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A modification of the Duformentel and Mouly split sliding flap
j. max.-fac. Surg. 14 (1986) J. max.-fac. Surg. 14 (1986) 4 3 4 5 © Georg Thieme Verlag Stuttgart . New York
A Modification of the Duformentel and Mouly Split Sliding Flap Yukimasa Sawada
43
Summary A modification of the Duformentel and Mouly split sliding flap technique is described. This technique does not create a dog ear compared to the original split sliding flap, and leaves a Z-scar, which runs in a similar direction to the wrinkle lines. Skin tension after suture is dispersed equally in the horizontal and vertical planes, so that an inconspicuous scar will result. This technique is excellent for the repair of skin defects on the face.
Department of Plastic and Reconstructive SLtrgery, Prefectural Central Hospital (Director: K. Unno, M.D.), Yamagata, Japan
Key-Words
Submitted 4. 1. 1985; accepted 28.2. 1985
Skin defect - Skin flap - Split sliding flap - Reconstruction
Introduction Duformentel and Mouly (1959) described a split sliding flap technique comprising the advancement of two opposing flaps which has the merit of leaving a Z-shaped scar, which will be inconspicuous if the scar can be laid along the wrinkle lines. But this flap risks creation of a dog-ear at the end of the suture line and eventually correction by Burlow's triangle is necessary. We wish to describe a modification of the split sliding flap (MSS flap), which does not create a dog-ear and remains an inconspicuous scar without much tension on the wound in one direction. Technique The lesion is excised in the shape of a tear-drop and two more incisions are made (Fig. 1). Line A-B is slightly oblique to the wrinkle line and almost equal in length to the long axis of the lesion, the excision of which should be designed to be parallel with the wrinkle line, also. Line C - D
runs from the line A-B to the tip of the tear-drop-shaped lesion. After excision of the lesion and elevation of flap 1 and 2, a wide dissection is required. Flap 1 is transposed to cover the defect, and then flap 2 is advanced to cover the defect made after flap I transposition. The tips of both flaps are carefully trimmed. In our experience with twenty cases of this procedure, dog-ear formation and much tension on the wound were not seen. Case Reports Case 1. In this case of a 56-year-old man with a basal cell carcinoma on his nasolabial groove, this technique for the repair of the defect after tumour excision was followed. Seven months after the operation, the scar is almost parallel with the wrinkle line and inconspicuous. The technique did not create any dog-ear or deformity of the nasal ala and upper lip (Fig. 2).
Wrinkle Line
/
/
/
/
/
/
Wrinkle Line
//
Fig. 1 Design of the MSS flap (Top). The lesion is excised and undermined widely, and both flap tips will be carefully trimmed, flap 1 is transposed to cover the defect (Middle). Flap 2 is advanced to cover the remaining defect (Bottom).
44
J. max.-fac. Surg. 14 (1986)
Yukimasa Sawada
Fig. 2 a Basal cell carcinoma of the right cheek. Marking the excision and the flaps.
Fig. 2 b
The results 7 months later.
Fig. 3 a
Fig. 3 b
The result 6 months later.
Naevus of temple.
Case 2. After excision of a naevus on the right temple of an 18-year-old woman, this technique was chosen because it will leave the scar parallel with the wrinkle lines, which cross at a rightangle in this area, starting from the forehead and from the lateral eyelid. After operation, a Z-shaped inconspicuous scar, parallel with each direction of the wrinkle line remained (Fig. 3). Case 3. A 51-year-old man had an accidental tatoo on his left cheek below the lateral eyelid. This was excised and the MSS technique was used for the repair. Two months after operation, the scar is inconspicuous and no dog-ear or deformity of the lateral eyelid are seen (Fig. 4).
Discussion and Conclusion Currently many techniques have been introduced to repair skin defects on the face. In all such procedures, the rhombic flap and its modifications are widely used today (Morgan and Samiian, 1969; Lister, 1972; Becker, 1979; Borges, 1981). But in some instances, the rhombic flap will leave conspicuous scars to some extent, for part of the suture line tends to cross the wrinkle line at an obtuse angle. Therefore, scar revision and Z plasty are needed later in some cases, because to obtain an inconspicuous scar, it is essential that the scar dose not cross the wrinkle line at an obtuse angle without much tension on the w o u n d (Converse,
A Modification of the Duformentel and Mouly Split Sliding Flap
Fig. 4a
Accidental tatoo of left cheek.
