CPD • Therapeutic vignette
CED
Clinical and Experimental Dermatology
Comet flap for the repair of large surgical defects of the face and scalp D. B. Lee,1 J. Y. Seong,2 H. S. Suh2 and Y. S. Choi2 1 Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea; and 2Department of Dermatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
doi: 10.1111/ced.12638
Repairing large surgical defects on the face and scalp, where cosmetics and maintenance of normal functions are important, is a challenge for a dermatological surgeon.1 There are many reconstructive options available, including a number of local flap techniques and full and split-thickness grafts, but many provide unsatisfactory results.1,2 One such technique, the comet flap (also called the dog-ear rotation flap) is a combination repair method, which is executed by first closing one end of the surgical defect in a primary side-to-side fashion, and then rotating the flap from the large remaining defect created at the distal end of the wound.1,2 The final lines of closure have a comet-like appearance. Although this technique is mainly used for surgery in the head and neck region, it can also be successfully performed at any anatomical location.2 From December 2009 to June 2013, we used the comet flap technique on 17 selected patients for the closure of surgical defects after removal of cutaneous malignancies (Table 1). The male : female sex ratio was 4 : 13, and the age of the patients ranged from 54 to 88 years, with a mean of 71.6 years. The lesions were located on the cheek (9 cases), temple (3 cases), scalp (2 cases), forehead (1 case), mandible (1 case), and groin (1 case). The average tumour size was 26 9 21 mm and average defect size was 33 9 28 mm. After removing the tumour, one end of the defect was closed in a side-to-side fashion until it reached a point at which the maximum tension across the wound was obtained without distorting the surrounding structure. The arc of rotation was designed at the proximal point of one lateral side of the remaining Correspondence: Dr Yu Sung Choi, Department of Dermatology, Ulsan University Hospital, Jeon-ha 1-dong, Dong-gu, Ulsan, Korea E-mail:
[email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 3 October 2014
708
Clinical and Experimental Dermatology (2015) 40, pp708–710
defect. The tip of the rotation flap was sutured into the distal end of the primary closure, creating a smaller secondary defect. The remaining primary and secondary defects were closed using the ‘rule of halves’ (Fig. 1a–d). However, 2 of the 17 defects located on the scalp were not appropriate for the ordinary comet flap, because of the unique characteristics of scalp, including the thick galea aponeurotica below the subcutaneous layer and the inelasticity of the scalp tissue. Thus, given the size and the anatomical location, a modification of the comet flap was used (Fig. 1e–i). The proximal portion of the defect, closest to the frontal part of the scalp, was first sutured. The arc of the rotation flap was created from the frontal point of the remaining defect. However, after the first rotation, a smaller secondary defect at the distal end still remained, so an additional rotation flap was created at the midpoint of the lateral margin. Closures of unequal sizes were performed, using the ‘rule of halves’. The comet flap was first reported by Mellette and Dieter in 1986 to offer superior cosmetic and functional results to other closure options, particularly for extensive defects of head and neck area.2 It has proven to be relatively quick and easy to perform, and the final diameter of the scar is relatively smaller with less undermining.1,2 In the head and neck area, the technique is most useful for the repair of surgical defects occurring at junctions of two cosmetic units, such as the temple and cheek, where the rotation flap incision line can be created outside the borderline of the face, where possible, thus allowing the incision line of the rotation flap to be concealed within the facial skin folds or wrinkles. The scalp is considered a very difficult area for reconstruction because the scalp tissue is relatively inelastic and the hairline must be taken into consideration in planning reconstruction.3,4 Although several local flap techniques, including the triple rhomboid, pinwheel, O-Z flaps and V-Y-S scalp plasty technique, can be considered, they usually require extensive
