Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology

IR PARA

ISSN-e 1984-8773

Volume 4 Number 1


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New Techniques

Post-adjusted M-plasty

M-plastia pós-ajustada

Flávio Barbosa Luz1, Luciana Antunes Chagas1

eceived on: 26 August 2011
Approved on: 28 February 2012

This study was carried out at the
Dermatology Department of the Faculdade
de Medicina da Universidade Federal
Fluminense (UFF) – Niterói, RJ.

Financial support: None
Conflicts of interest: None

 

Abstract

Post-adjusted M-plasty can be used in any surgical defect that can be closed by direct approximation of the borders to avoid the formation of apical protrusions. It is performed without prior planning; the tissue is removed only if the surgeon detects a protrusion during surgery. This method offers the advantage of sparing healthy tissue by adjusting the incisions to each patient’s skin’s tension lines, wrinkles and junctions of cosmetic units, in addition to the possible use of the “M”s pedicle as a small advancement flap. This study describes the procedure step by step, highlighting the differences and advantages compared to traditional M-plasty.

Keywords: SURGICAL PROCEDURES, MINOR, AMBULATORY SURGICAL PROCEDURES, ABDOMINAL WOUND CLOSURE TECHNIQUES

INTRODUCTION

M-plasty, first described by Webster in 1976, 1 is a surgical closure technique in which an "M-shaped" area is excised on one or both extremities of the surgical wound. It is used to pre- vent apical protrusions ("dog ears"), which can be caused by drawing together the borders of round lesions; this action com- presses the tissue – especially in angulated points – and forces it upward and outward. M-plasty was developed as an alternative to fusiform excision, and results in a smaller loss of healthy tis- sue and shorter scars.

In 1984, Salasche 2 used the M-plasty technique mainly to repair "dog ears" after the emergence of the protrusions, corres- ponding to the establishment of the post-adjusted M-plasty.

Improvements have since been introduced to the techni- que. In 1986, 3 Asken proposed the formation of a brim in the "M" shape after the fusiform excision of the wound. In 1988, Camacho 4 proposed an asymmetry in the size and shapes of the lateral sections of the "M" in the same extremity of the surgical defect. In 2009, Wisco and Wentzell 5 recommended increasing the distance between the lateral sections of the "M" to more than 30°.

Post-adjusted M-plasty is carried out using the same tech- nique as traditional or modified M-plasty, except that there is no prior planning. In this way, the lesioned tissue is excised normal- ly; tissue elevations in the border are excised using the above- mentioned method if the surgeon notices them at the begin- ning of the repair procedure. This approach allows not only the elimination of the apical protrusions (as proposed by Salashe 2), but also an improvement in the positioning of the incisions on the skin''''''''s tension lines, wrinkles, or at cosmetic junction units, in addition to saving healthy tissue. This technique variant''''''''s main objective is to achieve a better post-surgical aesthetic result.

TECHNIQUE

The post-adjusted M-plasty method is illustrated by the following sequence of pictures (Figure 1):
A. Surgical defect
B. After the detachment of the tissue around the surgical wound, a central suture is carried out in order to approximate the borders.
C. After the central suture is implemented, the apical pro- trusions become evident.
D. Lateral incisions are carried out at the appropriate angle in order to minimize healthy tissue loss or to avoid affecting anatomical structures.
E and F. Sections of the triangle and the resulting forma- tion of an "M."
G. Medial approximation and anchorage of the pedicle of the "M" – some tension-based advance can be used.
H. Suture of the entire surgical defect with simple stitches.

DISCUSSION

Post-adjusted M-plasty can be performed whenever the direct approximation of the tissue borders is possible. This tech- nique can also be used in situations where there is considerable tension, provided that there is extensive detachment of the adja- cent tissue. The main objectives of this technique are: 1) to spare healthy tissue from being excised during the reconstruction, 2) to reduce the size of the scars, and 3) to improve the aesthetic result by better positioning of the scars.

Webster 1 recommended a maximum 30° angle for the cutting of the triangles in excisions with smaller apical angula- tions in order to prevent the formation of "dog ears," despite the greater loss of healthy tissue. According to Wisco and Wentzell, 5 this original M-plasty technique does not take into account the tissues'''''''' dynamic movements. Salashe2 observed that the surgical defect often assumes an oval shape after its closure, due to the skin''''''''s natural tension lines. After the distribution of this tension following the central suture and detachment of adjacent tissues, the amount of tissue to be excised and the appropriate angle of the "M" become evident. Therefore, it is best to perform the M- plasty after this initial spontaneous adjustment of the tissue, allo- wing the post-adjusted M-plasty''''''''s main objectives to be rea- ched.

