Grabb’s Encyclopedia of Flaps Head and Neck

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(Fig. 96.2B). A line of 5.5 to 6.0 cm in length is drawn at a distance of 7.5 to 8.0 cm from the hairline.
OPERATIVE TECHNIQUE
The first stage of microtia reconstruction is the switch back of the lobule. This is followed in 3 months by inlay
grafting as a second stage (see Fig. 96.2).
Dacron mesh is bonded to the rim of the silicone frame using artificial thread and then sterilized. Saline solution
is injected subcutaneously into the operative area. (Epinephrine should never be used.) An L-shaped skin
incision then is made, followed by skin dissection, first with a scalpel and then with scissors, in the direction of
the hairline. Hemostasis should be meticulous.
The soft tissue of the mastoid area, including part of the parotid gland, is excised by electrocautery to the depth
of
the mastoid periosteum in such a way that the conchal part of the silicone frame is easily housed. At the same
time, a subcutaneous tunnel is excavated at the anterior aspect of the auricle. The ear lobule then is made into
two skin flaps so that the tail of the frame can be accommodated. The adequacy of the dissection is checked by
inserting a frame without a Dacron mesh into the sterilized area. A silicone tube (3 mm in outer diameter with
multiple holes) is inserted into the dissected area so that suctioning can be performed easily.
FIGURE 96.2 A: Superficial temporal artery marked on the scalp. B: Temporoparietal fascia exposed just
beneath the scalp skin. Vasae temporales superficiales indicated by forceps. C: Temporoparietal fascia ready to

be raised from temporalis muscle fascia. D: Temporoparietal fascia covers the conchal part of the frame. E:
Temporoparietal fascia ready to be pulled through the skin tunnel into the conchal site. (Continued)
FIGURE 96.2 Continued. F: After the temporoparietal fascia is anchored to the surrounding conchal skin, suction
is applied to clarify conchal depth. G: Full-thickness skin is grafted onto the fascia. Good conchal shape is
apparent.
A T-shaped incision is made (Fig. 96.2B), and the scalp skin is separated from the underlying temporoparietal
muscle, making sure that hair follicles are not unnecessarily destroyed. Care should be taken that the vasae
temporales superficiales are not damaged. When the dissection is completed, the fascia is separated from the
underlying lamina temporalis and brought to the conchal site through the subcutaneous tunnel (Fig. 96.2D and
E) previously created at the site of the anterior part of the auricle. The prepared silicone frame is inserted into
the excavated area, and a suction tube is applied at the site of the anthelix (Fig. 96.2F).
The fascia is anchored to the surrounding skin. When suction is applied, the shapes of the concha, helix, and
anthelix become visible. Also apparent is the shortage of skin necessary for covering the silicone frame. The end
of the skin flap is trimmed to a clean edge, which is sewn onto the underlying frame, making all convolutions
clear.
A 4 × 5-cm full-thickness skin graft taken from the inguinal region is placed over the temporoparietal fascia and
sutured to the surrounding skin (Fig. 96.2G). This may result in an excess of skin at some points, but the
concavity of the concha remains clearly visible. Wet cotton wool is packed into this concavity, followed by dry
gauze on top of the cotton, to make a tie-over dressing. Pressure is exerted by applying an ample amount of wet
cotton wool packed into the other convolutions.
A third-stage procedure, skin grafting to raise the reconstructed auricle off the skull, can be performed 3 months
after the second-stage procedure of inlay grafting.
CLINICAL RESULTS
In the period between September of 1974 and June of 1981, this refined technique was used on 147
patients (150 ears) with typical microtia (Fig. 96.3). Two silicone frames had to be removed, one because of
fistula from the parotid gland and the other because of sudden edema of unknown origin in the
reconstructed ear. The remaining 144 patients (147 ears) did not need frame removal, which I believe is an
outstanding outcome.

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I contacted approximately 66% of these patients; about 20% were not contacted; and about 14% did not
respond. These two latter groups are considered to be retaining their frames uneventfully as untoward
results generally seem to motivate patient contact.
Concerning the attitudes of my patients and their parents after 2 or more years postoperatively, (a) they
cease to pay particular attention to preventing exposure of the reconstructed ear to trauma, (b) exposure to
temperatures down to −1 or −2°C causes no trouble, and (c) the patients tend to have long hair, indicating
that they are still aware that their ears have been reconstructed.
Further disadvantages of the procedure are that the size and position of the reconstructed ear are not
always the same as those of the normal ear. This is due to the fact that there is only one type of prosthesis.
SUMMARY
In what I believe is an improved technique, the temporoparietal fascia is brought to the conchal part of the
silicone frame and anchored to the surrounding skin using extensive suction. Skin shortage is solved by
skin grafting, which prevents fistula formation. The method allows uniform reconstruction of the auricle.
There are few instances of removal of the silicone frame in follow-up 2 to 7 years postoperatively.
FIGURE 96.3 A: Preoperative view of a patient with congenital microtia. B: Postoperative result using a
temporoparietal fascial flap over a silicone frame. The fascia was covered with a full-thickness skin graft
taken from the inguinal region.
References
1. Cronin TD. Use of a Silastic frame for total and subtotal reconstruction of the external ear: Preliminary
report. Plast Reconstr Surg 1966;37:399.
2. Ohmori S, Matsumoto K. Follow-up study on reconstruction of microtia with a silicone frame. Plast
Reconstr Surg 1974;53:555.
3. Ohmori S. Reconstruction of microtia using the Silastic frame. Clin Plast Surg 1978;5:379.
4. Ohmori S, Nakai H, Takada H. A refined approach to ear reconstruction with Silastic frames in major
degrees of microtia. Br J Plast Surg 1979;32:267.

Chapter 97
V-Y Advancement Skin Flaps
E. G. ZOOK
R. C. RUSSELL
These flaps have an excellent blood supply from subcutaneous tissue and are ideal for use on the face (1, 2, 3,
4, 5, 6, 7). They are superior to rotation flaps (which leave dog-ears), skin grafts (which are depressed and
shiny), and primary closure (where tension is present).
INDICATIONS
Excision of facial lesions frequently leaves a circular or elliptical defect. If the skin is loose and can be
approximated without deformity of the surrounding tissue, that is the treatment of choice. The use of a V-Y
advancement flap eliminates secondary procedures to revise dog-ears that occur with rotation flaps.
In our patients, the most common of the V-Y flaps are the nasal dorsal flap to cover defects on the nasal
dorsum or ala and nasolabial flaps to cover defects of the ala or alar base. The flaps also have been found
to be excellent to close defects of the nasal tip and eyelid. They have been used in numerous areas on the
face (Fig. 97.1).
We found that large defects of the lower eyelid skin can be closed with a V-Y flap from the cheek without
ectropion. V-Y glabellar advancement flaps are excellent for closure of wounds of the medial canthal area.
V-Y flaps are also excellent for closure of forehead defects, where the flap can be advanced in the
transverse wrinkle lines of the forehead. We found this flap to be especially good in the area of the sideburn
in men, where one flap can be brought up from the beard area and another down from the temple area,
which reconstructs the sideburn (Fig. 97.3).
FIGURE 97.1 A,B: Some of the defects and flaps used to close them are shown. (From Zook, ref. 7, with
permission.)
FLAP DESIGN AND DIMENSIONS
After adequate excision and clear frozen-section margins on malignancies, closure by simple approximation is
evaluated. If significant distortion of the surrounding tissues results, a V-Y flap is designed to close the defect.
When possible, the line of advancement of the flap is designed parallel to the skin tension lines. If there is a
significant difference in the diameters of the defect, the flap is designed to have the shortest advancement. The

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flap is designed 1½ to 2 times the length of the diameter of the defect in the direction of the closure. Flaps from
the nasolabial fold in older persons with lax skin can be moved 3 to 4 cm onto the side of the nose, and nasal
dorsal flaps can be moved 2 cm to cover tip or alar defects.
OPERATIVE TECHNIQUE
After marking the flap, incisions are made completely through the skin. Vigorous skin hook traction on the
opposite sides of the incision is used to stretch the soft tissue and free the flap (Fig. 97.2B). Blunt scissor
dissection is carried out, if necessary, identifying and cutting bands that inhibit the advancement of the flap, in
the direction necessary to close the defect.
The V tip of the flap is the most frequent area of tightness and must be released. If extensive freeing is
necessary, it is done with loupe magnification until the flap moves easily into the defect. If adequate
advancement cannot be obtained without significant tension on the flap, a second flap is designed and advanced
from the opposite side. In the area of the nose and surrounding tissue, the flap will survive on only a few
small arteries and veins and can be dissected using loupe magnification.
FIGURE 97.2 A: 1- × 1.5-cm defect on the tip of the nose. The superior V flap is designed so that most of the
incisions fall beyond the crest of the nose. B: The V flap on the dorsum of the nose has been mobilized with
loupe magnification and freeing of bands that prevent motion. Several of the remaining vessels can be seen to
feed the flap. C: The nose 6 months later with little scar, no depression, and uniform skin quality of the nose tip.
(From Zook, ref. 7, with permission.)
The flap is sutured into place with subcuticular sutures at the advancing edge and at the base of the Y. It is
important in certain closure areas, such as the lower eyelid, that the Y be closed tightly to hold the flap up in
place and prevent ectropion (Fig. 97.3).
CLINICAL RESULTS
We have used more than 150 V-Y flaps over 5 years for defects secondary to excision of skin malignancies
and benign lesions (skin grafts placed where malignancies have previously been excised, large nevi, and
others). The flaps have been used equally in men and women. Eighty percent of defects were closed with a
single flap, and the remainder were closed with either two or three V-Y advancement flaps. The only
complications have been loss of the edge of a flap from too much tension (not enough freeing), loss of one