ª 2015 British Association of Dermatologists
Therapeutic vignette
Table 1 Clinical characteristics of the
Tumour
patients Patient
Sex
Age, years
1*
M
67
2 3 4 5 6 7 8* 9 10 11 12 13 14 15 16 17
F F F M M F F F M F F F F F F F
67 76 62 65 71 83 54 72 61 73 68 78 88 76 71 85
Diagnosis
Location
Size, mm
Defect size, mm
Lentigo maligna SCC in situ SCC SCC BCC SCC BCC SCC SCC in situ BCC SCC BCC SCC SCC SCC SCC SCC
Scalp
28 9 23
44 9 39
Cheek Cheek Cheek Groin Mandible Cheek Scalp Temple Temple Cheek Forehead Cheek Cheek Cheek Temple Cheek
24 50 26 25 27 13 35 14 27 24 23 24 08 38 24 23
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
19 50 25 20 20 12 25 11 22 22 18 18 07 25 19 12
26 70 30 31 47 17 51 18 29 26 27 28 10 42 28 27
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
21 70 29 26 40 16 41 15 24 24 22 22 09 29 23 16
BCC, basal cell carcinoma; SCC, squamous cell carcinoma. *Indicates modified comet flap, which was used in two cases with tumours located on the scalp.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
Figure 1 Patient 1: (a) Squamous cell carcinoma in situ on right cheek (patient 2); (b) the tumour was removed with 2 mm surgical
margins, and the proximal portion of defect was closed; (c) secondary defects were closed; (d) post-operative appearance at 1 month. (e) Patient 1: lentigo maligna on scalp; (f) the frontal portion of the defect was closed, and the rotation flap was designed from the frontal point of the remaining defect; (g) to cover the secondary defect, an additional rotation flap was created; (h) all defects were sutured using the rule of halves; (i) post-operative appearance at 2 months.
undermining, hence increasing the intraoperative risks, and may leave a longer scar line than expected.3,4 Compared with other repair options, the modified comet flap produces less tension across the wound edges, with less scarring. It also has better cosmetic results with regard to tissue matching compared with skin grafts. Other options such as tissue expansion and free tissue transfer can be considered for scalp defects. However, tissue expansion requires weeks to months, and the patient must be able to tolerate multiple surgeries,5 while free tissue transfer is technically difficult and time-consuming, so should be considered only when local flaps are insufficient or
ª 2015 British Association of Dermatologists
have failed previously.6 The drawback of the modified comet flat is that there still is a possibility of having a remaining dog-ear at the pivotal point, and there is a higher risk of ischaemic injury of the tip in making the second rotational flap. In conclusion, we reconfirm that the comet flap is a valuable surgical option for closure of surgical defects on the head and neck, and find the modified comet flap technique to be a fair method for moderately large scalp defects. Clinical judgment should be made regarding the location and size of the defect and the elasticity of the scalp before choosing which flap to use.
Clinical and Experimental Dermatology (2015) 40, pp708–710
709
Therapeutic vignette
References 1 Schmidt DK, Mellette JR Jr. The dog-ear rotation flap for the repair of large surgical defects on the head and neck. Dermatol Surg 2001; 27: 908–10. 2 Bugatti L, Filosa G. The comet flap. J Eur Acad Dermatol Venereol 2007; 21: 557–8. 3 Garcia del Campo JA, Garcia de Marcos JA, del Castillo Pardo de Vera JL et al. Local flap reconstruction of large scalp defects. Med Oral Patol Oral Cir Bucal 2008; 13: E666–70.
710
Clinical and Experimental Dermatology (2015) 40, pp708–710
4 Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol 2006; 94: 504–8. 5 Fowler NM, Futran ND. Achievements in scalp reconstruction. Curr Opin Otolaryngol Head Neck Surg 2014; 22: 127–30. 6 Cannady SB, Rosenthal EL, Knott PD et al. Free tissue transfer for head and neck reconstruction: a contemporary review. JAMA Facial Plast Surg 2014; 26: 367–73.
ª 2015 British Association of Dermatologists