Reconstruction of large rectangular infraorbital and malar skin defects in elderly patients with a modified "reading man flap" using local tumescent anesthesia.

Abstract

The classical "reading man flap" is a recently described flap named after its appearance and mainly used for reconstruction of circular malar or infraorbital skin defects. It avoids surgical complications such as lower lid retraction and ectropion but is limited to circular skin defects. Local tumescent anesthesia uses a diluted local anesthetic together with diluted epinephrine to anesthetize large skin areas without the need for general anesthesia. To assess the esthetic outcome, pain control, and complications of a modified "reading man flap" under local tumescent anesthesia in elderly patients with rectangular malar or periorbital skin defects. Two flaps are used to close the surgical defect, the first rectangular flap is transposed to the defect area, then approximately half to two-thirds of the flap's donor site are closed directly as done with transposition flaps, whereas a second smaller triangular flap is advanced for the closure of the last third of the remaining now triangular donor site, where the greatest tension would occur if closed directly. The median age of patients was 83 years (range 64-92 years) of the total 12 patients, 10 (83%) were women, and two were men. The mean defect size was 9.2 cm(2) (5.5-22.1 cm(2) ). The defect closure was possible in all patients, no lasting postoperative complications occurred, and cosmetic results were satisfactory. Twenty to 70 ml of local tumescent anesthesia were used, and a larger volume (≥ 40 ml) was associated with better pain control (P = 0.03). The modified "reading man flap" is a good option for the closure of larger rectangular facial skin defects especially in elderly patients, and the use of at least 40 ml of tumescent solution is suggested to achieve optimal pain control.