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of the pair of V-Y flaps over the nasal ala, and lack of hair growth after a V-Y scalp flap.
Of the 150-plus V-Y flaps we have used, none has required revision. In many areas, such as the dorsum
and tip of the nose, the advancement of local skin is the nearest possible color match and avoids the
depression that one gets with a skin graft (see Fig. 97.2). Early in our use of V-Y flaps, we used a flap from
the nasal dorsum and one from the columella to close nasal tip defects. As we have become more familiar
with and braver in mobilizing the dorsal nasal skin, we have closed such defects with only a single dorsally
based flap. This dorsal nasal flap is designed wide enough to place the scars lateral to the nasal dorsum,
so that they are least visible (Fig. 97.2A).
Over the nasal ala, the skin is tightly adhered to the cartilage; so it is not safe to advance a small local V-Y
flap. In this case, we advance a V-Y flap from the lax skin of the dorsum of the nose to close the defect. The
blood supply of the scalp is primarily transverse rather than vertical, and therefore use of the V-Y flap is not
advisable.
We have used V-Y flap closure on the trunk and upper extremity with good results also. It must be pointed
out, however, that the blood supply is not as good and more frequently two flaps have to be advanced,
each to close half the defect.
SUMMARY
V-Y advancement flaps are particularly useful for defects of the face, especially because secondary revision
is very rarely necessary.
FIGURE 97.3 A: A man with a recurrent basal cell carcinoma in the preauricular area involving most of the

right sideburn. After excision and free margins, the defect is seen. The V-Y flap is designed inferiorly in
beard-bearing skin and one superiorly in the temple area. B: Inferior flap is mobilized vigorously. The
vessels in the flap pedicle can be seen. C: Lower pedicle is raised; the upper is brought distally and closed.
D: Patient 1 year postoperatively with his sideburn preserved and minimal scarring.
References
1. Esser FJS. Island flaps. NY State J Med 1917;106:264.
2. Kubacek V. Transposition of flaps on the face on a subcutaneous pedicle. Acta Chir Plast 1965;2:108.
3. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
4. Trevaskis AE, Rempel J, Okuneki W, et al. Sliding subcutaneous pedicle flaps to close a circular defect.
Plast Reconstr Surg 1970;46:155.
5. DuFourmental C, Tallat SM. The kite-flap. In: Transactions of the fifth international congress of plastic
and reconstructive surgery. Melbourne: Butterworth, 1971;1223.
6. Argamaso RV. V-Y-S plasty for closure of a round defect. Plast Reconstr Surg 1974;53:99.
7. Zook EG. V-Y advancement flap for facial defects. Plast Reconstr Surg 1980;65:786.

Chapter 98
Triangular and Hatchet Subcutaneous Pedicle Skin Flaps
A. J. J. EMMETT
It is the natural elasticity of skin that enables defects to be closed, and it has been usual to fit the long axis of the
defect into the lines of minimal tension (1). Where a rounded defect is to be closed, the shape of the defect may
be tapered into the line of closure by adding a triangle at either end of the rounded defect to produce a tapered
elliptical shape. These triangles of tissue then are discarded. As the size of this round defect becomes larger, the
size of the triangle to be discarded also increases, to the point where these triangles themselves may be used as
a flap and slid into the original round defect with a V-Y closure of the base from which they have come (2, 3, 4, 5,
6, 7, 8, 9, 10).
INDICATIONS
Various triangular flaps are a safe and interesting way to close medium-sized defects in the 1.5- to 3-cm
range in all areas of the body. They have been used on the back, foot, hand, face, and chest. They are a
versatile design, with a great bulk of pedicle relative to the size of the flap, providing great flap viability. The
single triangular flap has an advantage for closure of rounded defects when one side of the defect is closed
by a natural boundary. The double-triangular subcutaneous pedicle skin flap has been used for forehead
defects above the eyebrow, eyebrow defects, and some hairy scalp defects. I have used the hatchet flap for
repair of the chin, eyelid, cheek, and lower lip.
FIGURE 98.1 A,B: Various forms and modifications of double triangular flaps, single triangular flaps, and
hatchet flaps. (From Emmett, ref. 10, with permission.)
ANATOMY
The pedicle is the subcutaneous tissue that lies beneath triangular flaps, and this can then be extended as deep
as necessary. It is all the better if muscle lying beneath is included. The flap is based on a random arterial blood
supply, but occasionally, it can be based over a direct nutrient artery.
FLAP DESIGN AND DIMENSIONS
These flaps are all rather free form and have a degree of adjustability; so the surgeon is not rigidly committed to

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the original cutout flap pattern and can vary the fit of the flap as the operation progresses.
A general principle of these flaps is that the defect is narrowed in around the pedicle. The tail of the flap is closed
in a V-Y fashion so that as the donor site is closed, it pushes the tapered tail of the flap forward toward the
recipient site. The line of the triangular flap is that of the line of minimal tension closure (Figs. 98.1 and 98.2).
FIGURE 98.2 A,B: Various forms and modifications of double triangular flaps, single triangular flaps, and hatchet
flaps. (From Emmett, ref. 10, with permission.)
OPERATIVE TECHNIQUE
Double Triangular Subcutaneous Pedicle Skin Flap
In a procedure to close a defect in the central forehead (see Fig. 98.1B), the flaps are incised down into the
subcutaneous tissue, tapering outward. The principle is that the pedicle should be dissected downward
sufficiently deeply and laterally so that the triangular flap will move freely into the defect. At times, this may be
down to deep fascia and muscle.
FIGURE 98.3 A-D: Closure of a forehead defect above the eyebrow. The underlying nerves were preserved.

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Eyebrow defects and some hair-bearing scalp defects can be closed this way.
The two triangular defects then are sutured together, and the defect is closed in a V-Y fashion behind each flap.
Thus, the tension of the closure lies in the wound on either side, and the flap itself has minimal tension (11).
On the face, I close the dermis with interrupted sutures to produce an even contour before inserting the skin
stitches. A variant with a fishtail or W flap at the lower end to fit the crease lines of the glabella is shown in Figure
98.2J. Double triangular flaps in the preauricular region and on the nasal bridge are also illustrated (Figs. 98.1D
and 98.2H). Closure of a forehead defect above the eyebrow, with preservation of the underlying nerves, is
illustrated in Figure 98.3.
Another variant of this flap, the V-Y-S flap, keeps partial skin pedicles that interrupt the pattern of circumferential
scar (Fig. 98.1C).
Single Triangular Flap
In a procedure using this flap for repair of an inner canthal area defect (Fig. 98.2L), one corner of the leading
edge is slid forward so that the end result is a tapered contour. This may better fit the scar line to the crease
lines.
In another variant (Fig. 98.4A), the horns of the flap end are brought together to make a secondary advancement
using the two extra triangles that sometimes are discarded. By using this method, the flap need not advance so
far, and shallower dissection is sufficient, preserving skin sensation more adequately.
FIGURE 98.4 A-D: Variant of the single triangular flap in which the horns of the flap end are brought together to

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make a secondary advancement using the two extra triangles that sometimes are discarded. This case shows
that the indications for these flaps are not limited to the face.
Hatchet Flap
In areas of loose tissue, the subcutaneous attachment may be left even to the flap tip. In areas of greater fixity,
the flap can be mobilized further and a smaller subcutaneous pedicle left. Illustrations are provided for the use of
the hatchet flap in repairing the chin (Fig. 98.1F), eyelid (Fig. 98.2K), cheek (Fig. 98.2N), and lower lip (Fig.
98.2P). In these procedures, the tail of the flap closes in V-Y fashion as the flap slips forward into the defect.
Where the hatchet flap is in more rigid skin, folding of the pedicle in V-Y fashion and shortening and insetting of
the trailing edge, pedicle side, may be difficult. In these circumstances, a secondary V flap helps close the base
(Figs. 98.1E and 98.2G). In a case of excision of a skin lesion of the cheek (Fig. 98.5A), a hatchet flap is
mobilized.
FIGURE 98.5 A-E: As the flap is drawn into the defect, the tail tends to kick out (C) over the area, and a
secondary triangular flap is raised just enough to fill the defect. It need not go right up to the angle of the base.
The front of the flap is sutured with buried dermal sutures before the tail of the flap is fitted with the secondary
triangular flap.
CLINICAL RESULTS
I have used various triangular flaps extensively over the last 20 years. The dissection around the pedicle of
the flap can be as deep as is permitted by the anatomy of the region, and in the central area of the face,
inclusion of the facial muscles is an advantage. Division of facial muscles is not a problem, since I have
repeatedly seen direct reinnervation of divided muscles in this area.

SUMMARY
Double triangular flaps, single triangular flaps, and the hatchet flap are all extremely useful for closure of
defects about the face.
References
1. Cox HT. The cleavage lines of the skin. Br J Surg 1941;29:234.
2. Kutler W. A new method for fingertip amputation. JAMA 1947;133:29.
3. Kubacek V. Transposition of flaps on the face on a subcutaneous pedicle. Acta Chir Plast 1960;2:108.
4. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
5. Fischl RA. A flap for nasolabial defects, or “save the dog-ear.” Br J Plast Surg 1969;22:351.
6. Atasoy E, Ioakimidis E, Kasdan M, et al. Reconstruction of the amputated fingertip with a triangular volar
flap. J Bone Joint Surg 1970;52:921.
7. Trevaskis AE, Rempel J, Okenski W, et al. Sliding subcutaneous pedicle flaps to close a circular defect.
Plast Reconstr Surg 1970;46:155.
8. DuFourmentel C, Tallat SM. The kite-flap. In: Transactions of the fifth international congress of plastic
and reconstructive surgery. Melbourne: Butterworth, 1971;1223.
9. Argamaso RV. V-Y-S plasty for closure of a round defect. Plast Reconstr Surg 1974;53:99.
10. Emmett AJJ. The closure of defects by using adjacent triangular flaps with subcutaneous pedicles. Plast
Reconstr Surg 1977;59:45.
11. Esser FJS. Island flaps. N Y Med J 1917;106:264.

