Grabb’s Encyclopedia of Flaps Head and Neck

FIGURE 106.3 A: Injection of Micropaque in the extended forehead showing contralateral anastomoses. B:
Diagram of anastomoses following injection studies. C: Vascular supply of the total forehead: (left) total
forehead, and (right) extended forehead flap, the contralateral superficial temporal vessels having retrograde
flow to the level of the malar bone.
FIGURE 106.4 A,B: Clinical example of extended forehead flap showing that it can reach to the cervical region.
(From Narayanan, ref. 17, with permission.)

FIGURE 106.5 A-C: Variations of pedicle of forehead flap (5, 9, 10, 20).
FIGURE 106.6 Outline of types of forehead flaps for intraoral use. A: The butterfly shape is used to repair
defects of the posterior tongue to allow mobility, the other wing closing the defect in the cheek. The distal
extension provides cover and seal, being supported by the cut end of the mandible. B: The narrow flap repairs
central and alveolar defects. C: The repair following total glossectomy should be in the form of a shield.
Small defects can be repaired by a flap taken high in the forehead, the pedicle donor site being closed by direct
suture and a small graft applied to the flap donor site (Fig. 106.8). This donor site can easily be disguised by a
change of hairstyle in the female patient.
The most satisfactory cosmetic result is achieved when the whole forehead is raised as a cosmetic unit by
beveling the margins of the flap to 45 degrees (Fig. 106.9). The marginal step deformity is thus kept to a
minimum. The line of the upper incision should be just below the hairline and the lower incision just above the
eyebrows. In the midline, it is carried down onto the glabellar region of the nose. The temporal hairline should be
preserved, if possible.
The forehead should be repaired with a sheet of skin taken by a dermatome, applied immediately, and sutured
into place with a tie-over foam dressing or as an exposed graft at 48 hours. The upper edge of the graft is
disguised in the bald patient by a wig.

FIGURE 106.7 A: Flap raised. B: Flap used to reconstruct the esophagus. C: Postoperative result at 1 month.
FIGURE 106.8 A: High forehead flap. B: Postoperative photograph showing reconstruction of the right side of
the nose.

FIGURE 106.9 The beveling of the skin by removal of two triangles of deep tissue to restore contour to the
forehead.
Intraoral Reconstruction
When the flap is used for intraoral reconstruction, it may be introduced through a transverse skin incision 1.5 cm
below the zygomatic arch (9). Blunt dissection avoids injury to the branches of the facial nerve and the parotid
duct. A tunnel of adequate size is therefore created to the edge of the intraoral defect. In central arch defects
using a narrow pedicle flap, the side of the tunnel can be at the nasolabial groove (Fig. 106.10).
A technique that increases the versatility of the flap is its introduction into the oral cavity deep to the zygomatic
arch (5) (Fig. 106.11). The coronoid process of the mandible is divided and passed upward, with its temporal
insertion under the zygoma to 4 cm above the arch. The segment of muscle then is excised to provide an
adequate tunnel. Only on rare occasions is it necessary to divide the zygoma or to remove a segment to provide
a larger tunnel to avoid compression of the narrow pedicle. This technique has the advantage of positioning the
temporary fistula above the level of the floor of the mouth, thereby establishing an immediate salivary seal.
FIGURE 106.10 Introduction of flap through the nasolabial groove.
Additional tissue may be gained for closure of soft-palate defects by using the severed end of the pedicle. This
can be performed at 14 days if no complication has occurred (14).
Variations in the Flap Pedicle
Shaved Pedicle
Immediate one-stage reconstruction can be performed by deepithelializing the pedicle. The pedicle then can be
permanently buried in the tunnel under the skin (15). This technique avoids a second operation in the elderly,
poor-risk patient but may result in some additional bulk or eventually the occasional development of epithelial
cysts.
Island Flap
A true island flap may be used to fill a defect. The course of the ASTB is carefully defined, and an incision is
made 1 cm medial to this. The skin then is elevated to expose the vessel. A 1-cm pedicle of vessels and
subcutaneous tissue of sufficient length to carry the flap to the defect without tension then is carefully elevated. A
subcutaneous tunnel between the base of the pedicle and the edge of the defect is created by blunt dissection,
and the island flap is passed through the tunnel and sutured into the defect.

If the flap blanches, it should be returned to the forehead for 10 minutes to relieve the vessel spasm that is often
caused by excessive stretching of vessels not supported by a skin pedicle. Particular attention should be paid to
obtaining complete hemostasis because hematoma in the tunnel will lead rapidly to necrosis of the flap.
FIGURE 106.11 Transposition of forehead flap into the mouth by means of a submalar approach.
FIGURE 106.12 A: Defect of lip following resection of a tumor. Vessels seen on undersurface of the flap are
marked prior to splitting the flap. B: Flap split and folded to provide lining and cover and a commissure of the
mouth. C: Early postoperative result.
Modifications of the Flap

Various modifications of the forehead flap are usually necessary to provide full-thickness repairs.
Lined Flap
Two weeks before the flap is required, it is lined by a split-thickness skin graft mounted on a stent mold that is
inserted by means of an incision in the hairline into a pocket under the forehead flap. Thus, preliminary grafting
of the forehead is achieved, and a lined flap is produced for the repair of full-thickness defects of the face.
Split Flap
The forehead flap may be split to provide lining and cover to two separate cosmetic units. The position of the
vessels is studied on the undersurface of the flap, and the flap is divided into two parts, each containing a
branch of the ASTB. This is well illustrated in a patient requiring reconstruction of upper and lower lips with the
adjacent tissues in the nasolabial region. The two flaps are folded axially to provide lining and cover to the lip
(Fig. 106.12).
FIGURE 106.13 Forehead flap with axial fold to reconstruct full thickness of upper lip.
Axial Fold
This is the safest method of folding, since it is carried out in the axis of the vessels. It is most useful when the
defect involves a free margin, such as in the full-thickness reconstruction of a lip (Fig. 106.13). If a vermilion
border is required, the appropriate area of the fold can be deepithelialized and a tongue flap sutured to the raw
area. If the mucosa is intact, this can be sutured to the free margin of the lip and the flap then provides a base to
the piriform opening to provide support for the simultaneous reconstruction of the nose.
Contraaxial Fold
This flap provides both lining and cover, but folding the flap through 180 degrees causes an acute angulation of
the vessels. On occasion, it is possible to deepithelialize the fold and obtain an immediate 90% inset; however, if
the flap is first folded and delayed (Fig. 106.14), the technique is usually free of complications. Alternatively, the
fold can be inset later, after leaving a temporary fistula. The flap then can be safely inset at 14 days.

