Zetaplasty as an alternative for reconstructing double surgical defects

The authors present the surgical reconstruction after excision of two synchronous adjacent basal cell carcinomas in the left infraclavicular region, using the Zetaplasty transposition flap technique. Being versatile and simple to perform, Zetaplasty was proven a useful solution for the reconstruction of double defects within a single procedure.


INTRODUCTION
The ultimate objective in the surgical treatment of skin cancer is the complete removal of the tumor with the best possible aesthetic and functional results.In the case of extensive tumors or those located in body areas where a primary closure is not possible, reconstruction techniques using grafts or rotation flaps are required.One of them, the zetaplasty, allows the position of the surgical scar to be changed, adjusting it to the tension lines and favoring greater mobility, making it widely-used in extension areas of limbs and in the revision of burn scars.
Despite being a classic technique, there are few reports of its use in the reconstruction of surgical defects arising from the removal of skin tumors.
The authors describe the use of the zetaplasty in the reconstruction of a double surgical defect caused by the removal of two adjacent basal cell carcinomas (BCC).

CASE REPORT
A 65-year-old male patient, Fitzpatrick phototype III, had two erythematous plaques with pearly borders on the left infraclavicular region, both diagnosed as superficial multifocal BCC, confirmed by histology.The initial treatment plan was surgical removal with 5 mm safety margins and a primary closure.However, due to the proximity of the lesions, the plan was to carry out a double advancement flap, where one of the defects would act as the compensation triangle (Burow) for the other defect and vice-versa (Figure 1).
During surgery, after the removal of the lesions and the undermining of the borders (Figure 2), a simulation of the flap's movement showed excessive tension and formation of tissular redundancy, implying the need for the additional removal of healthy tissue in order to compensate for the formation of "dog-ears" (Figure 3).Faced with this situation, the alternative of transposing the flaps (zetaplasty) was simulated when a more natural accommodation was demonstrated, with less tension in the surgical borders (Figure 4).After the transposition of the flaps, the fixation was carried out with mononylon 4.0 (Figure 5), followed by suture of the borders with mononylon 5.0.The final result in the immediate and late post-operative periods are shown in Figures 6 and 7, respectively, with excellent functional and aesthetic results.

DISCUSSION
The occurrence of synchronous BCCs represents a therapeutic challenge, especially when lesions are in close proximity to each other.In the reconstruction of double surgical defects after the removal of adjacent BCCs -as in the present case -the dermatologic surgeon is required to use knowledge, technique, and creativity in order to get the most appropriate result.In the present case, the first option to be considered was that of taking advantage of the two surgical defects in order to carry out a double advancement flap in opposite directions, so that one of the defects would act as a compensation triangle (Burow) for the second defect, and vice-versa. 1 This is an already described variant of the advancement flap that allows a simultaneous approach for the two closely located lesions. 2 , 3 During surgery, however, the simulation of this movement did not show a natural accommodation of the borders, which would require the implementation of additional corrections.As a result, the authors opted for the transposition of the flap elements, in a movement similar to that of a zetaplasty, allowing proper closure, with good accommodation and satisfactory functional and aesthetic results.
The zetaplasty technique is commonly used in reconstructive surgery, facilitating the change of the scar's direction so that it assumes a more suitable position in relation to the natural lines of the skin, providing greater mobility, relief of the stress caused by scar contracture, and improvement of the aesthetics and functionality.It is a tool that is widely used for the reconstruction of burn scars. 4In its original conformation, it consists of the rotation of two triangular and symmetrical flaps aimed at closing a central defect, with a 60º angle. 5lthough rarely reported in the literature, the use of zetaplasty for the removal of skin tumors located close to each other should be considered an efficient alternative in the reconstruction of surgical defects, with interesting results.l

Figure 1 :
Figure 1: Double advancement flap planning; a defect acting as a compensation triangle (Burow) for the other flap

Figure 2 :Figure 3 :
Figure 2: Intraoperative: appearance after the removal of the lesions and detachment of the borders

Figure 4 :Figure 5 :
Figure 4: Simulation of an alternative of transposition of flaps (zetaplasty), with more natural accommodation and less tension