INTRODUCTION
Cutaneous neoplasms are frequent on the face and cause functional and aesthetic morbidity
in patients, with basal cell carcinoma (BCC) being the most common type1. Melanoma and non-melanoma skin cancer affect the eyelid region in 5 to 10% of cases2. Reconstruction of the lower eyelid after excision of neoplasia or trauma is challenging
due to the small amount of excess tissue.
The choice of the best flap depends on the location, size, and depth (if there is
tarsal involvement, that is, the posterior lamella). Superficial surgical defects
only require reconstruction of the anterior lamella (skin and muscle), whereas full-thickness
defects require both anterior and posterior lamellae (tarsus and conjunctiva) to be
reconstructed3,4. This article aims to describe a new technique option for surgical wound reconstruction.
Flaps are preferred in defects greater than 33% of the affected eyelid to avoid retraction
of the area and prevent ectropion due to the vertical tension at the site. The flaps
most used for eyelid reconstruction are advancement with or without canthotomy; transposition;
mustard; McGregor; Fricke; Landolt-Hughes; Dutupuys-Dutemps-Hughes (uses skin and
mucosa of the upper eyelid); and Abbe3.
OBJECTIVE
This article presents a new surgical proposal to facilitate the reconstruction of
the lower eyelid when the anterior lamella is affected by more than two-thirds, using
a double transposition flap.
METHOD
Female patient, 70 years old, with recurrence, 9 years after the first surgery without
margin control, of BCC in the topography of the lower right eyelid, was admitted to
Instituto Azulay in Rio de Janeiro, RJ. A pearly lesion appeared 6 months ago on clinical
examination, with exulcerations and 19x12mm in diameter (Figure 1). Dermoscopy revealed the presence of erythema, ulceration, maple leaves, some ovoid
nests, and chrysalis.
Figure 1 - Dermoscopic delimitation of basal cell carcinoma in the lower right eyelid, measuring
19x12mm.
Figure 1 - Dermoscopic delimitation of basal cell carcinoma in the lower right eyelid, measuring
19x12mm.
On October 19, 2021, the patient underwent local anesthesia with Klein’s modified
tumescent solution and complete tumor excision with intraoperative freezing. After
enlarging the surgical margins of an infiltrative BCC, a defect greater than 50% of
the anterior lamella was obtained (Figure 2).
Figure 2 - After enlarging the surgical margins of an infiltrating basal cell carcinoma, a defect
greater than 50% of the anterior lamella was obtained.
Figure 2 - After enlarging the surgical margins of an infiltrating basal cell carcinoma, a defect
greater than 50% of the anterior lamella was obtained.
The McGregor flap was chosen first to close the wound; however, due to the tissue’s
low mobility, it was impossible to perform the programmed flap advancement movement
after interpolating the z-plasty triangles.
Therefore, the McGregor flap was modified. After making an M-shaped incision in the
temporal region – lateral to the defect – two symmetrical triangles were created with
their largest axis, the size of the largest radius of the wound (Figure 3). The tissue was detached from the malar and temporal regions, and the first triangle
was transposed towards the wound to close the primary defect, and then the second
triangle was transposed to close the area of the first triangle. Finally, the space
of the second triangle was primarily closed. Thus, the movement of the first triangle
was a combination of transposition and rotation movements to move the tissue toward
the surgical wound.
Figure 3 - Modification of the McGregor Flap Technique. Two symmetrical triangles were made with
their largest axis, the size of the largest radius of the wound. Transpose the first
triangle toward the wound to close the primary defect, and then transpose the second
triangle to close the area of the first triangle.
Figure 3 - Modification of the McGregor Flap Technique. Two symmetrical triangles were made with
their largest axis, the size of the largest radius of the wound. Transpose the first
triangle toward the wound to close the primary defect, and then transpose the second
triangle to close the area of the first triangle.
Gilles stitches were made to fix each tip of the transposed triangles and internal
and external stitches with mononylon 5.0 (Figure 4).
Figure 4 - Immediate postoperative.
Figure 4 - Immediate postoperative.