Chapter 99
Transposition Cheek Skin Flaps: Rhombic Flap and Variations
J. P. GUNTER
R. W. SHEFFIELD
EDITORIAL COMMENT
The editors commend this flap to you. The detailed explanation of the base geometry unravels the
mysteries of the rhombic flap.
Because of the different sizes and shapes of defects, the conditions, availability, and extensibility of surrounding
skin, and the proximity of different anatomic structures, there is no single transposition flap to reconstruct all
cheek defects. The rhombic flap is frequently used for reconstructing small to moderate-sized cheek defects.
Although is not applicable in all cases, an understanding of its basic principles is often helpful in the plan and
design of other transposition flaps.
INDICATIONS
The rhombic flap, described by Limberg (1), is the one we use most for reconstructing cheek defects. It has
a precise geometric design, and knowledge of its principles helps to understand flap transfer and to plan
and execute other transposition flaps.
ANATOMY
Axial-pattern (arterial) flaps are seldom used for reconstructing cheek defects. Random-pattern (cutaneous) flaps
are the rule, as there is little concern about their viability because of the favorable blood supply to the cheek
skin. Random-pattern flaps of the cheeks are raised at a level that preserves the subdermal vascular plexus,
which requires that a layer of the subcutaneous tissue remain on the flap.
The skin of the cheek is richly vascular. Perfusion is mainly through the facial artery, which courses superiorly
and medially from the inferior border of the mandible to the nasofacial groove. Other arteries supplying the cheek
skin are the transverse facial artery (a branch of the superficial temporal), the buccal branch of the maxillary
artery, the infraorbital artery (one of the terminal branches of the maxillary artery), and the zygomatic branch of
the lacrimal artery (a branch of the ophthalmic artery).
All the arteries supplying the cheek have corresponding veins that accompany them. The facial vein is the chief
vein of the cheek. It lies posterior to the facial artery and follows the course of the artery. It communicates with
the ophthalmic vein, which empties into the cavernous sinus, and with the infraorbital and deep facial veins,
which communicate with the cavernous sinus through the pterygoid plexus. It drains into the internal jugular vein
in the upper neck (2, 3, 4).
FLAP DESIGN AND DIMENSIONS
Transposition skin flaps use tissue adjacent to the defect but from a different plane to effect closure. Such flaps
are designed adjacent to the defect so that they share a portion or all of one side of the defect. Although flap
shapes may vary, all can be thought of as having two sides, a distal end and a base. If excision of a lesion can

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be designed in the shape of a rhombus, with adequate margins that do not excessively sacrifice normal tissue,
the rhombus is marked around the lesion with two sides parallel to the lines of maximum extensibility of the skin
(LME), when possible.
The rhombic flap is designed to reconstruct a 60-degree rhombic defect (1, 5, 6, 7, 8, 9, 10) ( ADEF in Fig. 99.1).
In such a defect, the length of all the sides and the short diagonal are equal (i.e., two equilateral triangles with a
common base). The distal end of the flap ( D' C') is a continuation of the short diagonal of the defect ( FD) and of
equal length. The side of the flap next to the defect ( AD') is also a side of the defect ( AD). The side of the flap
farthest from the defect ( BC') is parallel to the near side ( AD') and equal in length. All sides of the defect and the
flap are equal in length.
Four potential donor sites then are mentally pictured (Fig. 99.2), and the site with the most available skin is
determined by manual pinching, pushing, and pulling of the skin in these areas. (This is also helpful in assessing
the effect donor-site closure will have on surrounding anatomic structures.) The rhombic flap then is drawn in the
most favorable area and mentally transposed, checking the direction of the vectors of tension (VOT) and looking
for possible problems.
When possible, the flap should be planned so that the short diagonal of the flap donor site (DB) is in the same
direction as the lines of maximum extensibility (Fig. 99.3). This facilitates
closure of the donor site by taking advantage of the extensibility of the skin in that direction. We accomplish this
by designing the rhombic defect so that two parallel sides are in the same direction as the lines of maximum
extensibility. Of the four rhombic flaps possible, two will have their short diagonals in the direction of the lines of
maximum extensibility (Fig. 99.4). One of these flaps should be chosen for reconstruction, if there are no
contraindications.
FIGURE 99.1 Sixty-degree rhombic defect with adjacent rhombic flap. All sides of the defect and flap and the
short diagonals are equal in length.
The near corner of the flap base is adjacent to the defect. The far corner is the width of the base away from the
defect and serves as the pivot point during transfer of the flap. In the description of the classic transposition flap,
the pivot point is assumed to be stationary. This requires that the flap be longer than the defect in order to reach
the distal end of the defect when it is transferred (11, 12, 13). In the type of transposition flaps we commonly use,
however, the pivot point is advanced toward the defect as the flap is transposed. This facilitates primary closure
of the donor site and obviates additional length requirement.
When the shape of a lesion is predetermined and it is not practical to convert it to a rhombus, the elements of
design of the rhombic flap are often useful in devising other transposition flaps for closure (Fig. 99.5). This is
particularly true for circular, oval, and teardrop-shaped defects. A rhombus is drawn around the defect, and the
most favorable donor site is determined by using the same method already described for reconstruction of a
rhombic defect. A rhombic flap is drawn in that area. Inside the outline, a flap with dimensions and shape similar
to the defect is drawn, filling the rhombic flap outline in the same manner that the defect fills its surrounding

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rhombus (Fig. 99.5B). The flap then is visually transposed into the defect, assessing the areas that will be under
tension and the direction of the vectors of tension. If an area under tension is near a mobile anatomic structure
and the vector of tension points toward that structure, it will probably be distorted if that flap is used. In such
cases, another flap should be considered.
FIGURE 99.2 Possible rhombic flap donor sites. There are four theoretical donor sites for every 60-degree
rhombic defect.
FIGURE 99.3 Lines of maximum extensibility (LME). (From Borges, ref. 15, with permission.) These lines run
perpendicular to the relaxed skin tension lines (RSTL). The skin is most extensible in the direction of the lines of
maximum extensibility.
OPERATIVE TECHNIQUE
After the flap has been designed and it appears that there are no contraindications to its use, minor alterations
for improving the reconstruction are considered. It may be possible to make the defect smaller by undermining
and advancing the edges without distorting any anatomic landmarks. If so, the flap can be planned smaller,
facilitating closure of the donor site. As long as the donor site can be closed without undue tension, it is best to
keep the flap large, because this will result in less tension on the flap edges when they are sutured into the
defect.
The key to successful transfer of the rhombic flap is primary closure of the donor site. As the flap is transposed
to the defect, the edges of the donor site are approximated by advancing the pivot point of the flap (B) toward the
corner, at the junction of the short diagonals of the defect and donor site (D in Fig. 99.6). Closure occurs in one
of two ways (Fig. 99.7). The optimal procedure is for the pivot point of the flap ( B) to move to a point D at the
junction of the short diagonals of
the flap donor site and defect. When this occurs, there is no distortion of the defect or flap. The sides of the flap
can be approximated to the corresponding sides of the defect without tension. The only area of tension will be

along the donor-site closure, with the greatest amount at the end where point B is approximated to point D. This
will result in a vector of tension that is parallel to side DE.
FIGURE 99.4 Choosing the correct rhombic flap. The rhombic defect should be designed so that two sides are
as close to parallel to the lines of maximum extensibility (LME) as possible. This will result in the short diagonals
of two of the donor sites being nearly parallel to the lines (donor sites 1 and 3). One of these donor sites should
be used, when possible, to facilitate primary closure of the donor site.
FIGURE 99.5 Reconstruction of an oval defect using rhombic flap principles. A: Rhombus drawn to encompass
defect, with rhombic flap outlined. B: Oval flap drawn to fill the outlined rhombic flap in the same manner that
defect fills the rhombus. C: Final design of the flap. D: Flap transposed with primary closure of the donor site.
In many situations it is impossible to move point B the entire distance to point D. In such cases, point D must
move toward point B to effect donor-site closure. When this occurs, it results in a distortion of the defect. Side
DE must either elongate, or point E must move in the same direction and for the same distance as point D. If side
DE elongates, side BC' of the flap also must elongate in order to approximate DE.
As point D moves toward point B, the short diagonal of the defect (FD) is elongated, resulting in a widening of
the defect. When this happens, the short diagonal of the flap BD' also must elongate to fill the defect. This, in
effect, requires a widening of the flap. If the skin of the flap is extensible, this may not cause any problems, but if
the skin is not extensible, an area of tension will be created where point D' is approximated to point F. The
resulting vector of tension will be in the direction of the short diagonal of the defect (FD).
The farther point D has to move to meet point B and the less the extensibility of the flap, the greater will be the
tension at closure site D'F. As this tension increases, flap survival is jeopardized. A way to relieve this tension is
to undermine the skin adjacent to side AFE. This will allow point F to move toward point D, lessening the length
requirement of BD'. If there are anatomic structures in the proximity of point F, however, they may be distorted as
the area moves.