Fig. 4 b
J. max.-fac. Surg. 14 (1986)
45
The result 2 months later,
which looks loose in some instances. The DuformenteIand split sliding flap also seems to create a dogear at the end of the suture line. These are shown by an experimental model using gauze (Fig. 5). Hence, the MSS flap, not only prevents the scar from crossing the wrinkle line at an obtuse angle, but will also be able to make the scar almost parallel with the wrinkle lines. Moreover, this technique distributes tension, so that there is no concentration of tension in any part of the suture line. From our experience with twenty cases of the MSS flap, good results were obtained in all cases without any dog-ear formation and too much tension on the wound. We think that the MSS flap is useful in preventing much tension in one direction of the wound and the scar crossing the wrinkle line at an obtuse angle, for small skin defects on the face, especially when the defect is tear-shaped and its long axis runs along the wrinkle lines.
Mouly (1959)
References
Fig. 5 Split sliding flap (Right) and MSS flap (Left). Dog ears are shown in the Split Sliding flap with a gauze model.
Alvarado, A.: Reciprocal incisions for closure of circular skin defects. Plast. Reconstr. Surg. 67 (1981) 482 Becker, H.: The rhomboid-to-W technique for excision of some skin lesions and closure. Plast. Reconstr. Surg. 64 (1979) 444 Borges, A. F.: The rhombic flap. Plast. Reconstr. Surg. 67 (1981) 458 Converse, J. M.: Reconstructive Plastic Surgery (2nd edition). Saunders, Philadelphia 1979 Duformentel, C., R. Mouly: Chirurgie plastique. Flammarion, Paris 1959 Lister, G. D.: Closure of rhomboid skin defects. Brit. J. Plast. Surg. 25 (1972) 300 Morgan, B. L., M. R. Samiian: Advantages of the bilobed flap for closure of small skin defects of the face. Plast. Reconstr. Surg. 44 (1969) 58
1979). Sometimes the rhombic flap, and even a simple closure technique, may create much tension on the w o u n d and create a dog-ear (Alvarado, 1981; Borges, 1981). What is more, a simple closure technique leaves too long a scar
Y. Sawada, M.D. Department of Plastic and Reconstructive Surgery Yamagata Prefectural Central Hospital 7-17 Sakura-cho Yamagata City Yamagata Prefecture 990 Japan
A Modification of the Duformentel and Mouly Split Sliding Flap Yukimasa Sawada
43
Summary A modification of the Duformentel and Mouly split sliding flap technique is described. This technique does not create a dog ear compared to the original split sliding flap, and leaves a Z-scar, which runs in a similar direction to the wrinkle lines. Skin tension after suture is dispersed equally in the horizontal and vertical planes, so that an inconspicuous scar will result. This technique is excellent for the repair of skin defects on the face.
Department of Plastic and Reconstructive SLtrgery, Prefectural Central Hospital (Director: K. Unno, M.D.), Yamagata, Japan
Key-Words
Submitted 4. 1. 1985; accepted 28.2. 1985
Skin defect - Skin flap - Split sliding flap - Reconstruction
Introduction Duformentel and Mouly (1959) described a split sliding flap technique comprising the advancement of two opposing flaps which has the merit of leaving a Z-shaped scar, which will be inconspicuous if the scar can be laid along the wrinkle lines. But this flap risks creation of a dog-ear at the end of the suture line and eventually correction by Burlow's triangle is necessary. We wish to describe a modification of the split sliding flap (MSS flap), which does not create a dog-ear and remains an inconspicuous scar without much tension on the wound in one direction. Technique The lesion is excised in the shape of a tear-drop and two more incisions are made (Fig. 1). Line A-B is slightly oblique to the wrinkle line and almost equal in length to the long axis of the lesion, the excision of which should be designed to be parallel with the wrinkle line, also. Line C - D
runs from the line A-B to the tip of the tear-drop-shaped lesion. After excision of the lesion and elevation of flap 1 and 2, a wide dissection is required. Flap 1 is transposed to cover the defect, and then flap 2 is advanced to cover the defect made after flap I transposition. The tips of both flaps are carefully trimmed. In our experience with twenty cases of this procedure, dog-ear formation and much tension on the wound were not seen. Case Reports Case 1. In this case of a 56-year-old man with a basal cell carcinoma on his nasolabial groove, this technique for the repair of the defect after tumour excision was followed. Seven months after the operation, the scar is almost parallel with the wrinkle line and inconspicuous. The technique did not create any dog-ear or deformity of the nasal ala and upper lip (Fig. 2).