FIGURE 106.14 A: Delayed contraaxial folding of the flap. B: Early postoperative result for full-thickness defect
of the cheek following excision of a tumor.
Innervated Flap
If innervation is desirable in the flap, as in the case of reconstruction of the nose following ulceration resulting
from trigeminal anesthesia, a contralateral central flap including the supratrochlear nerve in its shaved pedicle
may be passed by means of a subcutaneous tunnel to provide a repair with normal sensation (16).
Centrally Based Forehead Flaps
See Chapters 52, 53, 54.
FIGURE 106.15 A: Central and lateral island forehead flaps for full-thickness nasal defect, the central flap for
lining and the lateral flap for cover, passing subcutaneously to the defect. B: Early postoperative result.
Combined Centrally and Laterally Based Forehead Flaps
If two separate cosmetic units require simultaneous reconstruction, a synchronous narrow-pedicle lateral flap
and a central flap may be used. The lateral flap based on the ASTB provides skin to the cheek and lip, which
gives an adequate soft-tissue platform for reconstruction of the nose by a central forehead flap based on the
supratrochlear artery. An area on the cheek flap is deepithelialized to provide a base for reconstruction of the
nose. This technique clearly defines the nose from the cheek, giving a superior cosmetic result.
In the elderly patient in whom a one-stage full-thickness reconstruction is required, a central flap and a lateral
island flap may be used (Fig. 106.15). The central flap provides lining to the nose, and the lateral flap provides
the skin cover.

FIGURE 106.16 Bipolar forehead and scalp flap for reconstruction of a full-thickness defect of the cheek. A:
Defect with the flaps raised on the anterior and posterior branches of the superficial temporal artery. B: Flaps
folded on each other to show the smaller flap internally to provide valvular seal. C: Flap sutured into position.
Bipolar Scalp and Forehead Flaps
The use of both terminal branches of the external carotid artery in full-thickness reconstructions has been
suggested (17). The ASTB is used to provide a lining flap for intraoral reconstruction, and a scalp flap based on
the posterior superficial temporal branch (PSTB) is used to repair the skin defect in the male patient (Fig.
106.16).
Transposition of Forehead on a Narrow Scalp Pedicle
Despite findings that there is decreased vascularity in the region of the vertex of the skull (18), the rich vascular
anastomosis between the PSTB and the ASTB allows the construction of a narrow-pedicle flap containing the
ipsilateral PSTB to be extended across the scalp to the contralateral forehead, anastomosing with the
contralateral ASTB and allowing reversed flow in the artery. This technique (Fig. 106.17) allows the safer
transfer of skin from one temple to the denuded bone of the other temple.
FIGURE 106.17 A: Flap based on the posterior branch of the superficial temporal artery from the contralateral
receding hairline. B: Flap transposed into position. C: Early postoperative result.
Investigations into the vascular supply to the skin of the forehead and clinical trials lead to the conclusion that
provided there is a proper artery arising from one of the major perforators included in the narrow pedicle, the

lengths of the pedicle and the flap are dependent solely on the strength of the vascular links between the
adjacent vascular territories, called angiotomes (19).
FIGURE 106.18 Postoperative appearance of total forehead graft at 3 months.
CLINICAL RESULTS
The main contraindication to the use of the forehead flap is the resultant smooth forehead with a lack of
expression (Fig. 106.18); however, it is possible to disguise this deformity with a change of hairstyle.
Another disadvantage of the forehead flap is its relative lack of elasticity that results in a degree of trismus
when it is used for the repair of full-thickness cheek defects. This may be partially overcome by a well-
placed Z-plasty in the region of the oral commissure after primary healing has occurred. A further significant
problem that results when the flap is used for full-thickness defects of the cheek is the apparent loss of bulk
of the cheek as a result of the relative lack of subcutaneous fat of the forehead skin (20).
Our series consists of 513 vascularly based narrow-pedicle flaps. The broad-based flaps are excluded
because they are usually required only if the superficial temporal system has previously been damaged.
One narrow-pedicle forehead flap in an elderly patient was too thick to allow its safe transposition into the
mouth; it was returned to the donor area without loss, and a deltopectoral repair was performed.
There was a marginal loss in 17 patients that was easily corrected by secondary advancement of the flap.
There was a partial loss in 10 patients that was treated by the secondary use of the pedicle or a local flap.
Ten flaps failed to survive. Four of these were true island flaps, and the cause was probably damage to the
vessel or tension on the transported fascial pedicle. It must therefore be concluded that this procedure
demands the most careful surgical technique (Figs. 106.19, 106.20, 106.21).

FIGURE 106.19 A: Island forehead flap designed for reconstructing lower eyelid. B: Flap sutured into
position.
In one patient, a prosthetic nose was substituted when further reconstruction was refused. In the other
cases, flaps were introduced from another region.
FIGURE 106.20 A: Large island flap transposed from the forehead of a patient with a receding hairline. B:
Early postoperative result.
SUMMARY
The forehead flap can be used in a variety of ways to cover cheek, neck, and intraoral defects. Nasal
reconstruction and centrally based forehead flaps are discussed further in other chapters.

FIGURE 106.21 Diagram illustrating the various forms of forehead flaps (see Chapters 52, 53, 54). A:
Extended central forehead flap. B: L-shaped flap. C: Extended flap to malar region. D: Bipolar flap. E:
Tripolar flap.
References
1. Gillies HD. Plastic surgery of the face. Oxford, England: Oxford Medical Publications: Henry, Frowde,
Hodder and Stoughton, 1920.
2. Conway H, Stark RB, Kavanagh JD. Variations of the temporal flap. Plast Reconstr Surg 1952;9:140.
3. Esser JFS. Biological or artery flaps of the face. London: Royal Society of Medicine, 1931.
4. Manchot C. Die Hautarterien des Menschlichen Corpers. Leipzig, 1889.
5. Wilson JSP. The application of the two-centimetre pedicle flap in plastic surgery Br J Plast Surg
1967;20:278.
6. Richbourg B, Mitz V, Lassau JP. Artère temporale superficielle. Etude anatomique et dèductions pratiques.
Ann Chir Plast 1975;2:197.
7. Stock AL, Collins HP, Davidson T. Anatomy of the superficial temporal artery. Head Neck Surg
1980;2:466.
8. Wilson JSP. Major flaps in the reconstruction of defects of the head and neck: cancer of the head and
neck. In: Proceedings of the International Symposium, Montreaux, Switzerland, April 2-4, 1975 (Series 365).
Amsterdam: Excerpta Medica, 1976.
9. McGregor, IA. The temporal flap in intraoral cancer: its use in repairing the postexcisional defect. Br J
Plast Surg 1963;16:4.
10. Millard DR. Immediate reconstruction of the lower jaw. Plast Reconstr Surg 1964;35:60.