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If the direction of the vector of tension created by closure of the donor site is not ideal, it can be changed
somewhat by extending or shortening the far side of the flap (Fig. 99.8). By extending the far side, the vector of
tension will rotate in a direction more parallel to the long axis of the defect (Fig. 99.8C). The more parallel the
vector of tension is to the long axis of the defect, the less tendency there is for the defect to widen as the donor
site is closed. As the length of the far side increases, that corner of the base of the flap moves farther from the
point at which it has to be approximated for donor-site closure. The farther apart these points are, the greater the
tension created by their approximation. If this distance grows too large, it may prevent primary closure of the
donor site. Varying the distance of the far side of the flap will cause discrepancies in the length of the opposing
sides of the flap and defect that must be sutured together. If this discrepancy is not too great, the elastic
characteristics of the skin will compensate.
FIGURE 99.6 A-C: Transfer of flap. As the flap is transferred, point B (pivot point of the flap) is moved toward
point D, resulting in primary closure of the donor site.
Another way to change the direction of the vector of tension created by donor site closure is to change the
direction of the longitudinal axis of the flap in relation to the longitudinal axis of the defect (Fig. 99.9). As the axis
of the flap rotates away from the defect, the vector of tension of the donor-site closure rotates in the same
direction. The more nearly parallel the direction of the longitudinal axis of the defect and donor site, the more
tendency there is for the defect to increase in width as the donor site is closed. If the longitudinal axis of the
donor site is perpendicular to that of the defect, closure of the donor site will result in a downward pull on the
proximal side of the defect without a tendency for widening the defect (14, 15). This will result in less tension on
the flap edges after closure (Figs. 99.10 and 99.11).
SUMMARY
Although the rhombic flap is not applicable in all cases, an understanding of these principles is often helpful
in the plan and design of other transposition flaps.
FIGURE 99.7 Effects of donor-site closure. A: Point D remains stationary as point B moves toward D to
accomplish closure of the donor site. B: This results in a vector of tension (VOT) parallel to side ED without

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distortion of the flap or defect. C: Points D and B move toward each other for donor-site closure. D: This
results in a widening of the defect and the short diagonal of the flap (D'B), with an additional VOT in the
direction of the short diagonal (E).
FIGURE 99.8 Changing direction of the vector of tension (VOT) of the donor-site closure by altering the
length of far side of the flap. A: Direction of vector after closure of donor site in routine design of flap. B:
Vector of tension becomes more perpendicular to long axis of defect if far side is shortened. This creates a
tendency for the defect to widen as the flap is transferred and the donor site closed. C: Lengthening of far
side results in less tendency for widening of defect, since closure of donor site will result in downward pull
on side of defect.
FIGURE 99.9 Effect of changing relationships of long axes of defect and donor site on the direction of the
vector of tension (VOT) of donor-site closure. A: The more nearly parallel the axes, the more nearly
perpendicular the vector of tension of closure of the donor site is to the long axis of the defect. This creates
a greater tendency for widening of the defect as the donor site is closed. B: As the axes become more
perpendicular, the direction of the vector of tension changes toward the same direction as the long axis of
the defect. C: When long axes of defect and donor site are perpendicular, the direction of the vector of
tension of the donor-site closure is parallel to the long axis of defect, creating a downward pull on side of
defect without a tendency for widening of the defect as the donor site is closed.
FIGURE 99.10 A: Closure of a rhombic defect with a rhombic flap. The rhombic defect has two sides
parallel to the lines of maximum extensibility. The donor site is favorable with the short diagonal running in
the direction of the lines of maximum extensibility. B: The flap transferred and closed under little tension. C:
Final result 1 year later. (From Gunter et al., ref. 8, with permission.)

FIGURE 99.11 A: Flap designed using rhombic flap principles to close a teardrop-shaped defect. The flap
is designed so that the vectors of tension are directed between the upper lip and the base of the nose. B:
The flap sutured into place with little tension on the base of the nose or the upper lip. C: The final result 2
years later.
References
1. Limberg AA. Design of local flaps. In: Gibson T, ed. Modern trends of plastic surgery. London:
Butterworth, 1966;38-61.
2. Warwick R, Williams P, eds. Gray's anatomy, 35th ed. Philadelphia: WB Saunders, 1973;626-630.
3. Hollinshead WN, ed. Anatomy for surgeons, vol. 1: The head and neck, 2d ed. New York: Hoeber,
1968;341-346.
4. Woodburne RT. Essentials of human anatomy, 3d ed. New York: Oxford University Press, 1965;219-222.
5. Becker FF. Rhomboid flap in facial reconstruction. Arch Otolaryngol 1979;105:569.
6. Borges AF. The rhombic flap. Plast Reconstr Surg 1981;67:458.
7. Brobyn TJ. Facial resurfacing with the Limberg flap. Clin Plast Surg 1976;3:481.
8. Gunler JP, Carder HM, Fee WE. Rhomboid flap. Arch Otolaryngol 1977;103:206.
9. Jervis W, Salyer KE, Busquets MAV, Atkins RW. Further applications of the Limberg and Dufourmentel
flaps. Plast Reconstr Surg 1974;54:335.
10. Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of Limberg and Dufourmentel. Br J Plast
Surg 1972;25:300.

11. Converse JM, ed. Reconstructive plastic surgery, Vol. 1: General principles, 2d ed. Philadelphia: WB
Saunders, 1977;202-207.
12. Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975;111-131.
13. McGregor IA, ed. Fundamental techniques of plastic surgery, 6th ed. London: Churchill-Livingstone,
1975;119-129.
14. Schrudde J, Petrovici V. The use of slide-swing plasty in closing skin defects: A clinical study based on
1308 cases. Plast Reconstr Surg 1981;67:467.
15. Borges AF, ed. Elective incisions and scar revision. Boston: Little, Brown, 1973;1-15.

Chapter 100
Rhombic and Rhomboid Schwenklappen-Plasty
E. ROGGENDORF
EDITORIAL COMMENT
The reader will find this chapter difficult to assimilate. The mathematics are correct and helpful in the
planning of flaps; however, one should realize that the skin is an elastic tissue, but with varying degrees of
elasticity, depending on anatomic location and age of the patient.
The term Schwenklappen comes from the German schwenken, meaning “to move, swing, or turn about.”
Whereas a transposition flap rotates only about a pivot point, a Schwenklappen flap not only rotates about a
pivot point, but the reserve skin adjacent to the base slides in the direction of the rotation as the flap donor site is
closed (1, 2, 3, 4). (Note that a rhombus, e.g., a Limberg flap, is an equilateral parallelogram, with all four sides
equal, whereas a rhomboid is an oblong parallelogram, with only opposite sides and angles equal.)
INDICATIONS
Rhombic and rhomboid Schwenklappen-plasties can be applied in any region of the body if blood supply,
skin reserves, and the need for flap delay are taken into account. One of their advantages is that the
optimal use of existing skin reserves can easily be calculated. These flaps are especially suited for skin
defects in the face and on the neck because of the good blood supply found in these areas. In other
regions, flap design and flap delay also can favor their application.
Skin defects should be closed under minimum tension by making use of available skin reserves. This
includes mobilization of defect margins for diminishing the size of the primary defect, extension of the flap
itself (pure advancement or extension flaps), extension of the surrounding skin of the donor area (pure
Schwenklappen-plasties), and no extension of skin at all (pure transposition flaps). Figures 100.1, 100.2,
100.3, 100.4 illustrate the ease with which Schwenklappen-plasties may be performed in various
combinations with other techniques for covering skin defects when skin reserves are minimal.
FLAP DESIGN AND DIMENSIONS
Planimetric Schwenklappen-Plasties
Planimetric Schwenklappen-plasties are flaps that involve only two dimensions of the skin; stereometric
Schwenklappen-plasties use three dimensions, creating curved surfaces.
For these flaps, the shapes of rhombi (Limberg, Fig. 100.5A) and rhomboids (Roggendorf, Fig. 100.5B) provide
skin-saving incisions, since Burow's triangles are included in the flap design. Primary closure of the donor area is
a prerequisite for Schwenklappen-plasties. As the donor area is closed, the flap base is rotated; as a result, the
flap transfer is effected. Tension is thus shifted into the suture line of the flap donor area. With exact planning,
therefore, the flap itself can be transferred into the defect without any tension.
The skin reserve r must be equal to or greater than the required skin extension s. Planning of planimetric
Schwenklappen-plasties is simplest if small circular defects are to be covered by rhombic flaps with angles

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between 60 and 70 degrees. Whatever the direction of extension, the skin extension vector s can be planned in
line with the maximum skin reserve vector rmax without any difficulty (Fig. 100.6).
In oblong skin defects, the skin reserve will lie mostly in the direction of the long axis of the primary defect, and
here too rhomboids with angles α of 60 to 75 degrees are best (Fig. 100.7A). These rhomboids can be
constructed easily using the angle α plus the width and length of the defect.
If skin reserve is smaller than required skin extension (that is, r < s), the maximum skin reserve vector rmax should
be determined and the skin extension vector s planned in that direction.
The mutual dependence between Schwenkungs-angle α and the direction of skin extension s (Fig. 100.7A)
makes it possible to calculate the ideal angle α for planimetric Schwenklappen-plasties by using the formula α =
2 (90 + δ)/3 (Fig. 100.7B). This formula can be applied in rhomboid as well as rhombic planimetric
Schwenklappen-plasties.
Stereometric Schwenklappen-Plasties
As has been pointed out, the direction of the skin extension vector s depends on the transfer angle α in
planimetric Schwenklappen-plasties (Fig. 100.7A). This leads to a limited applicability of planimetric
Schwenklappen-plasties in difficult reconstructions; however, when a stereometric
Schwenklappen-plasty with additional transposition is used, better results are obtained (Fig. 100.1C).
FIGURE 100.1 Adjustment of the Schwenklappen-plasty to the maximum skin reserve. Defect, possible flap
donor site, and maximum skin reserve are determined by the needs of the case. A: Planimetric Schwenklappen-
plasty with angle α = 90 degrees, taking into account the defect and flap donor site, but not the direction of the
maximum skin reserve rmax. Skin extension vector s shows that realization is not possible. B: Planimetric
Schwenklappen-plasty with the angle α = 40 degrees. Skin extension vector s and maximum skin reserve rmax lie
in the same direc-tion, but raising the flap is not possible. C: Skin extension vector s lies in the direction of
maximum skin reserve rmax. No interference with the lower eyelid or the scarred area. (From Roggendorf, ref. 4,
with permission.)