Wrinkle Line
/
/
/
/
/
/
Wrinkle Line
//
Fig. 1 Design of the MSS flap (Top). The lesion is excised and undermined widely, and both flap tips will be carefully trimmed, flap 1 is transposed to cover the defect (Middle). Flap 2 is advanced to cover the remaining defect (Bottom).
44
J. max.-fac. Surg. 14 (1986)
Yukimasa Sawada
Fig. 2 a Basal cell carcinoma of the right cheek. Marking the excision and the flaps.
Fig. 2 b
The results 7 months later.
Fig. 3 a
Fig. 3 b
The result 6 months later.
Naevus of temple.
Case 2. After excision of a naevus on the right temple of an 18-year-old woman, this technique was chosen because it will leave the scar parallel with the wrinkle lines, which cross at a rightangle in this area, starting from the forehead and from the lateral eyelid. After operation, a Z-shaped inconspicuous scar, parallel with each direction of the wrinkle line remained (Fig. 3). Case 3. A 51-year-old man had an accidental tatoo on his left cheek below the lateral eyelid. This was excised and the MSS technique was used for the repair. Two months after operation, the scar is inconspicuous and no dog-ear or deformity of the lateral eyelid are seen (Fig. 4).
Discussion and Conclusion Currently many techniques have been introduced to repair skin defects on the face. In all such procedures, the rhombic flap and its modifications are widely used today (Morgan and Samiian, 1969; Lister, 1972; Becker, 1979; Borges, 1981). But in some instances, the rhombic flap will leave conspicuous scars to some extent, for part of the suture line tends to cross the wrinkle line at an obtuse angle. Therefore, scar revision and Z plasty are needed later in some cases, because to obtain an inconspicuous scar, it is essential that the scar dose not cross the wrinkle line at an obtuse angle without much tension on the w o u n d (Converse,
A Modification of the Duformentel and Mouly Split Sliding Flap
Fig. 4a
Accidental tatoo of left cheek.
Fig. 4 b
J. max.-fac. Surg. 14 (1986)
45
The result 2 months later,
which looks loose in some instances. The DuformenteIand split sliding flap also seems to create a dogear at the end of the suture line. These are shown by an experimental model using gauze (Fig. 5). Hence, the MSS flap, not only prevents the scar from crossing the wrinkle line at an obtuse angle, but will also be able to make the scar almost parallel with the wrinkle lines. Moreover, this technique distributes tension, so that there is no concentration of tension in any part of the suture line. From our experience with twenty cases of the MSS flap, good results were obtained in all cases without any dog-ear formation and too much tension on the wound. We think that the MSS flap is useful in preventing much tension in one direction of the wound and the scar crossing the wrinkle line at an obtuse angle, for small skin defects on the face, especially when the defect is tear-shaped and its long axis runs along the wrinkle lines.
Mouly (1959)
References
Fig. 5 Split sliding flap (Right) and MSS flap (Left). Dog ears are shown in the Split Sliding flap with a gauze model.
Alvarado, A.: Reciprocal incisions for closure of circular skin defects. Plast. Reconstr. Surg. 67 (1981) 482 Becker, H.: The rhomboid-to-W technique for excision of some skin lesions and closure. Plast. Reconstr. Surg. 64 (1979) 444 Borges, A. F.: The rhombic flap. Plast. Reconstr. Surg. 67 (1981) 458 Converse, J. M.: Reconstructive Plastic Surgery (2nd edition). Saunders, Philadelphia 1979 Duformentel, C., R. Mouly: Chirurgie plastique. Flammarion, Paris 1959 Lister, G. D.: Closure of rhomboid skin defects. Brit. J. Plast. Surg. 25 (1972) 300 Morgan, B. L., M. R. Samiian: Advantages of the bilobed flap for closure of small skin defects of the face. Plast. Reconstr. Surg. 44 (1969) 58
1979). Sometimes the rhombic flap, and even a simple closure technique, may create much tension on the w o u n d and create a dog-ear (Alvarado, 1981; Borges, 1981). What is more, a simple closure technique leaves too long a scar
Y. Sawada, M.D. Department of Plastic and Reconstructive Surgery Yamagata Prefectural Central Hospital 7-17 Sakura-cho Yamagata City Yamagata Prefecture 990 Japan