Surgical Corner. The Temporal Suspension Flap for Malar Defects: A Novel Technique

February 2013 | Volume 12 | Issue 2 | Feature | 206 | Copyright © 2013

Isaac Zilinsky MD,a-c* Nimrod Farber MD,a-c* Oren Weissman MD,a Hadar Israeli MD,a Eyal Winkler MD,a and Josef Haik MDa

aMohs Micrographic Surgery Unit, bDepartment of Plastic and Reconstructive Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel cThe Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel *I. Zilinsky & N. Farber contributed equally to this work.

Abstract

The upper lateral cheek bear unique and distinct local characteristics that are key features in facial aesthetics and functionality. Its main landmarks are the lower eyelid, the lateral canthus and the temporal hairline. When contemplating treatment options for defects in this area the surgeon should take into consideration the possible effects of the reconstructive method on the preservation of aesthetics and function. Hence, the goals of a successful reconstruction are correct and stable lid positioning, inconspicuous malar (zygomatic) scars and avoiding disturbance to the temporal hairline.

J Drugs Dermatol. 2013;12(2):206-207.

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BACKGROUND

The upper lateral cheek bears unique and distinct local characteristics that are key features in facial aesthetics and functionality. Its main landmarks are the lower eyelid, the lateral canthus, and the temporal hairline. When contemplating treatment options for defects in this area, the surgeon should take into consideration the possible effects of the reconstructive method on the preservation of aesthetics and function. Hence, the goals of a successful reconstruction are correct and stable lid positioning, inconspicuous malar (zygomatic) scars, and avoiding disturbance to the temporal hairline.1 There are several suitable approaches, based on defect size, anatomical details, and functional concerns. Locally based skin grafts and flaps provide the best results because of superior color and texture compared with distant donor sites.2

In general, postoperative complications include mismatched skin (in terms of color, texture, and thickness), bulgy appearance of an inappropriately large graft, pincushioning of the flap (“trap door” deformity), and retraction of the lateral eyelid, causing lateral lower-eyelid ectropion.1-3 The risk for the latter complication increases as defects become larger and when the extent of lid involvement is substantial. We suggest a reconstructive technique that uses local skin and minimizes the risk of lower-lid retraction and consequent ectropion.

SURGICAL TECHNIQUE

A template of the malar defect is copied to the ipsilateral temple above a virtual horizontal line from the lateral canthus to the superior border of the crus of helix. Incisions should be placed within relaxed skin tension lines4 to conceal scars (Figure 1). The defect and its outlined copy are joined by superior and inferior outline “lazy S’s” (Figure 2). The healthy skin is excised and placed in a saline solution until the reconstruction is completed. The malar skin is undermined to create a flap that is raised and secured with deeply placed braided nonabsorbable sutures such as 3-0 TiCron™ (Covidien, Mansfield, MA) at the level of the temple. Closing the gap laterally facilitates approximation of the edges of the original defect while alleviating tension on the lower-eyelid skin, thereby minimizing the chance of ectropion (Mustardé principle5). If despite careful preoperative planning the final defect proves too large for a tension-free closure or lower-lid ectropion becomes an impending risk, the healthy skin excised from the temporal template can be grafted as reinforcement (Figure 3).

RESULTS

Between 2005 and 2011, 7 patients (6 male, 1 female) underwent reconstruction of malar defects with the temporal suspension flap. Two patients required a combination of a temporal suspension flap and a salvage skin graft, one of whom underwent a canthopexy at a later stage. All patients had excellent cosmetic and functional results.

DISCUSSION

When reconstructing defects in the proximity of the lower eyelid, the surgeon should aim toward achieving correct height and stable lid margins. The malar skin texture is smooth and telangiectatic, giving it a ruby red appearance. It also has a convex contour, which makes it shiny when illuminated from any direction. There-


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