Repairing the Loss of Areas of the Palpebromalar Region: A Modified Mustardé Skin Flap Technique

Abstract

Sir: First described by Mustardé in 1971, the advancement-rotation temporojugal skin flap has been used largely for the loss of areas of the cheek, the temple, and the inferior eyelid.1 Reconstruction by a temporojugal flap using a deep plane sub–superficial musculoaponeurotic system (SMAS) flap, as first described by Barton and Zilmer and popularized by Kroll et al., is used when there is loss of temporojugal substances, or even the external canthus, where the SMAS is well-defined and separable.2,3 However, the role of the SMAS is weak in the palpebromalar region. In effect, the palpebromalar region is the sum of two aesthetic units: the palpebro-orbital region, where the orbicularis oculi muscle plays the role of the SMAS; and the malar region, which is essentially constituted of subcutaneous fatty tissue.4 Consequently, we propose our temporojugal skin flap associated with a malar lift adapted for use in the case of loss of the palpebromalar area. This technique is of special interest in elderly patients, where the risk of ectropion is increased because of a defective skin-SMAS system. Our technique consists of the following: Resection of the tumor according to the Mohs' technique. Lesion repair after finding the margins of healthy tissue using biopsy excisions and microscopy: make the incision starting from the inferior eyelid in line with the lacrimal point, then make one upward and outward line starting from the lateral canthus and curving toward the tip of the eyebrow, then toward the temple and descending to 2 cm below the ear lobe. Then, move 1 cm forward perpendicularly. Incision and broad dissection of the subcutaneous fat above the SMAS plane. Rotation of the skin flap upward and inward. Malar lift: separation of the subperiosteum of the malar fat pad and then fixation the periosteum of the margo orbitalis (Fig. 1).Fig. 1.: Malar lift: subperiosteum dissection.Prior placement of the inferior eyelid under tension using lateral canthopexy: remove the inferior canthal lateral tendon from its orbital attachments, totally free the inferior eyelid and create a neotendon, which is then reinserted in the orbital periosteum at the desired position. Subcutaneous fixation of the cutaneous-fat skin flap at the temporal aponeurosis to give anchorage points. Cutaneous closure by separate points. At the end of surgery, the cutaneous coverage is satisfactory and the stasis of the inferior palpebral region is conserved (Fig. 2).Fig. 2.: Conservation of the stasis of the inferior palpebral region.The aim is to achieve a deep plane with vertical traction, which is fixed firmly to the periosteum.2,3,5 Use of the sub-SMAS is feasible for the loss of substance of the temporal or the external canthus. However, the SMAS is limited to the lower palpebral and malar regions with the loss of central or paracentral substance. With the same purpose as deep dissections, we propose a subperiosteal detachment of the malar region with vertical traction. Associated with a classic lateral canthopexy, the malar lift provides major support for the inferior eyelid. This technique should be used for the reconstruction of large defects of the inferior eyelid and the malar region. DISCLOSURE The authors have no financial or commercial interests to disclose. Sophie Converset-Viethel, M.D. Philippe Kestemont, M.D. Jose Santini, M.D. Alexandre Bozec, M.D. Nicolas Guevara, M.D. Head and Neck Surgery Department University Hospital Nice, France