Treatment of Trapdoor Deformity After Facial Skin Flap Reconstruction

The trapdoor deformity is a common postoperative complication characterized by bulging tissue within a depressed, semicircular scar, often seen after reconstructive procedures with curved flaps. It results from complex physiomechanical forces, including scar contraction vectors, tissue bunching, lymphatic or venous obstruction, and excess subcutaneous fat. Despite various theories, its exact pathophysiology remains unclear. Traditional treatments like Z-plasties and peripheral undermining aim to redirect contraction forces, though recurrence is frequent. Emerging research explores lymphatic dysfunction as a contributing factor. This study systematically reviews all flap types associated with trapdoor deformity and evaluates both current and emerging management strategies.

A systematic literature review on trapdoor deformity was conducted following PRISMA guidelines, using PubMed, Scopus, and Web of Science. Inclusion criteria covered original clinical studies on trapdoor deformity treatment and prevention in facial flaps, while reviews, unclear reports, and animal studies were excluded. Two investigators independently extracted data, with a third reviewer resolving discrepancies. Both English and select non-English articles were analyzed.

Out of 1864 screened citations, 867 duplicates and 898 irrelevant articles were excluded, leaving 99 for full-text review. Fifty met inclusion criteria, reporting 521 trapdoor deformity cases from 1982 to 2024. The bilobed and nasolabial flaps were most associated with TD, especially in nasal reconstruction. Only 12 of the included studies focused on treatment as the primary endpoint.

Triamcinolone injections are an effective first-line treatment. Laser therapy shows potential and warrants further research, whereas super shaving lacks robust data on long-term outcomes and complication.

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