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The “reading man” flap in facial reconstruction: Report of 12 cases

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Letter: The “reading man” flap in facial reconstruction: Report of 12 cases
Roberto Cecchi MD, Laura Fancelli MD, Michela Troiano MD
Dermatology Online Journal 18 (2): 16

Department of Dermatology, Spedali Riuniti, Pistoia, Italy


Reconstruction of defects in the infraorbital, malar, and temporal areas after tumor resection may present problems such as distortion of anatomic points and extra normal skin removal. The “reading man” flap is a recent local flap procedure, which has been used to solve those problems. We report our experience with this procedure, which has been used for the closure of circular defects in 12 patients (7 men and 5 women), aged 68 to 86 years (mean age: 77 years), who had undergone surgical excisions of basal cell carcinomas of the temporal, malar, and infraorbital regions. The functional and aesthetical results were satisfactory in all cases. In our experience, the “reading man” flap is a useful option for the reconstruction of circular defects in these facial areas.

The repair of skin defects on the malar, infraorbital and temporal regions is often challenging. Potential complications of reconstructions in these areas include scar formation, dog-ear occurrence, trapdoor deformity, and displacement or retraction of neighboring anatomic structures, such as the lower eyelids, nasal ala, and oral commissure.

A variety of local flap procedures, such as advancement, rotation, transposition, or combinations thereof can be employed, depending on the anatomic location, wound width, and wound depth [1, 2, 3, 4]. Generally, the aesthetic results of flap techniques exceed those obtained from second intention healing or skin grafting. Because many defects are circular in shape, the availability of new flap procedures for circular wound coverage is always welcome.

The “reading man” flap (RMF) is a recently developed reconstruction technique based on the use of two random pattern flaps, designed in an unequal Z-plasty manner [5]. It has been originally proposed to repair circular defects of various sizes in different skin areas [5]. Afterword, this procedure has been mainly employed for the reconstruction of surgical defects involving the malar and infraorbital regions [6, 7]. The RMF consists of an upper quadrangular flap with the upper pedicle lateral to the primary defect, and a lower triangular flap, with the vertex at the base of the substance loss. Both flaps have the same length. After adequate undermining, the first flap is transposed to repair the primary defect, whereas the triangular flap restores the first flap’s donor site [5, 6, 7]. The flap’s name refers to the silhouette, which resembles a person who is reading a newspaper.

Figure 1Figure 2
Figure 1. Basal cell carcinoma of the right infraorbital region with the preoperative design of the “reading man” flap (Case 1)

Figure 2. Final suturing (Case 1)

Figure 3
Figure 3. Postoperative view after 18 months (Case 1)

For over 3 years, this procedure has been used in our department for the closure of circular defects in 12 patients (7 men and 5 women), aged 68 to 86 years (mean age: 77 years) with basal cell carcinomas (BCC) of the temporal, malar, and infraorbital regions. All patients were diagnosed with BCC.. Most of the tumors were located on the malar and infraorbital areas (75%, n=9), whereas only three patients (25%) had tumors on the temporal site. Eight patients underwent tumor excision by Mohs micrographic surgery. The defect size ranged between 1.2 x 1.2 and 3.5 x 3.5 cm (mean: 2.2 x 2.2 cm). These data are summarized in Table 1. All procedures were performed under local anaesthesia, without any relevant complications. Patients were followed with preoperative, immediate postoperative, and long-term digital photographs. Surgical outcomes were evaluated by two dermatologic surgeons of our department, who examined patients at follow-up visits. Evaluation criteria included the presence of local complications, such as facial nerve injury, lower eyelid retraction, ectropion, epiphora, dog ear formation, and overall cosmesis. Overall cosmesis grade was considered as: 0 = unsatisfactory, 1 = satisfactory or good, 2 = very satisfactory or excellent. A mean follow-up of 12 months (range 4-20 months) revealed satisfactory functional and aesthetic results in all patients. In three cases cosmetic outcomes were considered excellent. The mean overall cosmesis grade was 1.25. Flap color, texture, and thickness were similar to those of the neighboring skin. No trapdoor effect, dog-ear formation, or ectropion were apparent and the residual scars were acceptable. Two cases are illustrated in Figures 1 through 5.

Figure 4Figure 5
Figure 4. Residual defect after Mohs micrographic surgery for basal cell carcinoma of the left temporal area repaired with “reading man” flap (Case 12)

Figure 5. Postoperative view after 3 months (Case 12)

Our experience supports the utility and advantages of the RMF in the reconstruction of circular defects in the temporal, malar, and infraorbital regions. It does not require transforming a circular into a lozenge-shaped defect that would require an additional excision of healthy tissue. It allows a tension-free coverage, without causing distortions of the neighboring anatomic structures. The flap is easy to carry out and does not require complex planning. Limitations to the use of RMF are defects localized in areas with poorly distensible skin, such as the scalp, and substance losses larger than 2 cm in the infraorbital area and 4 cm in the malar area [6]. Nevertheless, other authors have employed this technique to restore defects up to 8.5 cm in the malar region and 14 cm in other body areas [5, 7]. In our case series all defects were confined to the malar, infraorbital, and temporal regions, and did not exceeded 3.5 cm in diameter. Alternative options should be considered to repair major defects in these areas.


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