RESULTS
The patient had no major complications during the postoperative period. Eyelid swelling
is expected, with difficulty opening the eyes and a slight hematoma in the first days
after surgery, which usually resolves within a week. She received prophylactic antibiotic
therapy with cefadroxil. The stitches were removed on the 14th postoperative day, and from the 21st day onwards, massage was recommended for drainage of residual edema and photoprotection.
The photos were taken immediately, on the 7th, 14th, 21st, and 45th postoperative days (Figure 5).
Figure 5 - 45th postoperative day, good aesthetic and functional result.
Figure 5 - 45th postoperative day, good aesthetic and functional result.
The result was satisfactory, maintaining aesthetics and local functionality and providing
a discreet and barely perceptible scar.
DISCUSSION
Eyelid reconstruction is challenging due to this area’s anatomical and physiological
characteristics. It is mainly based on two factors: thickness and extension of the
defect5. The lower eyelid and medial canthus are the most affected regions, and these periorbital
cutaneous tumors can be difficult to manage, commonly treated with surgical excision6.
Although many surgical techniques are available, there is no preferred method of choice.
Among the available modalities for closing the lower eyelid transposition flaps such
as the Tripier, which consists of a myocutaneous transposition flap, the Fricke flap,
the Kreibig flap, and the nasolabial flap with an upper base. Among the advancement
flaps, there is the McGregor (which associates the advancement technique with z-plasty)
and the Imre flap. As for the rotation ones, the Mustardè technique is a widely used
option to repair extensive defects in the anterior lamella of the lower eyelid or
combination with cartilage and mucosa grafts to close the posterior lamella7.
The transposition flap with zetaplasty is a possibility for closing several surgical
defects on the face, as it allows a complete redirection of the stress vector through
islands of healthy skin. Due to these characteristics, it is indicated for closing
defects close to the free margins, such as the nasal wing, lips, helix, and eyelids8.
In 1973, McGregor published the lateral periorbital z-plasty associated with forward
movement, an excellent alternative within the reconstructive therapeutic arsenal6,9. In this case, z-plasty is performed at the lateral end of the incision, with the
defect’s width corresponding to the central branch of the Z. The lateral descending
branch and the ascending branch of the Z are the same length as the central branch
and form an angle of 60 degrees with it. Lateral canthotomy is performed to allow
advancement of the flap and coverage of the eyelid defect. After interpolation of
the flaps, any excess skin is trimmed6,9.
In contrast, instead of performing the forward movement after interpolation of the
z-plasty triangles, in this patient, we performed an M-shaped incision. We combined
the movement of transposition and rotation of the first triangle (Figure 6) with the subsequent transposition of the second triangle. In the other studies found
in the literature, the construction of a double, triple, or even quadruple transposition
flap is performed at opposite angles and equidistant from the largest diameter of
the surgical defect. However, in this case, there would be a risk of ectropion, a
different technique than those already published.
Figure 6 - The drawing compares the previously described McGregor technique (A) and the modified
flap (B) with transposition and rotation of the first lobe (illustrated by a star
or circle) for closure of the primary defect and transposition of the second lobe
(3) for closure of the secondary defect.
Figure 6 - The drawing compares the previously described McGregor technique (A) and the modified
flap (B) with transposition and rotation of the first lobe (illustrated by a star
or circle) for closure of the primary defect and transposition of the second lobe
(3) for closure of the secondary defect.
Thus, this report demonstrates a technique of a double transposition flap, in which
its design was inspired by the McGregor flap, differing from the other described techniques.
1. Instituto de Dermatologia Prof. Rubem David Azulay, Cirurgia Dermatológica, Rio
de Janeiro, Rio de Janeiro, Brazil
Corresponding author: Lissiê Lunardi Sbroglio Bastian Departamento de Cirurgia Dermatológica, Instituto de Dermatologia Professor Ruben
David. Azulay. Rua Santa Luzia, 206, Centro, Rio de Janeiro, RJ, Brazil. Zip code:
20020-022 E-mail: lissiesbroglio@gmail.com