FIGURE 100.2 A: Closure of oversized rhombic defects by a rhomboid two-flap plasty if coverage by rhombic
flaps is insufficient. A recurrent basal cell carcinoma with reduced skin reserve due to previous tumor excision.
Defect closure is achieved with two planimetric Schwenklappen-plasties, additional flap transposition, and small
diminution of the defect. The skin extension vectors relate to the maximum skin reserve next to the primary
defect. B: Note that tension occurs only at the donor site and that there is no tension in the flap itself.
FIGURE 100.3 Closure of circular defects by rhombic and rhomboid three-flap plasties. A: Planning and
construction of a rhombic three-flap plasty using a pair of compasses, with the distance between the two
branches being a = s = radius progressing from x0 to x3. B: Planning and construction of the rhomboid three-flap
plasty in the same manner, but a = r = 0.75 radius only, progressing from x0 to x5; b = 2a − 10%. With the
rhomboid three-flap plasty, 77% more defect area can be covered than with rhombic flaps if the skin reserve
vectors are the same. (Continued)
FIGURE 100.3 (Continued). C: Tumor of the scalp; diameter of the skin defect was 4.5 cm. D: After defect

closure by rhomboid three-flap plasty. E: Same area 5 weeks later.
FIGURE 100.4 Maximum skin rotation obtained by combining two techniques: planimetric Schwenklappen-plasty
and transposition flap. A: Note pivot point of Schwenkung. B: Note pivot point of transposition. With an
increasing transposition angle, flap length available for covering the defect is reduced.
FIGURE 100.5 A,B: Schwenklappen-plasty with Schwenkungs-angle α of 60 degrees. Rhombic (A) and
rhomboid (B) designs, the latter covering nearly twice the extent of the former, although the same skin reserve
vector r is used. s, skin extension vector; r, skin reserve vector.
FIGURE 100.6 If the donor site can be freely selected, the skin extension vectors of rhombic Schwenklappen-
plasties can easily be brought in line with the maximum skin reserve rmax.
The stereometric Schwenklappen-plasty is modeled from a foldlike elevation surrounding the flap base (Fig.

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100.8A and B). In this case, the skin extension vector s is brought in line with the maximal skin reserve vector
rmax (Fig. 100.9). When the smallest skin extension vector smin is chosen, maximal skin reserve will result (Fig.
100.9A).
FIGURE 100.7 Interrelationship of the direction of skin reserve, Schwenkungs-angle α, and donor site for both
rhomboid and rhombic Schwenklappen-plasties. A: Direction and size of the skin extension vector s as a
function of the Schwenkungs-angle α. Note the increase in length of skin extension vector s from angle α = 0 to
90 degrees. If angle α = 60 degrees, the tension lines run parallel to the margin of the primary defect. If angle α is
smaller, the tension lines run across the primary defect and could broaden it eventually. If the angle is larger, the
tension lines do not touch the primary defect but, under certain circumstances, could tighten it. Not only is the
skin extension vector s determined by the planimetric Schwenkungs-angle α but so also are the donor site and
flap shape. B: Calculation of the ideal Schwenkungs-angle α that brings skin extension vector s in line with the
maximum skin reserve rmax. Applicable for both rhomboid and rhombic Schwenklappen-plasties.
If the Schwenklappen, after its transfer by rotation of the flap and its base (i.e., Schwenkung, Fig. 100.8B), is
additionally transposed (further rotation of the flap, Fig. 100.8C), stereometric unevenness in the flap surface
may result. The elevation in the area surrounding the flap base (Fig. 100.9C) will level out by itself or can be
excised or retransferred later.
To plan a transposed stereometric Schwenklappen-plasty to make full use of all available skin reserve, first
outline the defect (Fig. 100.9A). Then calculate the maximum skin reserve vector rmax in the direction of C1 (Fig.
100.9A). The width of the defect is marked with the minimum skin extension vector smin, determining the
preferred donor site. The flap length is determined using an overlong flap design that includes Burow's triangle
(Fig. 100.9B and C). The combined stereometric Schwenklappen-plasty can be carried out if r is greater than s.
A combination of stereometric Schwenklappen-plasty with additional transposition has the advantages of ease in
calculating dimensions, permits optimal utilization of maximum skin reserve, allows extensive choice of donor site,

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and leaves no permanent skin reserve in the area surrounding the flap base. When closure of the primary defect
does not require all the skin in a planned flap, the flap can be adjusted to any shape; however, until the final
decision (Fig. 100.4), the whole of the flap skin is available for defect closure.
FIGURE 100.8 Stereometric local flap composed of a stereometric Schwenklappen and a transposition flap. A:
Calculating the stereometric flap by choosing the flap base DC2 and angle α = 55 degrees. B: After stereometric
transfer of the flap base, α = 55 degrees. C: Stereometric flap model after stereometric transfer of the flap base
and transposition of the flap itself. (From Roggendorf, ref. 4, with permission.)
Compared with planimetric Schwenklappen-plasties, the transposed stereometric Schwenklappen needs a
somewhat greater length because of the additional transposition. The additional length required in elderly
patients or for regions other than the head and neck may be provided by flap delay for 8 to 10 days, using
parallel incisions in the long sides of the flap with undermining, and/or inclusion of direct cutaneous vessels.
CLINICAL RESULTS
In my experience with more than 75 Schwenklappen-plasties, minor marginal tip necroses developed in a
few aged patients but without major consequences. In all patients, the incision lines calculated
preoperatively were quite adequate, and no additional incisions were required (Figs. 100.2 and 100.3).
SUMMARY
Schwenklappen-plasties, which involve both transposition of the flap and rotation of the flap base, can be
used to close many defects of the face. These flaps also can be extended by using a flap that creates a
curved surface at the flap base.

FIGURE 100.9 Planning transposed stereometric Schwenklappen-plasty to make full use of available skin
reserve. A: Maximum skin reserve vector rmax in direction of C1 is defined. Marking the defect width either
with minimum skin extension vector smin or at a preferred donor site. In the first case, the utilization of
maximum skin reserve is optimal. In the second case, length of skin extension vector s is increasing and flap
shape is changing. B: Using an overlong flap model with the flap base C2D. C: Stereometric flap transfer by
convergence of C2 → C1. Fitting the flap model into the stereometric elevation of the flap base. Marking the
flap model at A1 and B1. Copying the marked outlines onto the donor site in order to fix A2 and B2. Raising
Burow's triangle from s.
References
1. Borges AF. Choosing the correct Limberg flap. Plast Reconstr Surg 1978;62:542.
2. Limberg AA. Planimetrie und Stereometrie der Hautplastik. Jena: Fischer Verlag, 1967.
3. Lister GD, Gibson T. Closure of rhomboid skin defects: the flap of Limberg and DuFourmentel. Br J Plast
Surg 1972;25:300.
4. Roggendorf E. The oblong parallelogram-shaped Schwenklappen-plasty. Plast Reconstr Surg
1980;65:635.

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Chapter 101
Rhomboid-to-W Flap
H. BECKER
The rhomboid-to-W flap eliminates many of the problems associated with other flaps (1, 2, 3). The rhomboid
defect is converted into a W-shaped scar, which is easier to conceal in the natural crease lines. It is possible to
borrow tissue from all four directions, thereby causing minimal distortion of tissue with no dog-ear formation. A
scar that has a W shape is also less likely to develop trapdoor scarring (Fig. 101.1)
INDICATIONS
The rhomboid-to-W technique has been used most successfully for the closure of facial defects. The W-
shaped scar is easily concealed, and other problems associated with local flaps are largely overcome. This
technique also has been used successfully on the dorsum of the hand, on the digits, and for the closure of
small decubitus ulcers.
FIGURE 101.1 When a circular lesion is excised, the adjacent triangles are normally discarded to avoid
dog-ear formation. This tissue can normally be salvaged and advanced as sliding subcutaneous pedicle
flaps. However, the resultant scar is not very desirable, and trapdoor scarring is common. With the
rhomboid-to-W technique, the tissue of the adjacent triangles is used. By transposing this tissue into the
defect, a W-shaped closure is achieved. (From Becker, ref. 3, with permission.)
FLAP DESIGN AND DIMENSIONS
In planning the rhomboid-to-W flap, the axis of the W should follow the crease lines. The availability of skin is
assessed in all directions, and the flap is planned according to the amount of tissue to be borrowed in each
direction.

