap has a number of advantages. It facilitates the repair of small defects; provides a robust vascular pedicle and good tissue compatibility; minimizes tension; and preserves nasal architecture, symmetry, texture and color.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Both functional and cosmetic outcomes are excellent 6 months after surgery.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The east-west flap is used mainly on large or long noses with defects that are longer than they are wide and located on sebaceous skin.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–8</span></a> Our patients met these criteria.</p><p id="par0065" class="elsevierStylePara elsevierViewall">A limitation of this flap is the difficulty of using it to repair medium-sized or large defects. It is also problematic in certain nasal locations, such as at the lower sidewalls, the edges of the alae, and the narrower portion of the tip.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The east-west flap is also a good choice for repairing defects on other facial structures, such as the upper lip, the eyelids, the external ear, and the cheek.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> These are all locations where there is extra tissue available for flaps.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The east-west flap is simpler than the bilobed flap, although the latter is preferred for closing paramedian nasal defects and may even be superior to transposition flaps (which can lead to tissue distortion) and to rotation flaps (which require larger incisions in nonexposed areas).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">To conclude, these surgical defect repairs are challenging. The east-west flap is indicated for small defects of less than 1.5<span class="elsevierStyleHsp" style=""></span>cm in diameter at the tip of the nose, where it provides excellent functional and cosmetic results.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1268599" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1268597" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1174188" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1268598" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0015" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1174189" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Case Descriptions" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 3" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1174188" "palabras" => array:5 [ 0 => "Surgical dermatological procedures" 1 => "Mohs micrographic surgery" 2 => "Skin cancer" 3 => "Basal cell carcinoma" 4 => "Squamous cell carcinoma" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1174189" "palabras" => array:5 [ 0 => "Procedimientos quirúrgicos dermatológicos" 1 => "Cirugía micrográfica de Mohs" 2 => "Cáncer de piel" 3 => "Carcinoma basocelular" 4 => "Carcinoma espinocelular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Repair of distal nasal defects resulting from Mohs micrographic surgery is a challenge, but surgeons can choose from a number of techniques. We present 3 cases in which an east-west flap was used to close the defect. The east-west flap is an easily conceived advancement flap that consists of a superior triangle used to cover the defect and an inferior triangle whose base is located along the advancement line. The flap results in an optimal cosmetic outcome and involves minimum movement of tissue (preserving the nasal architecture) and well-camouflaged suture lines.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La reparación de los defectos nasales distales producidos durante la cirugía micrográfica de Mohs representa un desafío para el cirujano. Existen múltiples técnicas por las cuales se puede optar para el cierre del defecto. Presentamos 3 casos en los que se realizó el colgajo <span class="elsevierStyleItalic">este-oeste</span>, un colgajo de avance, de fácil diseño, que consiste en un triángulo que cubre el defecto y un segundo triángulo de descarga con sus bases en la línea de desplazamiento. Con este colgajo se obtiene un óptimo resultado estético con un movimiento mínimo de los tejidos, preservando la arquitectura nasal y con líneas de sutura bien disimuladas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Magliano J, Abelenda MP, Navarrete J, Bazzano C. Colgajo este-oeste después de la cirugía micrográfica de Mohs.Eczema y urticaria en Portugal. 2019;110:759–762.</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" => 1440 "Ancho" => 2500 "Tamanyo" => 108658 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A, Defect and design of an east-west flap. B, Release and advancement of the triangular flaps. C, Closure (suture lines).</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" => 1750 "Ancho" => 1750 "Tamanyo" => 507290 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Incision lines drawn on patients 1, 2, and 3 (A, D, and G, respectively), their results immediately after surgery (B, E, and H), and their results at the 6-mo follow-up visits (C, F, and <span class="elsevierStyleSmallCaps">I</span>).</p>" ] ] 2 => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 551 "Ancho" => 1333 "Tamanyo" => 38442 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consensus for nonmelanoma skin cancer treatment: Basal cell carcinoma, including a cost analysis of treatment methods" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.N. 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