11. Hamaker RC, Conley J. Modified nondelayed forehead flaps. Arch Otolaryngol 1975;101:189.
12. Lee ES, Wilson JSP. Carcinoma involving the lower alveolus: An appraisal of past results and an account
of current management. Br J Surg 1973:60.
13. Smalley JJ, Cunningham MD. Forehead flap rotation to protect the carotid artery. Plast Reconstr Surg
1972;49:96.
14. Chambers RG, Edwards SC. Palatal reconstruction utilizing retrieved forehead flap. J Surg Oncol
1975;7:191.
15. Kemahan DA, Littlewood AHM. Experience in the use of arterial flaps about the face. Plast Reconstr Surg
1961;28:207.
16. McLean NR, Watson ACH. Reconstruction of a defect of the ala nasi following trigeminal anaesthesia
with an innervated forehead flap. Br J Plast Surg 1982;35:201.
17. Narayanan MS. Immediate reconstruction with bipolar scalp flap after excisions of huge cheek cancers.
Plast Reconstr Surg 1970;46:548.
18. Corso PF. Variations of the arterial, venous and capillary circulation of the soft tissues of the head by
decades as demonstrated by the methyl methacrylate injection technique and their application to the
construction of flaps and pedicles. Plast Reconstr Surg 1961;27:160.
19. Behan FC, Wilson JSP. The principle of the angiotome: a system of linked axial-pattern flaps. In:
Transactions of the sixth international congress of plastic and reconstructive surgeons. Paris: Masson,
1975.
20. McGregor IA, Reid WH. The use of the temporal flap in the primary repair of full-thickness defects of the
cheek. Plast Reconstr Surg 1966;38:1.

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Chapter 107
Bilobar and Trilobar Forehead and Scalp Flaps
M. NARAYANAN
Immediate reconstruction of head and neck defects resulting from excisions of huge cancers is a unique
procedure in plastic surgery. The principles of immediate reconstruction after excision of oropharyngeal cancers
are well documented (1, 2, 3).
Wide variations are reported in the geographic incidence of squamous cell carcinoma of the mouth. Although it is
as low as 2% of all cancers in Western countries, it offers a formidable problem in South India, accounting for
39.52% of all cancers in males and 18.80% of all cancers in females. Management becomes even more difficult
because 86% of these patients report in the late stages of their disease; consequently, conventional
radiotherapy cannot cure the primary growth more than 50% (4).
In patients with residual primary growth, the threat to life can be treated only operatively. If the tumor and the
draining lymph nodes can be excised and the face reconstructed, solutions to the problems of offensive odor,
trismus, pain, and drooling can be offered. Fortunately, distant metastasis occurs in only 1% of patients. The
predominant concern of the surgeon is cancer clearance, however mutilating the excision may be. Not less
important, though, are reconstruction and rehabilitation of the patient. The surgeon is encouraged to perform a
wider excision if a versatile flap that can effectively reconstruct large postexcisional defects is available.
FIGURE 107.1 Anatomic distribution of cheek cancers. Dotted lines indicate the extent of possible postexcisional
defects in huge facial cancers. The probable carcinogen is chewing tobacco in the buccolabial sulci. A:
Retromolar. B: Anterior. C: Intermediate.
INDICATIONS
In the flaps described below, irradiation is still possible postoperatively because the blood supply to the
flaps is quite good. In males, a beard can be grown to help conceal facial asymmetry.
The anatomic locations of postexcisional facial and neck defects are shown in Figure 107.1. Treatment of
the primary tumor, including neck dissection, was previously described by the author (5).
FLAP DESIGN AND DIMENSIONS
Bilobar Flap
The superficial temporal artery divides into a frontal and an equally large parietal (posterior) branch. The frontal

branch is the one used for the forehead flap, and it can be used to reconstruct the intraoral mucosa. The scalp,
supplied by the parietal branch, can be used for external skin coverage (see also Chapter 108).
OPERATIVE TECHNIQUE
Bilobar Flap
The branches of the superficial temporal artery are identified by palpation or with a Doppler device. The lines of
incision start as with the standard forehead flap, but at a point about 5 cm above the bifurcation of the anterior
and posterior branches of the temporal artery, the incision deviates posteriorly to enclose a wide parietal scalp
flap that has the exact dimensions of the skin defect. The flaps can be measured accurately by cutting out
patterns of the mucosal and skin defects on sterile gauze. The frontalis muscle and the parietal scalp flap are
raised at this same loose areolar tissue level.
FIGURE 107.2 A: Defect of cheek and upper neck at completion of tumor excision. B: Scheme of the bilobar
forehead skin and scalp flap based on the frontal and parietal branches of the superficial temporal artery. The
forehead portion is used to restore cheek lining to the defect. C: Scheme of folding over the scalp portion of the
flap to provide skin coverage. Note that the fold posteriorly is not divided or set into place at this operation, so a
fistula is present. The scalp defect is skin-grafted. D: Several weeks later, the fold in the flap is divided. The
inner edge is used to close the lining, and the outer edge is used to close the skin surface. (From Narayanan,
ref. 5, with permission.)
The single bilobar flap narrows to a small pedicle 2.5 cm wide just above the zygomatic arch (6). The whole flap
is everted and turned down (Fig. 107.2B). The forehead flap at this stage fits snugly into the mucosal defect,
where it is sutured. The parietal scalp flap then is folded forward across the face to fit exactly into the skin defect
of the cheek, chin, and lips (Figs. 107.2C and 107.3). It is sutured there except for the fold at the posterior
border. To cover the raw area of the forehead, a split-thickness skin graft from the clavicular area is applied. The
scalp defect is covered with a split-thickness skin graft from the trunk.
A fistula will present at the folded portion of the flap just in front of the ear. This fistula drains the pterygoid fossa
and the submandibular area. Saliva may leak through, but this is not a great disadvantage because the patient is
tube fed for the first 2 weeks. The flap pedicle is returned after a convenient interval.

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Island Bilobar Flap (7)
Where it is possible to isolate the superficial temporal vascular pedicle without injury, the fistula can be avoided.
This is done by raising a rectangular scalp flap of skin only overlying the branching of the superficial temporal
artery and above
(Fig. 107.4A). When this is done, the superficial temporal vessels soon come into view. The vessels, surrounded
by dense fibrous tissue, are preserved to form the vascular pedicle. Often it is not safe or easy to isolate the
vessels completely. In such cases, the skin alone is undermined at the upper end of the carrier pedicle for a
suitable distance.
FIGURE 107.3 A: A retromolar growth perforating the cheek. B: Postoperative result 3 years later.
The rectangular scalp flap overlying the pedicle of the island flap then is cut off and discarded. The superficial
temporal vessels and surrounding fibrous tissue are retracted posteriorly, and a vertical incision is made in the
zygomatic skin bridge (Fig. 107.4B). The edges of this are turned back, and the incision is deepened and
spread, taking care to avoid injury to the facial nerve branches to the eyelids. As soon as a suitable trough is
prepared, the fibrous tissue-vascular pedicle is placed within it (Fig. 107.4B). The skin flaps over the zygomatic
arch are brought together, and the forehead and parietal scalp flaps are sutured in place. This island-flap
technique has the advantage of further reducing morbidity and hospital stay.
Trilobar Flap
Where the skin loss is below and posterior to the ear, this area cannot be covered by the bilobar forehead and
scalp flap. A trilobar flap is designed consisting of the usual forehead and parietal flap with an added vertical flap
from the frontal area of scalp on the end of the forehead flap. This whole flap is turned down so that the
transverse portion of the forehead flap covers the mucosal defect. When the scalp flap is folded forward, the
portion of flap from the frontal scalp (the third lobe) everts posteriorly to cover the defect on the surface of the
neck. The parietal scalp covers the cheek (Fig. 107.5).

