\s=b\The trapdoor effect is an elevated and bulging deformity of tissue within the semicircular confines of a U-, C-, or Vshaped scar. Various theories to explain this phenomenon are lymphatic and venous obstruction, hypertrophy of the scar, excessive fatty and redundant tissue, beveled wound edges, and contracture of the scar. Our data suggest that scar contracture is the predominant cause of the trapdoor effect in nasolabial flaps. For mild to moderately severe trapdoor deformities, multiple, small Z-plasties about the periphery of the nasolabial flap are indicated. Intralesional triamcinolone acetonide injections may produce a "pharmacologic Z-plasty" effect in some trapdoor deformities. For marked trapdoor deformities, the combination of multiple, small Z-plasties along the semicircular scar and peripheral undermining about the trapdoor defect is the corrective procedure. The trapdoor deformity may be prevented or lessened by peripheral undermining about the recipient site of the flap equal to or greater in area than the recipient site. (Arch Otolaryngol 1985;111:421-424) The trapdoor effect is the bulging elevation of tissue within the con¬ fines of a depressed, semicircular scar.Mustarde1 has descriptively called it a pincushion scar. This phe¬ nomenon may be seen with any semicircularly configured scar, such as from trauma, with skin grafts, or with U-or V-shaped flaps. It usually occurs about three weeks after surgery, but its appearance may be delayed six to eight months.The trapdoor effect is common with nasolabial flaps. On the basis of observations and revisions carried out on 23 patients with nasolabial flaps, a rationale for therapeutic approaches to the trapdoor deformity has been formulated.
SUBJECTS AND METHODSFollowing excisions of basal cell carcino¬ mas, 23 patients had reconstruction of their surgical defects with nasolabial flaps. Ten of the patients were female and 13 were male. Seventeen of the nasolabial flaps were to the ala nasi. Of these flaps, 11 were inferiorly based and six were superi¬ orly based. Five nasolabial flaps were to the upper lip. Two of these were superiorly based and three were inferiorly based. One nasolabial flap that was superiorly based was to the dorsolateral area of the nose.Trapdoor deformities occurred in every nasolabial flap except for the one to the dorsolateral area of the nose. The trap¬ door deformities developed between three and five weeks postoperatively.All of the patients were instructed to massage the area of the trapdoor defect 50 times in circular fashion three times a day. However, this massage did not obviate the need for further treatment.Fifteen patients were treated with intralesional injections of triamcinolone acetonide (Aristocort) at an initial concen¬ tration of 20 mg/mL. Usually 0.4 to 0.8 mL was injected. If there were no response within three to four weeks, the concentra¬ tion was increased to 40 mg/mL. In three cases, the injections were begun one week after the surgery in an attempt to prevent the trapdoor deformity, but the defe...
Undermining and imbricating the superficial musculoaponeurotic system (SMAS) have been advocated by many recent authors to enhance the results of face lifting procedures. Because all undermining has dangers, we compared in 5 fresh cadavers and 15 patients the immediate operative effects on the labial commissures, buccolabial grooves, submental areas, and cervicomental regions of undermining and imbrication with those of plication without any undermining. Closures were made on both sides and with each technique with the layers pulled to their limit of stretch. We found no significant difference between the two methods in the effects on the areas mentioned.
Disproven by this study is the theory that undermining and imbricating of the SMAS by itself will permit, at the time of surgery, greater displacement of esthetically important landmarks than will mere SMAS plication without undermining.
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