ARTICLE
For many years, skin surgery has looked for new techniques to remove
tumors completely and close the remaining defect with the best possible
functional/cosmetic results and the minimal removal of tissue. This was
the purpose of designing the M-plasty technique which turns an ovoid or
square wound into a fusiform defect. Two lateral triangles of 1.5 times
the length of the defect are designed to obtain the optimal dimensions
for closing the defect without dog-ears. However, if we excised all of
this area we would eliminate excessive normal tissue on both sides. For
this purpose we reduce the size of each triangle; the height of these
triangles is exactly half of the former large one (Scheme
1). These two new triangles represent the area to be excised so
to leave a romboid on each side of the fusiform excision. We then suture
these triangular defects, so that the central area is brought together.
An intradermal suture is usually sufficient, and superficial steri-strip
or stitches may be used additionally at the surgeon's discretion [1].
In some locations it may be unsuitable, if not
impossible, to use M-plasty as it was originally designed. For this kind
of situation Asken introduced a series of modifications in the M-plasty
technique with far better cosmetic results [2, 3]. The main modification
was to use the technique at one end only with an elliptical or fusiform
incision outlined at the opposite side. Asken also modified the size and
shape of the lateral branches enabling different lateral triangles to
be designed: one branch may be longer than the other or both triangles
may be curved and have identical or different branches, depending on the
amount of normal tissue to be spared (Scheme
2).
The use of the M-flap at one edge, with a fusiform excision at the opposite
edge, is best suited to avoid retractile linear scarring near the cavities
in the external or internal canthus, mouth angles and nasogenian folds.
But it is also suitable to avoid crossing facial cosmetics units; for
example, when a labial V-block is made, the procedure can be completed
with M-plasty to avoid cutting the chin [4]. Furthermore, when the defect
is located in the glabellar area, because of the wrinkle orientation (lion's
wrinkles) resulting from glabellar muscle contraction, M-plasty is useful
to avoid bringing the eyebrows together [1].
We wanted to evaluate this last possibility so we reviewed all M-plasties
performed in the interglabellar edge for the last six years.
Patients and methods
In our archives we found 11 cases of mediofrontal and interglabellar
basal cell carcinomas (BBC) which had been treated using this technique.
Out of these patients, 5 were females between 33 and 67 years old and
6 were males between 43 and 72. The clinical forms of the carcinomas were:
4 nodular, 4 cystic, 2 noduloulcerative and 1 superficial cicatrizing
basal cell carcinoma. The histological types were 9 nodular and 2 multifocal
superficial-spreading BCC. In all cases, we performed a histological study
of the margins, although we did not performed Mohs micrographic surgery
in any of them.
The technique was always the same. Marking of the area to be excised
surrounding the basal cell carcinoma (Figs.
1A and 1B).
Removal of the designated tissue which had a fusiform distal edge; the
interglabellar area was cut in the M-plasty form (Figs.
2A and 2B).
Six days later the stitches were removed and steri-strips applied (Fig.
3A).
Results
After 10-12 days, all the patients were discharged from hospital (Figs.
3A and 3B)
without any dehiscences nor complications. One month later we considered
that the results were excellent (Fig.
4).
Discussion
The only way to confirm that this technique is better than the previous
ones used by us was a retrospective study of all patients with interglabellar
basal cell carcinomas treated using other techniques. We have checked
19 previous cases in which we had performed fusiform excisions with short
branches to avoid excising 1.5 times the size of the tumor on each side,
in addition to 9 cases in which we had used a Limberg's flap and transposed
superior mediofrontal skin to close the defect [5].
According to our previous results we can confirm that M-plasty at one
edge is an easy technique that maintains the tissues in their natural
position or with their wrinkle orientation, avoids bringing the eyebrows
together and presents few complications. However, this technique can only
be useful when the excision is small; if the interglabellar defect is
large it is necessary to close the defect with a frontal transposition
flap, preferably the Limberg's flap [6, 7].
REFERENCES
1. Camacho F, Dulanto F. Corte de los tejidos. In: Camacho F, Dulanto
F, eds. Cirugía dermatológica. Madrid. Grupo Aula
Médica, 1995: 83-100.
2. Asken S. A modified M-plasty. J Dermatol Surg Oncol 1986;
12: 369-73.
3. Asken S. Modified M-plasty. In: Robins P, ed. Surgical gems in
Dermatology. New York. Journal Pub. Group, 1988: 26-7.
4. Camacho F, Dulanto F. Normas para obtener una buena cicatriz y corregir
las defectuosas. In: Camacho F, Dulanto F, eds. Cirugía dermatológica.
Madrid. Grupo Aula Médica, 1995: 101-11.
5. Camacho F, Dulanto F. Cirugía de la frente. In: Camacho F,
Dulanto F, eds. Cirugía dermatológica. Madrid. Grupo
Aula Médica, 1995: 505-18.
6. Peres Correia M, Ortega M, Sánchez Conejo-Mir J, et al.
El colgajo de Limberg en terapéutica dermatológica. Actas
Dermosifiliogr 1990; 81: 714-7.
7. Camacho F. Glabellar flap with geometric measurements. Similarity
to the Limberg and Dufourmentel flaps. J Dermatol Surg Oncol 1987;
13: 1066-8.
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