Successful Treatment of Infraorbital Trapdoor Following Transposition Flap Using Intralesional Corticosteroid: A Case Report

Khairuddin Djawad

Department of Dermatology and Venereology, Faculty of Medicine, Hasanuddin University, Makassar, South Sulawesi 90245,Indonesia.

Abstract Introduction:The trapdoor effect can pose a significant cosmetic issue after transposition flap surgery or trauma.It is characterized with bulging of tissue around a circular or semi-circular scar commonly found after removal of cutaneous tumors.Here, we report a female with infraorbital trapdoor successfully treated by intralesional corticosteroid.Case presentation:A 60-year-old female patient with trapdoor effect after surgery was successfully treated with long-term non-invasive technique of intralesional triamcinolone acetate set with a biweekly interval for twelve months.Discussion:There are currently no definitive methods of removing this condition.Non-surgical approach is often more preferred by patients, such as with the use of intralesional corticosteroid of triamcinolone acetate.However,information about this is still limited.In this case, the patient experienced satisfying result without observed complications related to corticosteroids injection on the infraorbital region.Conclusion: Intralesional corticosteroid is a safe and economical method to treat the trapdoor effect.

Keywords: trapdoor effect, infraorbital, intralesional injection, corticosteroid, triamcinolone acetate

Introduction

The gold standard treatment for removing basal cell carcinoma (BCC) is with surgery, such as Mohs micrographic surgery.1However, when the BCC lesion is extensive,surgery can cause defects that require further repair.Defects in the face and neck area are often closed using a transposition flap.2One of the potential complications of transposition flap surgery is the trapdoor effect,comprising an elevation or bulging of tissue around a circular or semicircular scar.There is currently no established definitive treatment for the trapdoor effect.3The treatment options include surgical and non-surgical approaches.One non-surgical approach to treat the trapdoor effect is the intralesional injection of corticosteroids,but there is limited information available about the effectiveness of this approach.3-4Herein,we report a case in which a 60-year-old woman with the trapdoor effect in the right infraorbital region after Mohs micrographic surgery and transposition flap surgery was successfully treated with long-term intralesional corticosteroid injections, to provide evidence for treatment for the trapdoor effect.

Case report

A 60-year-old woman presented with a chief complaint of bulging skin under her right eye after surgery for BCC(Fig.1A).The bulge had a rounded edge and had appeared 2weeks after transposition flap surgery.The patient wanted this bulging removed for cosmetic reasons, but did not wish to undergo further surgery.We decided to treat the patient with a non-invasive intralesional injection of 0.2–0.3mL of triamcinolone acetate(TCA)(10mg/mL)using a 26G needle every 2weeks for 12months.The patient did not have any history of diseases,was not taking any medications, and did not have any known drug allergies.She was monitored for possible complications related to the infraorbital injection of corticosteroids.Follow-up examinations were performed every month,with noticeable improvement seen in the first month of treatment(Fig.1B).After 5months of treatment,the bulge was minimal, leaving only hyperpigmentation at the surgical site.After 12months, the whole bulge had vanished, leaving only hyperpigmentation macules(Fig.1C and 1D).The patient did not report any complications such as impaired vision or pain at the injection site.In addition, there was no atrophy observed at the injection site.The patient has consented to the publication of her case.

Figure 1. The treatment effects for trapdoor defect caused by Mohs micrographic surgery for basal cell carcinoma treatment using intralesional corticosteroid of triamcinolone acetate.(A)The defect immediately after the operation.(B)Substantial improvement in the infraorbital trapdoor after 1month of treatment.(C)Significant improvement of the lesion after 5months treatment.(D)Full recovery with hyperpigmentation after 12 months of treatment.

Discussion

One of the possible complications of transposition flap surgery is the trapdoor effect, also known as the pincushioning effect.The trapdoor effect is characterized by the bulging of tissue around a circular or semicircular scar left after surgery or trauma.The exact pathophysiology of the trapdoor effect is unknown.However, the most accepted etiology is the retraction of a U-,C-,or V-shaped curved scar.4The formation of the trapdoor effect has been reported to occur as early as 3weeks postoperatively and as late as 6 to 8months postoperatively.5

Intralesional corticosteroids have long been used to treat various dermatological conditions.One of the benefits of intralesional injection is the ability to utilize a high concentration of corticosteroids without the various adverse effects of systemic administration.6In addition,intralesional corticosteroid injection is economical and widely available, with a relatively easy method of administration.6In the present case, corticosteroids were used to promote the degeneration of collagen in hypertrophic scars by inhibiting α2-macroglobulin and subsequently activating collagenase.We used TCA because it is the most well-known and most commonly used intralesional corticosteroid.4,7Although some previous studies have reported that surgical treatment of the trapdoor effect produces a better outcome than a nonsurgical approach,3we chose to use intralesional corticosteroids in accordance with the patient’s preference for non-invasive treatment.Injecting into the infraorbital region can be challenging due to the proximity to the eye.We overcame this issue by using a relatively low dose of TCA(0.2–0.3mL of 10mg/mL)and injecting it through a small 26G needle.

Some advantages of TCA are that the solution is less likely to cause vessel occlusion,causes less pain,and is less likely to clog the vessels;furthermore,TCA is less likely to affect the pituitary-adrenal axis.6The TCA was administered every 2weeks, which reduced the possibility of complications related to the long-term administration of high-dose corticosteroids to the orbital region, such as perforation,elevated intraocular pressure,proptosis,or fat atrophy.8To gain the best result with the highest level of safety, long-term TCA injection with a long interval was needed.However,this long-term intralesional corticosteroid administration is time-consuming compared with the surgical approach.Surgical options include flap removal or the more radical super shaving technique that involves shaving the bulge with a razor and leveling it with sandpaper.3

Our patient responded very well to intralesional TCA injections in the infraorbital region,and the response was evident after the first injection.The patient was closely monitored for clinical improvements and possible adverse effects.After 12months of treatment, the trapdoor effect was no longer visible, leaving only hyperpigmentation macules.A similar good result was reported in a South Korean study.4However, their method was slightly different to ours, as they performed a subcision of the bulge before injecting the TCA,and added 2% lidocaine to the TCA to reduce pain.

In conclusion, this case report demonstrates that intralesional TCA injection can be a safe and economical method with which to resolve the trapdoor effect.Utilizing a low dose of TCA and a long inter-injection interval can minimize the risk of complications associated with injecting in the infraorbital region.This non-invasive method may be an option for patients who do not wish to undergo surgical treatment.However,as there are limited results of monotherapy with intralesional TCA available,further studies are needed.