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FIGURE 107.4 Operative steps of an island bilobar flap. A: The superficial temporal artery and surrounding
fibrous tissue are isolated as a pedicle in the first stage. B: Final position of the island carrier pedicle and the
flaps before suturing. (From Narayanan, ref. 5, with permission.)
Every effort should be made to improve the cosmetic appearance of the forehead. Methods include the use of
total forehead flaps (8) and use of a supraclavicular skin graft (9).
CLINICAL RESULTS
Hemorrhage from the flaps and excised area has been noticed only in association with partial tracheal
obstruction and was largely relieved when the airway was cleared. There were only two partial necroses of
the forehead flap in a series of 132 patients. There has been no delay in wound healing. When the scalp
flap is larger than the size of the defect, contractures occur and produce secondary trismus. Blowing
exercises should be encouraged in such patients.
FIGURE 107.5 A: Huge fungating carcinoma of the intermediate area of the cheek. B: Trilobar flap raised

and everted. The parietal scalp flap extends to the left. Note the third lobe directed inferiorly in lower part of
the photograph. This lobe is the vertical extension into the frontal scalp on the end of the forehead flap.
C,D: Final result 3 years later. Note the area behind and below the ear that has been reconstructed with the
third “lobe” of the flap. Notice also the donor defect.
The method cannot be employed in those rare patients in whom the tumor involves the superficial temporal
artery. Growth of hair on a female's face is a disability, and an epilation dose of irradiation is advised. A
narrow forehead flap may not provide full mucosal cover in some patients.
SUMMARY
Bilobar forehead and scalp flaps can be used to cover both the mucosal and skin surfaces in cheek defects.
A third lobe can be added to cover the neck area if necessary.
References
1. Conley J. Crippled oral cavity. Plast Reconstr Surg 1962;30:469.
2. Edgerton MT, DePrez JD. Reconstruction of the oral cavity in treatment of cancer. Plast Reconstr Surg
1957;19:89.
3. Millard DR Jr. Forehead flap in immediate repair of head, face and jaw. Am J Surg 1964;108:508.
4. Krishnamurthy O, Shanta V. In: Proceedings of the 11th international congress of radiology and combined
therapy in oral cancer.
5. Narayanan M. Immediate reconstruction with bipolar scalp flap after excision of huge cheek cancers. Plast
Reconstr Surg 1970;46:548.
6. Wilson JSP. The application of two-centimetre pedicle flaps in plastic surgery. Br J Plast Surg
1967;20:278.
7. Narayanan M. New variation of cheek reconstruction. Plast Reconstr Surg 1971;48:3.
8. Hoopes JE, Edgerton MT. Immediate forehead flap repair in resection of oropharyngeal cancer. Am J Surg
1966;112:527.
9. Edgerton MT, Hansen FC. Matching facial contour with split-thickness graft from adjacent areas. Plast
Reconstr Surg 1960;25:455.

Chapter 108
Superficial Temporal Artery Forehead and Scalp Flaps
I. K. DHAWAN
EDITORIAL COMMENT
This location was the site of probably one of the earliest free flaps that was transposed using the temporal
vessels and the hair-bearing area. The flap was transferred to the contralateral hairless side.
The first flap to use the superficial temporal artery specifically included the forehead skin supplied by the frontal
branch (1). Subsequently, flaps using both branches of the superficial temporal artery were described (2, 3, 4).
The scalp is vascular and richly supplied by branches of the superficial temporal artery. Defects on the scalp can
be camouflaged easily, and scalp skin is a large reservoir situated away from radiated areas in the neck and
face.
INDICATIONS
I have used these flaps for the repair of extensive defects in the cheek after excisions for cancer. Flaps can
be designed to fit the particular defect. In two patients in whom the external carotid artery had to be ligated,
a bilobar flap was successfully used after a delay.
ANATOMY
The external carotid artery divides into its two terminal branches behind the neck of the mandible. The branches
are the superficial temporal and the internal maxillary arteries. The former pierces the deep fascia under cover of
the parotid gland and then ascends over the zygomatic arch. It enters the scalp in a plane superficial to the
aponeurosis of the occipitofrontalis muscle. At a variable distance above the zygomatic arch, it divides into a
frontal branch going to the forehead and a posterior branch supplying the temporal and parietal regions. The
artery and its branches are easily palpated. The accompanying veins are often prominent and mark the course of
the artery.
FLAP DESIGN AND DIMENSIONS
The variety of flaps based on the superficial temporal artery may be classified as follows (Fig. 108.1): (a) flaps
using one branch of the artery (i.e., frontal [forehead] or parietal [scalp]); (b) flaps using both branches of the
superficial temporal artery (i.e., the bilobar forehead skin and scalp flaps); and (c) flaps using the frontal branch
of both superficial temporal arteries to carry large areas of the forehead and scalp to cover the face (i.e., the
visor flap) (see Fig. 108.3).
During excision of a facial tumor, care must be exercised to prevent damage to the external carotid artery if it is
not involved in the tumor. It is especially vulnerable near its bifurcation into its terminal branches, where the
internal maxillary artery should be carefully ligated to preserve the superficial temporal artery. Preoperatively, the
superficial temporal artery and its branches are carefully marked out on the skin by palpation. The nonhairy
frontal flap forms the lining of a cheek defect, and the hairy parietal flap forms the skin cover of a cheek defect in
a male patient (Fig. 108.2).

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OPERATIVE TECHNIQUE
The requisite length of the carrier segment of the flap is marked, depending on the distance of the defect from
the base of the pedicle. The required dimensions of the flaps for lining and cover are marked on the forehead
and parietal scalp. The flaps are raised in the loose areolar plane between the pericranium and the frontalis
muscle—the galea aponeurotica. Great care is taken not to damage the superficial temporal artery near the ear.
If the entire forehead is needed for repair and must be carried on a single pedicle, one delay 7 to 10 days earlier
improves flap survival. The flaps also may be carried as island flaps on a subcutaneous vascular pedicle (Fig.
108.3).
CLINICAL RESULTS
The forehead in dark-skinned people is not a suitable donor site because of the cosmetic defect that
results. The scalp is not a suitable donor site for females because the cover provided by it is hairy. Partial
flap loss has been seen in one forehead and one scalp flap.
FIGURE 108.1 Flaps based on the superficial temporal artery may be designed in various ways. Either only
the forehead (A) or the parietal scalp (B) or both the forehead and parietal scalp (bilobar flap) (C) may be
used. Also, the forehead and hairy scalp based on the superficial temporal artery of both sides may be
carried down as a visor flap (D).