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FIGURE 101.2 Difference between the Limberg flap and the rhomboid-to-W technique. Note the large dog-ear
formation with the Limberg flap and tissue borrowing from one direction only. With the rhomboid-to-W technique,
there is no dog-ear formation and tissue is borrowed in all four directions.
OPERATIVE TECHNIQUE
The lesion is excised as close to a rhomboid as possible. Reciprocal flaps are raised on each side (Fig. 101.2).
The rhomboid-to-W technique involves a combination of Z-plasty lengthening and V-Y advancement in four
different directions. It is noted that by transposing flaps A and B and C and D, the Z-plasty transposition effect is
used on either side of the rhomboid. Further tissue borrowing is achieved by advancing flap A to the apex of the
rhomboid and flap C to the opposite of the apex of the rhomboid.
Thus tissue is borrowed from all directions (Fig. 101.3). By altering the size of flaps A and C, the amount of
tissue borrowing from either direction can be preplanned. The shorter flaps A and C are made, the greater is the
V-Y advancement effect. By extending flaps A and C to the apices of the rhomboid, minimal V-Y advancement is
used and greater tissue borrowing is achieved by the bilateral Z-plasty transposition effect.
Once flaps A and C are sutured to each other, the donor defects are closed by flaps B and D (Figs. 101.4 and
101.5). If flaps B and D do not close the defects completely, they can be closed as a V-Y and, in some cases,
even left open to heal spontaneously, or rarely, they can be skin-grafted.
SUMMARY
The rhomboid-to-W technique has several advantages over standard techniques, especially for closure of
defects of the face and hands.

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FIGURE 101.3 A,B: Note that tissue is borrowed from all directions for closure of the defect. (From Becker,
ref. 3, with permission.)
FIGURE 101.4 A: Lesion excised from scalp, showing outline of flaps. B: After transposition of flaps,
closure is achieved. (From Becker, ref. 3, with permission.)
FIGURE 101.5 A: Patient with lesion on tip of nose excised, showing rhomboid defect. B: Closure after
rhomboid-to-W technique. C: Final result.
References

1. Becker H. The rhomboid-to-W technique for excision of some skin lesions and closure. Plast Reconstr
Surg 1979;64:444.
2. Becker H. The use of a new flap in the management of facial lesions. Plast Surg Forum 1979;II:198.
3. Becker H. Rhomboid-to-W flap. Ann Plast Surg 1983;11:125.

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Chapter 102
Double-Z Rhomboid Plasty for Reconstruction of Facial Wounds
F. N. GAHHOS
EDITORIAL COMMENT
This is a good alternative procedure, particularly for defects in which there is no mobility for correction with
a single rhomboid flap. The use of two flaps gives a more satisfactory result without creating secondary
deformities.
The double-Z rhomboid plasty, a technique of four transposition pedicle flaps, is characterized by borrowing the
required tissue from two nonadjacent, opposite sides of the defect (1). When used in the face, where primary
closure or reconstruction with direct tissue advancement is not feasible, the technique will avoid displacement or
distortion of mobile anatomic landmarks (2). The flaps can be developed as strictly cutaneous, fasciocutaneous,
or myocutaneous.
INDICATIONS
There are four main indications for the use of the double-Z rhomboid plasty in the face and neck: (a) when
there is tissue availability in only two opposite directions, where closure by advancement flaps is not
possible; (b) for prevention of the displacement of tissue landmarks such as lips, eyebrows, and nose; (c)
for reconstruction of defects of two different tissue types, such as skin and mucosa or skin and hair-bearing
skin; and (d) in the presence of wrinkles, to support the requirements of placing most scars in that direction.
Proper orientation, planning, and rotation of the flap axis and placement of mobile landmarks along relaxed
skin tension lines, as well as minimizing the need for advancement of the transposed flaps, will provide
excellent cosmetic results.
ANATOMY
The double-Z rhomboid plasty is a technique involving multiple transposition pedicle flaps. The underlying
muscle fascia or muscle can be incorporated into the flaps in areas of compromised circulation. As with other
cutaneous flaps in the face, the axial skin blood supply can be disregarded. The design is simple, and the
orientation is based on relaxed skin tension lines.
FLAP DESIGN AND DIMENSIONS
The first consideration in design is the optimal orientation of the rhombus containing the lesion, which is marked
along with an appropriate margin of normal skin. A standard rhombic defect has a long and short axis; the
double-Z rhomboid
plasty borrows from each side of the long axis. Determining the optimal orientation is perhaps the most difficult
aspect, and adequate time should be taken to design the flaps correctly. The relaxed skin tension line is
determined, which can be done by pinching the skin between the thumb and index finger in the area of the lesion
to determine the direction of maximum tissue availability. Two lines are drawn along the edges of the planned
skin defect, which must be parallel to the relaxed skin tension lines (Fig. 102.1). There are two possible

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orientations that will result in both minimal closure tension and maximal cosmesis. The surgeon will choose the
design that least distorts adjacent anatomic landmarks.
FIGURE 102.1 Technique of determining optimal orientation of the double-Z rhomboid plasty in relation to
relaxed skin tension lines (RSTL). Two orientations of the excisional rhombus are possible (see text for
description). In both orientations, three of the five suture-line segments will parallel the RSTL.
The desired direction of the final incisions may also aid in the choice of orientation. Regardless of the orientation
used, the major incision and two of the minor incisions will end up parallel to the relaxed skin tension lines and to
each other. The remaining two incisions will vary in direction, depending on the chosen rhombic orientation.
FIGURE 102.2 Multiple pedicle flap design of the double-Z rhomboid plasty technique. The length of all sides of
the rhombus and each limb of the Z-plasty flaps are equal. Closure of the rhombic excisional defect is
accomplished by transposition of the four pedicle flaps: A with B and C with D.
Frequently, when reconstructing defects in the face, tissue may be available in all directions; in such cases, the
relaxed skin tension lines can be ignored. The rhombus can be oriented to avoid displacement of tissue
landmarks. In cases where the excisional defect contains more than one tissue type, the rhombus can be
oriented so that one of the long pedicle flaps contains tissues similar to those resected.
After determining orientation, designing the flap is relatively simpler (Fig. 102.2). The excisional defect is a
standard 60/120 degree rhombus, and all four sides are the same length. Four
flaps ( A, B, C, and D) are designed in the form of Z-plasties. Flaps A and D have long pedicles and are used to

reconstruct the excisional defect; their short sides are equal in length to the sides of the rhombus, and their long
sides are equal to twice that length. Flaps B and C have short pedicles and are used to reconstruct the long flap
( A, D) donor-site defects. Both sides of these two short-pedicled flaps are equal in length to the sides of the
rhombus; all four flap corners are 60 degrees. Establishing the correct 60-degree angle for each of the four Z-
plasty flaps requires no angle measurements because the backcuts are made parallel to two of the sides of the
rhombic defect. Closure of the rhombic excisional defect is accomplished by elevation and transposition of all
four flaps (Fig. 102.2).
FIGURE 102.3 Wide undermining (stippled area) is required for optimal cosmetic results. Arrows show direction
of tissue advancement.
OPERATIVE TECHNIQUE
Once orientation of the double-Z plasty and limb design have been completed, execution of the technique
requires only basic surgical skills. The rhombic-shaped tissue containing the lesion is excised to the indicated
depth; the underlying muscle fascia can be included in the specimen, when indicated, as with melanomas. The
four pedicle flaps can be elevated as cutaneous, fasciocutaneous, or myocutaneous flaps by including
underlying muscle fascia or muscle. Incisions must be made perpendicular throughout the flap thickness in order
not to compromise blood flow to the four flap tips. Incisions can be made at an angle when preservation of hair
follicles is desirable. Adequate undermining of the area (Fig. 102.3) is imperative to prevent dog-ear formation.
Also, adequate wide undermining will reduce tension along the central long segment of the incision, thus
improving circulation. Following creation of the four flaps, adequate undermining, and hemostasis, the flaps are
transposed (see Fig. 102.2). Closure of the four short incisions is easier and should be performed first. This
leaves the long central segment, which is usually closed under moderate tension.
FIGURE 102.4 An 82-year-old woman with a large basal-cell carcinoma of the nose. A: The excisional rhombus
was oriented in such a direction that the alar rim and inner canthus location would not change with
reconstruction B: Results 1 year following surgery, showing no alar rim displacement (right). (From Gahhos,
Cuono, ref. 2, with permission.)

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Thin cutaneous flaps can be approximated in a single layer using nondissolvable skin sutures. Thicker flaps
containing subcutaneous tissue, fascia, or muscle can be closed in layers, using dissolvable sutures for the deep
layers. Cutaneous flaps under great tension also may benefit from a layered closure, which facilitates early
removal of skin sutures.
Use of drains in the face is rarely required; however, elevation of the flaps and undermining at the level of the
superficial muscle fascia are more likely to result in postoperative seromas. In these cases, as well as where
excessive bleeding is encountered, use of drains may be indicated. As with all flaps, use of tight dressings
should be avoided. With thin cutaneous flaps showing signs of vascular distress, use of an ointment or cream
may prevent drying and facilitate survival as a composite graft. Use of 60-degree angles throughout the double-Z
rhomboid plasty minimizes dog-ear formation; the tested technique of subcutaneous fat removal at the corners
will avoid the occurrence of dogears altogether.
CLINICAL RESULTS
Experience with 197 double-Z rhomboid plasties over a 10-year period has shown that skin grafting seems
a much faster procedure at the nasal tip and alar margin, with equally good results; use of the plasty
procedure also results in a slightly depressed scar at this site. Among other perceived
disadvantages of the double-Z rhomboid plasty are that it is a lengthy procedure compared with skin
grafting or the rhomboid flap. Recurrence of tumor along the edges of rhombic excision will result in multiple
local recurrences. Also, there is a possibly higher incidence of flap-tip necrosis compared with
advancement, rotation, and rhomboid flaps.
FIGURE 102.5 Basal-cell carcinoma of the upper lip in a 49-year-old patient. A,B: Immediate reconstruction
of the rhombic defect with the double-Z rhomboid technique. The tissue to be excised contains upper-lip
skin, vermilion border, and mucosa. The rhombus is oriented in such a way that the superiorly based
lateral-pedicle flap contains equivalent amounts of skin, vermilion, and mucosa. C,D: Appearance 15
months after surgery shows reasonable upper-lip symmetry and an uninterrupted vermilion border. (From
Gahhos, Cuono, ref. 2, with permission.)

