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Achieving Symmetry in Facial Palsy with the Trapdoor Flap

Calderón, Wilfredo Luis M.D.; Umana, Miguel M.D.; Borel, Claudio M.D.; Leniz, Patricio M.D.; Israel, Guillermo M.D.

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Plastic and Reconstructive Surgery: January 2008 - Volume 121 - Issue 1 - p 349-350
doi: 10.1097/01.prs.0000300294.75821.fe
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One of the disappointing aspects of static facial surgery is the flat nasolabial fold on the paralyzed side of the face. Many procedures have been advocated to avoid a deep nasolabial fold, including botulinum toxin,1 fillers such as hyaluronic acid, fascia lata string,2 fat, and dermis, and, in some cases, superficial musculoaponeurotic system grafting, as we previously reported in Plastic and Reconstructive Surgery.3 However, there are no publications on how to achieve a nasolabial fold in aesthetic or reconstructive surgery. In this communication, we describe a procedure that improves facial symmetry in facial palsy surgery by using a beveled incision on the paralyzed side of the face, resulting in a trapdoor scar.

Our observation of beveled wounds in different parts of the body showed that the direct suture results in a trapdoor deformity, with one side of the wound being thicker than the other. The trapdoor is a semicircular or U-shaped surface scar associated with the following two phenomena: lumpy elevation of the skin inside the U-shaped scar and a sheet of internal scar.

In 1990, Hosokawa et al.4 put forward a new theory, claiming that the force of contraction of the sheet of internal scar is mainly responsible for elevating the skin, thereby generating a vector of force that arises perpendicular to the skin’s surface. So we made a beveled incision in the paralyzed and flat side of the facial palsy at the site where the nasolabial fold should be located. The thicker side of this trapdoor scar, which ended in a trapdoor flap, was in the lateral aspect of the check, imitating a natural nasolabial fold.

In this 40-year-old patient, the facial palsy was the sequela of resection of a left acoustic neurinoma (Fig. 1). Static facial palsy surgery was performed with masseter advancement plus fascia lata string5 (Fig. 2). Despite the good results in this patient, we could not achieve facial symmetry because of the flat nasolabial fold in the paralyzed zone. The trapdoor flap in this area corrected the defect (Fig. 3).

Fig. 1.
Fig. 1.:
Left facial palsy secondary to resection of an acoustic neurinoma.
Fig. 2.
Fig. 2.:
Left masseter advancement for facial palsy plus fascia lata string (white arrow). Beveled incision on the left nasolabial fold (black arrow).
Fig. 3.
Fig. 3.:
Correction of the facial palsy, with creation of the left nasolabial fold with the trapdoor flap (arrows).

Finally, we can say that observation of these scars produced in the nature gave us the solution to this difficult problem.

Wilfredo Luis Calderón, M.D.

Miguel Umana, M.D.

Claudio Borel, M.D.

Patricio Leniz, M.D.

Guillermo Israel, M.D.

Department of Burns and Plastic Surgery

Hospital del Trabajador

Santiago, Chile


1. Bullstrode, N., and Harrison, D. The phenomenon of the late recovered Bell’s palsy: Treatment options to improve facial symmetry. Plast. Reconstr. Surg. 115: 1466, 2005.
2. Senechal, G., Senechal, B., and Contancin, P. Palliative surgery for facial paralysis. Ann. Otolaryngol. Chir. Cervicofac. 99: 313, 1982.
3. Calderón, W., Andrades, P., Cabello, R., Israel, G., and Leniz, P. SMAS graft of the nasolabial fold area during deep plane rhytidectomy. Plast. Reconstr. Surg. 114: 559, 2004.
4. Hosokawa, K., Suzuki, T., Kikui, T., Masada, Y., and Hashimoto, H. Sheet of scar causes trapdoor deformity: A hypothesis. Ann. Plast. Surg. 25: 134, 1990.
5. Baker, D. C., and Conley, J. Regional muscle transposition for rehabilitation of the paralyzed face. Clin. Plast. Surg. 6: 317, 1979.

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