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FIGURE 108.2 A: Defect after excision of cheek cancer. B: Postoperative appearance with a parietal scalp
flap replacing cheek skin. A posterior cervical skin flap provided the lining for the cheek.
FIGURE 108.3 A: Appearance after the excision of a lower lip cancer involving the mandible. B: The visor
flap brought down to reconstruct the lower lip and chin. C: Postoperative appearance with the visor flap
shaved of hair. (From Dhawan, Aggarwal, ref. 3, with permission.)
SUMMARY
Scalp flaps are ideally suited to repair large defects in the face after excisions for cancers of the cheek,
alveolus, floor of the mouth, and tongue. Both lining and cover can be provided, and very large defects may
be repaired. However, if the external carotid artery is compromised during excision, then the flaps lose their
main blood supply and are in danger of being lost.
References
1. McGregor IA. The temporal flap in intraoral cancer: its use in repairing the postexcisional defect. Br J Plast
Surg 1963;16:318.
2. Narayanan M. Immediate reconstruction with bipolar scalp flap after excision of huge cheek cancers. Plast
Reconstr Surg 1970;46:548.
3. Dhawan IK, Aggarwal SB. The use of scalp flaps following resection of oral cancer. Aust N Z J Surg
1972;41:363.
4. Zembacos J. Bipolar scalp flaps. In: Transactions of the sixth international congress of plastic and
reconstructive surgeons. Paris: Masson, 1976;392.w

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Chapter 109
Galeal Flaps
J. M. PSILLAKIS
J. AVELAR
J. PERSSONELLI
EDITORIAL COMMENT
This flap is based on the same principle as the temporoparietal fascial flap. Galea can be included when a
thicker flap is desired. In ear reconstruction, the thinner fascial flap by itself is preferable.
Aponeurotic galeal flaps can be used for the correction of various facial deformities. They can be used not only
for bulk but also to support skin and bone grafts through their increased vascularity.
INDICATIONS
Reconstruction of the Auricular Framework (1, 2)
See Chapter 96.
Cancer Surgery of the Head and Neck
Tumors of the orbital and frontal regions sometimes necessitate resection of soft tissue, including
periosteum. A galeal flap with the superficial temporal artery as its pedicle can be rotated for coverage of
the bone and as a vascular bed for a skin graft.
Hemifacial Atrophy
Patients with hemifacial atrophy have very thin skin and a poor blood supply. Management sometimes calls
for segmental osteotomies of the maxilla and mandible with bone grafts. The galeal flap introduced
subcutaneously ensures a successful surgical outcome because of increased volume of skin coverage and
improvement in vascularity (Fig. 109.4).
Treacher Collins Syndrome
The cleft and hypoplasia of the orbital framework require a bone graft. The lack of soft tissue necessitates
Z-plasties, skin grafts, or flaps. The galeal flap over the bone graft makes an increase in the thickness of
soft tissue possible; consequently, a smoother bone contour can be achieved.
Other Deformities (3)
The aponeurotic flap is also useful in patients with sequelae of facial fractures as well as in those with
hemicraniofacial microsomia (4). Again, the flap also may be used as coverage for bone grafts.
ANATOMY
The cranial galea aponeurotica is the tendinous aponeurosis that connects the frontal and occipital muscles.
Originating laterally in the anterior and superior auricular muscles, it loses
its aponeurotic character and continues with the temporal fascia up to the zygomatic arch. It adheres to the skin
of the scalp by means of a firm, thick layer of fibroadipose tissue, forming the superficial fascia of the scalp. Its

adherence to the periosteum by means of loose cellular tissue confers mobility to the scalp. Together with the
temporal fascia, the galea forms the substrate for the superficial network of vessels and nerves that irrigate the
scalp (5).
FIGURE 109.1 Blood vessels that form the pedicles of galeal flaps.
Branches of the occipital, superficial temporal, and posterior auricular vessels are the possible pedicles for
galeal flaps (Fig. 109.1). These vessels anastomose, forming a real vascular network. Thus, the anterior
occipital artery anastomoses with its contralateral counterpart and with the parietal branch of the superficial
temporal artery, the posterior auricular artery anatomoses with the parietal branch of the superficial temporal
artery, the parietal and frontal branches of the superficial temporal artery anastomose with their contralateral
counterparts.
FIGURE 109.2 A: Racquet-shaped galeal flap. B,C: Arc of rotation.
FLAP DESIGN AND DIMENSIONS
Various shapes of galeal flaps are possible, including different lengths of a racquet-shaped flap with one of the
vascular pedicles as its base (Fig. 109.2) or a bipedicle flap on the superficial temporal and posterior auricular
vessels (Figs. 109.3 and 109.4). The size of the flaps, starting from the insertion on the zygomatic arch to the
midline of the cranium, varies from 15 to 17.5 cm.
SUMMARY

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Galeal flaps can be used to reconstruct various areas of the face, providing increased vascularity to support
skin and bone grafts.
FIGURE 109.3 A-C: Bipedicled galeal flap based on both the superficial temporal and posterior auricular
arteries.
FIGURE 109.4 Patient with hemifacial atrophy managed by segmental osteotomy of the maxilla and
mandible and a bipedicled galeal flap. A-C: Preoperative appearance. D-F: Postoperative appearance.
References
1. Fox JW, Edgerton MT. The fan flap, an adjunct to ear reconstruction. Plast Reconstr Surg 1976;58:663.
2. Avelar J. Total reconstruction of the auricle in one stage. Rev Bras Cir 1977; 67:139.

3. Holmes AO, Marshall KA. Uses of the temporalis muscle flap in blanking out orbits. Plast Reconstr Surg
1979;63:336.
4. Avelar J, Psillakis JM. The use of galea flaps in craniofacial deformities. Ann Plast Surg 1981;6:464.
5. Perssonelli J. The anatomy of the vascularization of aponeurotic galeal flaps. Presented at the Annual
Meeting of the Brazilian Society of Plastic Surgery, São Paulo, Brazil, 1980.