SUMMARY
Where primary closure is not possible and displacement of adjacent mobile landmark structures needs to be
avoided, the double-Z rhomboid plasty is the technique of choice in the reconstruction of difficult facial skin
defects.
References
1. Cuono CB. Double-Z plasty repair of large and small defects: the double-Z rhomboid. Plast Reconstr Surg
1983;71:658.
2. Gahhos FN, Cuono CB. Double-Z rhombic technique for reconstruction of facial wounds. Plast Reconstr
Surg 1990;85:869.
3. Katoh H, Nakajima T, Yoshimura Y. The double-Z rhomboid plasty: an improvement in design. Plast
Reconstr Surg 1984;74:817.

Chapter 103
Subcutaneous Pedicle Flaps
J. N. BARRON
M. N. SAAD
The use of subcutaneous pedicle flaps in the repair of cheek and neck defects is governed by the same basic
principles laid out in Chapter 44 on the use of these flaps for the repair of nasal defects (1, 2, 3).
INDICATIONS
Skin and lining defects of the cheek can be repaired by mobilizing an appropriate island of skin from
adjacent redundant areas of the cheek (Figs. 103.1 and 103.2). The nasolabial fold is an ideal abundant
source of tissue for the repair of adjacent skin defects (4, 5). It has a robust blood supply and provides an
excellent texture and color match. Circular defects of the cheek also can be repaired by using two sliding
subcutaneous pedicle flaps (6) (Fig. 103.3). Skin defects of the neck can be repaired by suitably designed
subcutaneous pedicle flaps, although other techniques, such as free skin grafts or standard flaps, are
usually preferred.
It should be noted that subcutaneous pedicle flaps should not be used to repair circular defects less than 2
cm in diameter, especially in the lax region of the cheek, because peripheral scar contraction can cause
mushrooming of the flap.
ANATOMY
It has been suggested that flaps used for the repair of lower cheek defects should be based inferiorly on the
branches of the facial artery, while flaps for the repair of upper cheek defects should be based laterally on the
transverse facial artery (7).
FIGURE 103.1 A,B: The design of the V-Y cheek advancement flap based on a subcutaneous pedicle.
FLAP DESIGN AND DIMENSIONS
The design, geometry, and pivot point at the base of the pedicle must be arranged so that there is no longitudinal
tension on the transplanted pedicle. Whenever possible, the pedicle should contain an axial vascular system,
such as the terminal branch of the facial artery. Otherwise, one should ensure that the subcutaneous pedicle

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contains sufficient vascular elements to sustain the viability of the flap. It is advantageous to include the platysma
in the pedicle when a subcutaneous pedicle flap is taken from the neck. (This no longer constitutes a
subcutaneous pedicle flap but is a musculocutaneous flap based on the platysma; see Chapter 124.)
Whether the subcutaneous pedicle is based inferiorly or laterally, the actual geometry of the skin flap is planned
in V-Y fashion, thus siting the scars in the lines of facial expression.
For the repair of lining defects of the cheek, an adjacent skin flap based on the subcutaneous tissues at the
edges of the defect may be turned in and sutured to the mucosal defect (2) (Fig. 103.4). In female patients, the
flaps should be based on the mandibular or submandibular region, while in male patients, the hairless malar
region is preferred (2).
FIGURE 103.2 A,B: Basal cell carcinoma of the cheek excised and repaired by a V-Y subcutaneous pedicle flap.
Note the tulle gras bolster anchoring the deepithelialized medial corner of the flap, thus relieving the tension on
the flap and minimizing the risk of ectropion.
FIGURE 103.3 A,B: Closure of elliptical defects repaired by two V-Y sliding subcutaneous pedicle flaps.

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FIGURE 103.4 A: Technique for the repair of cheek lining defects (2). The flap is based on a subcutaneous
pedicle at the inferior margin of the defect. B: Proximal upper edge of the flap sutured to the inferior edge of the
mucosal defect. C: Flap turned up and fully inset into the mucosal defect.
OPERATIVE TECHNIQUE
The operative technique of raising and insetting a subcutaneous pedicle flap has been fully described in Chapter
44. Atraumatic technique and thorough hemostasis are essential, and if necessary, suction drainage should be
provided.
Instead of discarding the pointed corners of cheek flaps to fit the defect, it is advantageous to deepithelialize
them and use them as subcutaneous anchorage points. This relieves the tension on the flap proper and
eliminates the risk of ectropion (Fig. 103.2).
SUMMARY
Subcutaneous pedicle flaps can be used in many instances for repair of cheek, neck, or intraoral defects.
References
1. Barron JN, Emmett AJJ. The subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
2. Chongchet V. Subcutaneous pedicle flaps for reconstruction of the lining of the lip and cheek. Br J Plast
Surg 1977;30:38.
3. Spira M, Gerow FJ, Hardy SB. Subcutaneous pedicle flaps on the face. Br J Plast Surg 1974;27:258.
4. Herbert DC, De Geus J. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:90.
5. Grate MR Jr, Hicks JN. Nasolabial subcutaneous pedicle flap. South Med J 1973;66:1234.
6. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg 1975;28:85.
7. Trevaskis AE, Rempel J, Okunski W, Rea M. Sliding subcutaneous pedicle flaps to close a circular defect.

Plast Reconstr Surg 1970;46:155.

Chapter 104
Nasolabial Skin Flaps to The Cheek
H. OHTSUKA
EDITORIAL COMMENT
In treating defects of the face, the possibility of primary closure and even the use of split- or full-thickness
skin grafts should be considered first. The cases illustrated demonstrate a good alternative when the
simpler techniques will not suffice.
The nasolabial flap has long been used for coverage or reconstruction of the nose and its neighboring regions
(Fig. 104.1). The flap can be either inferiorly or medially based (1, 2, 3, 4).
ANATOMY
The facial artery and its main branches lie deep and run close to the oral and mucous membranes (Fig. 104.3A).
In contrast, the alar branch of the facial artery has a rich anastomosis with other arteries and supplies the
overlying skin and subcutaneous tissue (Fig. 104.2C). Based on these facts, the nasolabial flap may be elevated
as an axial-pattern flap centering around the alar base, even if the main artery itself is not actually contained in
the flap.
FIGURE 104.1 Range of coverage of a medially based nasolabial skin flap. X is at the site of the medial pedicle.
(From Ohtsuka et al., ref. 4, with permission.)
FLAP DESIGN AND DIMENSIONS
The flap is limited in size to about 3 × 10 cm from the standpoint of donor-site closure. The lower part of the flap
usually contains some hair in male patients.
OPERATIVE TECHNIQUE
This elliptical flap is designed along the nasolabial fold. The pedicle of the flap is usually located near the alar
base (like a mushroom), although it can be based near the mandibular end (Fig. 104.2B-D). The medially based
flap can be raised from the mandibular margin to the alar base. Some parts of the zygomaticus major and other
cutaneous muscles may be included in the flap. The flap can be transposed to cover the lower eyelid, cheek,
nose, and upper lip (see Fig. 104.1).

CLINICAL RESULTS
The nasolabial flap was used for coverage or reconstruction of the nose, lip, and cheek in 29 patients with
satisfactory results. Among them were seven reconstructions of the ala, seven of the cheeks, four of the
upper lips, two of the nasal dorsum, one of the columella, four improvements of nasal stenosis, and four
others. The flap was designed with its base medially in 26 patients and inferiorly in three patients. No
significant complications occurred. Occasionally, minor revisions were performed. Color and texture match
of nasolabial flaps was far superior to that of split-thickness or full-thickness skin grafts.
FIGURE 104.2 A: A 78-year-old man with a basal cell carcinoma on the left upper cheek. Preoperative
planning of the nasolabial skin flap. B: The basal cell carcinoma was excised, and a 3 × 8-cm left nasolabial
skin flap with a mushroom-shaped pedicle is being raised adjacent to the nasal ala. C: The relationship
between the nasolabial flap and the facial artery is illustrated. (The labial arteries are omitted.) D: Medial
view of the raised flap and its pedicle. E: Appearance 3 weeks postoperatively.

FIGURE 104.3 A: A 63-year-old man with a basal cell carcinoma on the upper lateral cheek treated by
using subcutaneous nasolabial flap. The route of the facial artery has been identified by palpation and
marked on the skin. B: Region to be excised and the flap are marked. C: Appearance 3 months
postoperatively.
SUMMARY
The nasolabial flap, especially when based medially, is a good flap for cheek defects.
References
1. Barron JN, Emmett AJ. The subcutaneous pedicle flap. Br J Plast Surg 1965;18:51.
2. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps: I. Observations on their blood supply. Br
J Plast Surg 1975;28:85.
3. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle flaps: II. Clinical experience. Br J Plast Surg
1964;28:63.
4. Ohtsuka H, Shioya N, Asano T. Clinical experience with the nasolabial flap. Ann Plast Surg 1981;6:207.