Wisco and Wentzell 5 initially proposed that M-plasty should be conducted using Webster''''''''s approach, 1 however with the lateral sections of the "M" located at a similar or greater dis- tance as the surgical defect''''''''s height. Increasing the distance bet- ween the M''''''''s lateral sections widens the apical angle, thus pro- gressively diverging the site''''''''s tension vectors and decreasing the compressive forces in the brims.

In modified M-plasty, 3 a fusiform excision is initially car- ried out with a subsequent incision parallel and lateral to the surgical defect, in one or both poles, depending on the location of the lesion. A brim is then formed in the desired extremity, according to the M-plasty approach, shortening the excision and better adapting the scars to the local tension lines. This is particularly important in the periorbital areas, to avoid distortions in the surrounding tissue and the nasal region, where the scar''''''''s contraction can lead to a deformity in the wing of the nose.

Camacho4 proposed another alteration to traditional M- plasty, which has a good aesthetic outcome: a modification in the size and shape of the M''''''''s lateral sections in a single extremity of the wound, which allows the removal of two triangles of diffe- rent sizes. This approach allows the maintenance of the tissue in its natural position and adapts to each patient''''''''s natural folds.

Another important point is the use of the M''''''''s pedicle as a small advance flap. Wisco and Wentzell 5 also describe the attach- ment of the pedicle towards the center of the surgical wound after its central closure (not advancing the pedicle more than is necessary for its accommodation). With the medial advance of the brim as a flap, there is a decrease in the tension in the region near the center of the surgical wound, which provides a better accommodation of the tissue and results in a more aesthetic sur- gical scar.

Unlike the proposals by Webster 5 and Star 6 in 2001, "a ver- tical mattress tip stitch" was used in the post-adjusted M-plasty to anchor the pedicle. This method provides a better closure, without causing protrusions in the tip of the brim, and keeps the pedicle''''''''s vascular supply intact and prevents the eversion of the wound''''''''s border. The suture is started using a far-far pattern and must be located in the reticular dermis, a few millimeters from the surgical border. When returning, the near-near pattern is used; the sutures are made 1 mm from the wound''''''''s border and do not cross the deep papillary dermis. The M''''''''s brim tip must be horizontally transfixed in the near-near stage, reaching the opposite border.

In general, post-adjusted M-plasty corresponds to the modifications suggested by Asken3 and Camacho4 to the "dog ears" repair technique proposed by Salasche. 2 If this concept is expanded, the M''''''''s pedicle could be possibly pulled towards the center, working as a small advancement flap to decrease the ten- sion medially in the scar. As a result, post-adjusted M-plasty not only repairs "dog ears," but also has an active role in the recons- truction of the wound, in the dissipation of the tensions invol- ved, and in the better positioning of the surgical scars.

CONCLUSION

Post-adjusted M-plasty allows a greater amount of untou- ched tissue to be spared. As in the attempt to avoid apical pro- trusions, there is no previous marking and the protruding tissue area is excised as necessary. Since this procedure is tailored according to the skin''''''''s tension lines, the technique can be adjus- ted to each patient, resulting in greater precision in the repair. Moreover, it is possible to use the M''''''''s pedicle as a small advan- cement flap, resulting in a more aesthetic scar.

References

1 . Webster RC, Davidson TM, Smith RC, Kitchens GG, Clairmont AA, Schwartzenfeld TH, et al. M-plasty techniques. J Dermatol Surg. 1976;2(5):393-6.

2 . Salasche SJ, Roberts LC. Dog-ear correction by M-plasty. J Dermatol Surg Oncol. 1984;10(6):478-82.

3 . Asken S. A modified M-plasty. J Dermatol Surg Oncol. 1986;12(4):369-73.

4 . Camacho FM, Garcia-Hernandes MJ, Perez-Bernal AM. M-plasty in the treatment of carcinomas located on the interglabellar region. Eur J Dermato.l 1998;8(8):548-50.

5 . Wisco OJ, Wentzell JM. When an M is a V: vector analysis calls for redesign of the M-plasty. Dermatol Surg. 2009;35(8):1271-6.

6 . Star J. Surgical Pearl: The vertical mattress tip stitch. J Am Acad Dermatol. 2001;44(3):523-4.


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