Chapter 110
Postauricular and Retroauricular Scalping Flap (The Paras Flap)
A. D. DIAS
P. CHHAJLANI
EDITORIAL COMMENT
This would not be the editors' first choice for donor tissue material, although the flap will survive on the axial
blood supply.
The skin behind the ear and in the retroauricular region, although restricted in area, can be raised as an axial
pattern flap with wide maneuverability. It provides a good skin match for the face without leaving any defect on
the front of the face (1, 2, 3, 4, 5, 6).
INDICATIONS
This axial-pattern scalp flap with a random extension is an alternative choice for covering facial defects. The
flap is easy to dissect and raise without prior delay. It can reach nearly the whole face and down to the
hyoid bone on the contralateral side. The donor site is not visible from the front and, in profile, the skin-
grafted area is covered by hair. The absence of any visible donor-site defect and an excellent color match
are worth the possibility of a certain amount of morbidity in the postoperative period.
ANATOMY
There is a cross-communication between the frontal branches of the superficial temporal arteries, with the artery
dividing into two branches: frontal and parietal. The frontal branch divides into two parts, one supplying the
forehead and the other the hair-bearing scalp of the frontoparietal region. The forehead branch communicates
with the ipsilateral frontal and bilateral supraorbital and trochlear vessels.
The main vessel of the flap is the posterior branch supplying the hair-bearing scalp. This is a constant vessel of
about 1 mm in diameter running across the flap and beyond the midline up to the glabrous skin but not entering
it. The postauricular and retroauricular scalping flap (PARAS) flap has a profuse circulation, primarily from the
contralateral superficial temporal vessels, boosted by the postauricular and occipital vessels, the frontal branch
of the ipsilateral superficial temporal vessels, and the bilateral supratrochlear and supraorbital vessels (Fig.
110.1).
FLAP DESIGN AND DIMENSIONS
The flap is designed for a transverse incision at the level of the lower limit of the concha, going across
postauricular and retroauricular skin and ascending anteriorly upward just behind the helical margin of the ear
(see Fig. 110.1A). Posteriorly, the transverse incision goes into the hair-bearing scalp for 1.5 to 2 cm and then
ascends, running parallel to the anterior incision in a slightly expanding fashion. The flap is elevated just
superficial to the perichondrium of the ear and in the loose areolar plane of the scalp. Flap-delineating ascending
incisions are extended transversely across the scalp. A posterior incision extends across one parietal eminence
and ends just after crossing the opposite one; the anterior incision stops at the midline. Forehead skin and flap

base are undermined (7), leading to descent and rotation of the flap and providing an additional 4 to 5 cm.
The postauricular and retroauricular skin can be considered to be a random pattern extension of an axial pattern
flap (8). It is advisable that a 1:1 ratio be maintained. With its ample circulation, it seems justifiable to transfer the
flap in single stages, keeping the random pattern extension limited to the 1:1 ratio. The postauricular (mastoid
region) and retroauricular (posterior surface of the pinna) areas provide, on average, 20 to 25 cm of skin. The
width of the flap is at least 10 cm in the sagittal plane. The reach of the flap extends down to the hyoid bone in
the neck on the contralateral side.
Even in cases where only hairless skin is required, some of the hair-bearing scalp from the mastoid region is
included to give uniform width to the flap; it is returned in a second stage.
FIGURE 110.1 A: Schematic delineation of the flap on the ipsilateral side. B: Vascular pattern on the
contralateral side (base). C: Relationship of the flap incision to the vascular network. The forehead branch
(ipsilateral) escapes the incision and anastomosis with the contralateral forehead branch and both the
supraorbital and trochlear branches bilaterally. (From Dias, Chhajlani, ref. 6, with permission.)
OPERATIVE TECHNIQUE
The donor site is examined and the superficial temporal vessels palpated. The hair is trimmed and shampooed 2
days before the operation. With the patient under general anesthesia, the flap is marked out using a pattern
made preoperatively. Saline-adrenaline 1:150,000 is infiltrated and the flap is raised. The width of the flap
increases gradually as the base is approached, taking care to prevent narrowing at the top of the ear.
The anterior incision runs within 1.5 to 2 cm of the hairline in a normally hirsute scalp and goes up to the midline.
The posterior incision runs over the ipsilateral parietal eminence and gradually deviates posteriorly to run behind
the contralateral parietal eminence, just beyond which it stops. The forehead and base are undermined, bringing
the flap down by 4 to 5 cm. The length of the incisions ultimately will depend on the area of the face to be
covered.

Glabrous skin is sutured over the defect, and the donor raw area behind the ear is covered with a split-thickness
skin graft. The rest of the raw area on the skull is covered with either amniotic membrane or a split-thickness skin
graft. The raw area in the bridge segment partly folds on itself, and the remainder is suitably dressed. Three
weeks later, the flap is divided and the bridge segment returned to the donor-site area.
CLINICAL RESULTS
There have been circulatory problems in the distal few millimeters of the flap, but they have not
compromised the end result; there is enough laxity in the flap to excise the problem margin, if necessary,
and resuture without any significant defect. Rather than delay the flap, it might be preferable to keep its
distal margin a few millimeters more proximal.
Dissection of the skin on the back of the ear may result in venous damage. This skin is very thin and floppy
and may suffer venous thrombosis as a result of kinking. It might be preferable to include the perichondrium
of the back of the ear in the flap, to increase its stiffness, and also to protect the venous circulation during
dissection. Problems of skin grafting the donor area will arise; if small strips of cartilage are removed at
short intervals, skin grafts could take. It is also suggested that the temporal fascia should be included while
the flap is being harvested to protect the scalp circulation, as there is no galea aponeurotica in this area.
SUMMARY
Postauricular and retroauricular skin flaps have withstood the test of time with respect to color match, and
the skin texture is quite good. This flap can be a useful addition to the various other flaps used for facial
reconstruction.
References
1. Crickelair GF. A method of partial ear reconstruction for avulsion of the upper portion of the ear. Plast
Reconstr Surg 1956;17:438.
2. Washio H. Retroauricular temporal flap. Plast Reconstr Surg 1969;43:162.
3. Orticochea M. A new method for total reconstruction of the nose: the ears as donor areas. Br J Plast Surg
1971;26:150.
4. Nahai P, Hurteau J, Vasconez LO. Replantation of an entire scalp and ear by microvascular anastomosis
of only one artery and one vein. Br J Plast Surg 1978;31:339.
5. Galvao MSL. A post-auricular flap based on the contralateral superficial temporal vessels. Plast Reconstr
Surg 1981;68:891.
6. Dias AD, Chhajlani P. The post- and retro-auricular scalping flap (the PARAS flap). Br J Plast Surg
1987;40:360.
7. Converse JM. Clinical application of the scalping flap in reconstruction of the nose. Plast Reconstr Surg

1969;43:247.
8. Smith PG, McGregor IA. The vascular basis of axial pattern flaps. Br J Plast Surg 1973;26:150.