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Chapter 105
Bilaterally Pedicled V-Y Advancement Flap
L. PONTES
M. RIBEIRO
EDITORIAL COMMENT
A modification of the V-Y flap that allows greater mobility of the flap.
The bilaterally pedicled V-Y advancement flap, based on two lateral subcutaneous pedicles and subtotally freed
from its underlying bed on the superficial muscular aponeurotic system (SMAS), is a versatile, cosmetically
elegant flap, with a reliable blood supply.
INDICATIONS
Traditional V-Y advancement flaps for reconstruction of soft tissue have been widely used for decades (1,
2, 3). Several subsequent modifications have been proposed to maximize its
advancement, fundamentally by ameliorating its undermining (4) or by the addition of an extended flap
segment (5, 6). The laxity of the underlying subcutaneous tissue and its attachments to the fascia determine
the degree of advancement in traditional V-Y flaps. When a thin subcutaneous layer is present, this
movement is restricted and results in tension on the flap. The subcutaneous bilateral bridges of the flap we
present allow for more extensive advancement and coverage of the defect.
ANATOMY
The advancement principle of this flap is based on the subdermal plexus flow to the skin island via subcutaneous
bilateral bridges (7) (Fig. 105.1). It differs from traditional V-Y advancement flaps in that it does not rely on the
classic subcutaneous central “vertical” pedicle, so that the flap can be advanced more freely to cover a more
extensive defect, based only on its bilateral pedicles.
FLAP DESIGN AND DIMENSIONS
The V-Y flap is designed on the skin, taking account of the fact that the ratio of flap length to defect diameter
must range between 2:1 and 3:1 (Fig. 105.2). However, this is not necessarily pertinent if the blood supply of the
flap is not totally random. The lateral portions of the flap are positioned, whenever possible, to consider the
aesthetic units and subunits of the face, the presence of skin folds and preexisting scars, the quality of the
neighboring skin (including the effects of irradiation), the maximum extensibility lines and rest tension lines, and
the overall facial appearance.

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FIGURE 105.1 The blood supply to the skin island is based on the subdermal plexus flow through subcutaneous
bilateral bridges. In contrast to the traditional V-Y flap, the central subdermal base is cut from its bed on the
superficial musculoaponeurotic system, so that the skin island can be advanced more freely, based only on its
bilateral pedicles, to cover a further defect.
FIGURE 105.2 With Bonney blue, the V-Y flap is planned on the skin, taking into account that the flap length to
defect diameter ratio must range between 2:1 and 3:1. However, this does not necessarily always need to be the
case if the blood supply of the flap is not totally random.
OPERATIVE TECHNIQUE
The incisions of the lateral portions of the flap are made by beveling outward just up to the subdermal plane,
continuing the dissection in this plane by undermining both cheek flaps (Fig. 105.3). Often, when a higher blood
perfusion of the subcutaneous tissue is presumed, due to unilateral anatomic proximity of a major artery, just one
pedicle at that side can be taken. The next step is to dissect and elevate the whole central segment of the flap
from its bed on the SMAS, extending the dissection with scissors laterally under the cheek
flaps, to create and to free the inferior aspect of the pedicles (Fig. 105.4). At this point, the tip of the V is freed,
and with the help of a skin hook, the top of the flap is extended. Very cautious blunt dissection is performed on
the lateral pedicles until the flap covers the defect without tension. Although this technique is also possible in
younger patients, it is in older ones that the tissue moves more freely. The skin is closed with nylon 4-0 stitches,
creating a classic “Y” pattern (Fig. 105.5).

FIGURE 105.3 The incisions of the lateral segments of the flap are made by beveling outward just until the
subdermal plane, continuing the dissection in this plane by undermining both cheek flaps.
FIGURE 105.4 Elevation of the central part of the flap from its bed on the superficial musculoaponeurotic system,
extending its dissection with scissors laterally under the cheek flaps, to create and to free the inferior aspect of
the pedicles.
CLINICAL RESULTS
The bilaterally pedicled V-Y advancement flap, based on the two subcutaneous pedicles that vascularize
the skin island via subdermal plexus lateral bridges, was used in 959 soft-tissue reconstructions all over the
face after oncologic resections. Three hundred ninety-eight (41.5%) were located on the cheek, 328
(34.2%) were periorbital, 165 (17.2%) were buccomandibular, and 68 (7.1%) were paranasal. All 959 flaps
survived, except in 11 cases (1.15%) in which complete necrosis occurred in patients who had previous
local irradiation. In 29 patients (3.02%), local infection occurred, which resolved by conservative means.
The flaps healed without further problems, with a very low frequency of congestion or edema, and a good
cosmetic result was consistently obtained. No major revisions were required, except in cases of local
recurrence.

FIGURE 105.5 Skin closure with nylon 4-0 sutures, creating a classic Y pattern.
SUMMARY
The bilaterally pedicled V-Y advancement flap, with its subcutaneous bilateral bridges, reliable blood
supply, and versatility, adds to the armamentarium of traditional V-Y advancement flaps, allows for coverage
of more extensive defects, and produces good cosmetic results.
References
1. Bairon JN, Emmet AJ. Subcutaneous pedicle flap. Br J Plast Surg 1965;18:51.
2. Zook EG, Van Beek AL Russell RC. V-Y advancement flap for facial defects. Plast Reconstr Surg
1980;65:786.
3. Peled I, Kaplan H, Wexler MR. Lower eyelid reconstruction by V-Y advancement cheek flap. Ann Plast
Surg 1980;5:321.
4. Chan ST. A technique of undermining a V-Y subcutaneous island flap to maximize advancement. Br J
Plast Surg 1988;41:62.
5. Pribaz JJ, Chester CH, Barral DT. The extended V-Y flap. Plast Reconstr Surg 1992;90:275.
6. Terashi H, Kurata S, Hashimoto H. Extended V-Y flap: reports and reconsideration. Ann Plast Surg
1997;38:147.
7. Pontes L, Ribeiro M, Vrancks JJ, Guiniarães J. The new bilaterally pedicled V-Y advancement flap for face
reconstruction. Plast Reconstr Surg 2002;109:1870.

Chapter 106
Forehead Skin Flaps
J. S. P. WILSON
N. M. BREACH
EDITORIAL COMMENT
Historically, the forehead flap is one of the first axial flaps described, and it achieved enormous importance
in head and neck reconstruction. Its major drawback is the secondary defect, which consequently led to the
exploration and use of other flaps. Nevertheless, because of the reliability of its vascular supply, the
excellent color match (particularly for resurfacing the cheeks and upper lips), and its proximity to the face, it
should be given serious consideration by reconstructive surgeons.
The forehead flap provides the largest area of donor skin with matching color and texture to facial skin (Fig.
106.1). It is one of the safest cutaneous flaps available in reconstructive surgery (1, 2).
INDICATIONS
A forehead flap is long enough to reach any part of the ipsilateral face and will provide cover to the carotid
artery in the upper neck. It also can be used to reconstruct the cervical esophagus, provided that it is
passed under the malar region and that the body of the mandible is removed. The elderly patient is not
confined to bed with a limitation of neck movements with the use of a forehead flap.
Skin taken from other regions for facial reconstruction does not provide a good color and texture match and
does not supply the deep support necessary, as in the reconstruction of a nose. The difference in color and
texture is difficult to disguise.
ANATOMY
A knowledge of the arterial pattern of this flap and its variations is essential to enable the full use of the forehead
skin in reconstructive surgery (3). The lateral forehead is supplied by the zygomatic and anterior branches of the
superficial temporal artery. The main artery arises as a terminal branch of the external carotid artery. It comes to
lie in a superficial plane just anterior to the tragus of the ear (4). Proximal to this, it lies deep in the parotid gland,
which prevents its further mobilization.
The superficial temporal artery ascends superficial to the zygomatic arch and soon divides into the anterior
superficial temporal branch (ASTB), which passes upward and medially into an ascending posterior superficial
branch that passes vertically to supply the scalp.
Cadaver studies revealed that in 80% of cases the zygomatic branch arises from the trunk of the superficial
temporal artery, and in the remaining 20% of cases, it arises from the anterior branch (Fig. 106.2) (5, 6). It also
has been found that the point of origin of the zygomatic artery was 60% above the zygomatic process, 32% over
the zygomatic process, and 2% below the level of the zygomatic process (7). Failure to include a large zygomatic
branch may be the reason for reported cases of failure. The ASTB sends perforating branches through the
frontalis muscle that is included in the flap to supply the skin. The flap should therefore be regarded as a

musculocutaneous flap.
FIGURE 106.1 Forehead flap to cheek for melanoma showing restoration of contour.
FIGURE 106.2 Variations in terminal branching of the superficial temporal artery (6).
Centrally, the forehead is supplied bilaterally by the supratrochlear artery, which becomes superficial 1 cm
medial to the inner canthus, and the supraorbital artery, which is palpable at the junction of the lateral two thirds
of the rounded supraorbital ridge with the sharp medial one third. Both vessels are branches of the ophthalmic
artery and then pass vertically upward to the scalp.
Micropaque injections of the superficial temporal artery (STA) in cadaver specimens show the rich anastomotic
plexus between these vessels (Fig. 106.3). The blood supply to the forehead is therefore basically four
interconnecting vascular territories or angiotomes.
FLAP DESIGN AND DIMENSIONS
If Micropaque is injected into one ASTB, the dye flows across the forehead into the supraorbital and
supratrochlear angiotome and hence to the contralateral STA, in which the flow is reversed (Fig. 106.3A). This
allows the creation of an extended flap passing from one malar bone to the contralateral malar bone (Fig.
106.3C). The flap is 25 cm long in an average adult and can be carried safely on a pedicle no wider than 2 cm at
its base. It is obvious that this pedicle, based just anterior to the tragus containing the STA, is highly mobile (8)
(Fig. 106.3C). This flap, provided that the STA and its small accompanying veins are intact, is perfectly safe in
clinical practice (Fig. 106.4).