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Chapter 111
Lateral Cheek and Posterior Auricular Transposition Flap
R. O. DINGMAN
G. H. DERMAN
EDITORIAL COMMENT
An alternative to the procedure diagrammed in Figure 111.1 would be to continue the incision parallel to the
nasolabial fold into the neck to create a large, posteriorly based flap and to advance it superiorly. A
transverse cut across the neck with a back cut would be needed.
The posterior auricular transposition skin flap provides an excellent donor source to close soft-tissue defects in
the buccal and parotid-masseteric areas. Even large areas can be reconstructed by this flap alone or with
additional transposition, advancement, or bilobed flaps (1, 2, 3, 4) (Figs. 111.1 and 111.2).
INDICATIONS
Primary closure of defects or local flap reconstruction is complicated by the proximity of important anatomic
structures that are fixed or easily distorted when tension is applied. Important among these are the facial
nerve, ears, lips, eyelids, nose, and hairline. Exact or close matches of skin color, texture, and contour are
prime considerations because of the highly visible location of these areas and the concern regarding an
optimal aesthetic result.
ANATOMY
The posterior auricular transposition flap is composed of non-hair-bearing skin and a thin layer of subcutaneous
tissue overlying the superficial cervical fascia covering the
sternocleidomastoid, occipitalis, and posterior auricular muscles anteriorly as well as the superior portions of the
splenius capitis, semispinalis capitis, and trapezius muscles further posteriorly. The platysma muscle is present
sometimes at the extreme anterior portion of the flap base. This muscle is not included in the flap but is left in
place to protect the cervical and mandibular branches of the facial nerve.

FIGURE 111.1 A-C: This older patient with a large amount of lax skin of the cheeks had malignant degeneration
of a deeply pigmented lesion of the left face. The diagnosis was malignant melanoma. The lesion was excised
with moderately wide margins and closed by development of a large cheek-neck flap advanced and rotated into
the defect. If the single flap is not adequate for closure of the defect, it can easily be combined with a
postauricular transposition flap (see Fig. 111.3).
This flap is richly vascularized, with its major blood supply entering the dermal-subdermal plexus from the base of
the flap in the neck and originating from the superior thyroid branch of the external carotid artery (5). Muscular
perforators supply the flap after piercing through the sternocleidomastoid muscle. Branches of the
sternocleidomastoid artery as well as direct superficial skin branches from the superior thyroid artery also supply
the flap.
Venous drainage is by means of a plexus of small branches feeding the posterior auricular and external jugular
system. Sensory nerve supply is from branches of the greater auricular (C2-3) and lesser occipital (C2) nerves
entering at the base of the flap. Preservation of these branches should retain flap sensibility; however, patients
should be cautioned regarding the possibility of sensibility loss about the ear.
FLAP DESIGN AND DIMENSIONS
The flap is designed using a rotation template such as a cloth towel. The longest flap we elevated was 10 cm,
and we have used this as our size limit. The base of the flap should be designed along the path of the
sternocleidomastoid muscle obliquely across the neck. The sides of the flap are cut parallel to the muscle belly,
with an extra width of skin approximately 1 cm on either side, anterior or posterior, included if necessary. Tissue
expansion similar to that used in ear reconstruction can also be used to increase the size of the flap and to aid in
donor site closure.

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FIGURE 111.2 A-C: Planning for closure of a defect anticipated by excision of a benign lesion of the lateral face.
The combination of a preauricular and a postauricular flap provides a generous amount of tissue of the desired
skin for facial repair. The donor site is repaired with a split-thickness skin graft.
OPERATIVE TECHNIQUE
The incision is carried down to the plane just above the superficial fascia overlying the posterior auricular
musculature, and the flap is developed in the subcutaneous plane, similar to a neck lift. Care is taken to avoid
injury to the cervical and mandibular branches of the facial nerve by dissecting superficial to the platysma muscle
and designing the flap so that it lies posterior to the angle of the mandible. Careful dissection will prevent injury
to the greater auricular nerve, the external jugular vein, and the spinal accessory nerve. These structures should
all be kept deep to the level of elevation of the flap.
Once the flap has been elevated and transposed into position, the donor defect can be closed primarily, skin-
grafted, or closed by local rotation or advancement of a second flap. The bilobed flap technique also can be
used to close defects further anterior on the face. A dog-ear of excess tissue may be present at the anterior
rotation point. If it does not resolve spontaneously (as most do), revision at a later date may be necessary (Figs.
111.3 and 111.4).

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FIGURE 111.3 A: A healthy 77-year-old man 24 hours after removal of a squamous intraepidermal carcinoma of
5 months' duration over the angle of the right mandible. This had been removed one day earlier by Mohs'
surgical treatment with microscopically clear margins. B: A postauricular pedicle flap was developed and rotated
into the defect over the masseteric-parotid area. The donor site was dressed with a full-thickness skin graft. The
ear is temporarily held forward with a nylon suture. C: The postoperative course was uneventful. At 3 months,
the flap is well healed. There is a small dog-ear at the anteroinferior turning point of the flap. This should flatten
out without further surgical care.
CLINICAL RESULTS
The posterior auricular flap was used to close defects in the buccal and parotid-masseteric regions of
several patients. One patient required a bilobed flap for coverage further anteriorly. The only complication
encountered was a superficial skin slough at the distal end of the flap, and this subsequently healed
completely. Patient satisfaction was high, with no functional deficits noted, except for a mild transient
sensory loss in the occipital and posterior auricular region.
FIGURE 111.4 A: A 65-year-old man with scar lesion of the right cheek following spontaneous closure of a
large defect incident to Mohs' chemo-surgery. Note ectropion of the right lower lid and lymphedema due to
interruption of lymphatics to the right lower lid. B: View at termination of surgery showing flap from the right
preauricular region advanced to the right lower lid and right postauricular flap advanced into the
preauricular area. C: Ten years postoperatively.
SUMMARY
The lateral cheek and posterior auricular flaps provide one of the better cosmetic alternatives for
reconstructing cheek defects. With the use of tissue expansion the range and versatility of the flap may also
be augmented.
References
1. Converse JM. Defect of cheek closed by preauricular and postauricular flaps. In: Converse JM, ed.
Reconstructive plastic surgery, 2d ed. Philadelphia: WB Saunders, 1977;1582-1583.

2. Esser JFS. Die Rotation der Wang. Leipzig: Vogel Verlag, 1918.
3. Zimany A. The bilobed flap. Plast Reconstr Surg 1953;11:424.
4. DeCholonky T. The repair of extensive soft-tissue defects of the cheek. Plast Reconstr Surg 1955;16:288.
5. Clemente CD. Anatomy: a regional atlas of the human body, 2d ed. Baltimore: Urban & Schwarzenberg,
1981; Fig. 510.

Chapter 112
Slide-Swing Skin Flap
J. SCHRUDDE
V. PETROVICI
The slide-swing skin flap combines the principle of transposition with skin sliding. It can be used to close large,
round defects with a flap that is smaller than the original defect (1).
In the literature, it is stated that larger defects cannot be closed by means of simple transposition flaps; multiple
flaps must be used. According to our method, larger defects may be closed without any variation of the line of
incision. In the case of Limberg and his followers, a generally rounded defect must be turned into a geometric
figure, which inevitably results in the further excision of healthy skin. The flap must be cut exactly to the same
size as the defect. Our three types of flaps allow the line of incision to be adjusted to the shape of the defect, and
the flap is not only swung but slid into place.
INDICATIONS
Coverage of a round or oval defect is always difficult if the wound is large in relation to its surroundings.
Among the many procedures possible, a local pedicle flap is most advantageous because it matches skin
color and texture and has the potential for preserving sensibility. The slide-swing skin flap permits closure of
a wound using flaps that are small in comparison to the defect. The flap is swung over as usual, with the
base of the flap following in the same direction. Concurrently, the skin surrounding the defect is slid. The
principle involves exploiting the displacement of the skin necessary to close the secondary defect while
reducing the original defect as a result.
The slide-swing plasty may be employed on almost all parts of the body. The size of the flap is dependent
on the elasticity of the skin. This is greatest in the region of the trunk, especially in the area of the flank, and
in the back, abdomen, and buttocks. Skin reserves decrease in the distal regions of the limbs and are
reduced on the scalp. The possibilities of closing a defect are dictated by its size and location.
The main indications for the slide-swing plasty are the defects that remain after removing tumors (see Fig.
112.3), skin dysplasias, or scars that result from injuries. To avoid distortion of facial structures in the case
of larger defects, undermining of the skin and subcutaneous tissue should be undertaken mainly in the
direction of the peripheral parts of the face. The slide-swing flap may be used even in places where other
methods are doomed to failure. For example, the slide-swing plasty can be used on the nose and in other
less elastic skin areas where pure transposition flaps require skin grafting.
FLAP DESIGN AND DIMENSIONS
A more thorough analysis of the slide-swing skin flap reveals that it is in part founded on the principles of the
triangular exchange plasty (Z-plasty), the exact trigonometric rules for which were laid down by Limberg (2). The
slide-swing plasty is partly a combination of two asymmetrical figures with a common median incision, also
known as the basic incision. In contrast to the exchange plasty and to other methods further developed by
Limberg in which all incisions were straight, all lines of incision in slide-swing flaps take the form of arcs that are
partly stretched, with one exception (i.e., the initial section of the median incision that forms the bottom angle of
the defect).

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The additional mobilization of the skin around the defect as a part of the technique leads to a reduction in the
size of the defect. Exploiting the extent of skin reserves, the flap can be cut smaller than the defect. This has the
effect of reducing the size of the defect as well as the resultant scars. Unlike conventional transposition flaps and
those of Limberg, incisions in our flap types are never made parallel. Instead, the flap narrows to a point. In
addition, the sides of the flap are not cut to the same length, thus increasing the size of the flap base. Three
basic types of flaps have been developed (Fig. 112.1).
Type 1
This technique is used to close a round defect. The flap can be laid out at any point on the round defect. The
excision of the defect is arranged so that a right angle is formed at the base of the flap. The resulting movement
of the skin reduces the size of the formerly round defect so that the shape of the closed defect corresponds more
or less to that of the flap.
Type 2
The same principle is involved when using an oblong flap to close a defect. Here care must be taken to ensure
that when
closing the secondary defect the movement of the skin leads to a reduction in the length of the defect. This
technique is significant for the blood supply because the width is in inverse proportion to the length. Therefore,
the pole of the incision made at the flap base, removed from the defect, is placed vertically under the slip of skin
to be slid into the place created by the formation of the flap and the edge of the defect.
FIGURE 112.1 The three types of slide-swing skin plasty. (From Schrudde, Petrovici, ref. 1, with permission.)
Type 3
This technique allows the use of a straight stretch of an otherwise round defect edge when forming the flap. The
actual flap is kept quite small as a result of skin sliding to close the secondary defect and of further sliding of the
skin surrounding the defect. Relative to the size of the area operated on, there are few scars. Depending on the
site of the defect, a type 2 flap is sometimes converted into a type 3 flap to improve blood supply.
Mobilization of both the rounded flap and the three-cornered flap to close the secondary defect calls for elasticity
of the surrounding skin. The slide-swing plasty combines the principle of transposition flaps with that of skin
sliding. The triangular flap with which the secondary defect is closed is extremely mobile. By sliding it in the

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direction of the secondary defect, some of the circumference is drawn with it, thus reducing the size of the defect.
The secondary defect extends only marginally into healthy surrounding tissue, and less scar formation is the
welcome result. In the case of a Z-plasty, the triangular skin flaps are separated from their underlying tissue
down to their bases. When using the slide-swing flap, the skin surrounding the defect is also mobilized, resulting
in skin movement in all directions. The special recommendation of this method is that all the skin reserves
around the defect are exploited.
Head and Neck Area
In the head and neck area, the more caudal the defect, the easier it is to use the method because of the elasticity
of the skin. When properly planned, the technique permits optimal restoration of the contours of the head and
neck. The slide-swing plasty produces especially good results in early treatment of a facial injury. The injury is
thoroughly cleaned, and its irregular edges are excised slightly to give it a more or less round shape. A slide-
swing plasty then is outlined in accordance with the position and extent of the defect. A type 3 flap, with the
advantages already mentioned, is best.
OPERATIVE TECHNIQUE
In the case of type 1 slide-swing flaps, two skin flaps and the underlying tissue are mobilized and swung into
place (Figs. 112.2 and 112.3). First, there is the round flap with sides to meet at an acute angle (β), if one
imagines them extended. On the opposite side, on the median incision AB, there is a right angle (α). The flap AB'
C is used to close the defect. Second, the flap employed in closing the secondary defect is situated between the
defect and the transposition flap at an acute angle (γ). The median line B' B between the angles (β) and (γ) is
part of the basic incision AB, which belongs to the figure D' ABC.
Swinging the flap into the defect is the equivalent of an asymmetric exchange plasty (D'ABC), with the basic
incision AB and the differing side angles (α) and (β). The flap AB'C is thereby rounded off to fit the defect,
resulting in better blood supply. Along with the transposition of the flap, angle γ is moved into the place of angle
β; angle γ is increased, following the movement to C that results from straightening the line D'B', increasing the
blood supply.
FIGURE 112.2 Geometric principles of slide-swing plasty with exchange of asymmetrical triangles. (From
Schrudde, Petrovici, ref. 1, with permission.)

FIGURE 112.3 A: Rhabdomyosarcoma on left cheek removed, leaving a defect of 8 × 5 cm. A type 2 slide-swing
plasty is drawn. B: Transposition of the flap. C: After 5 years, no signs of relapse or metastases of the tumor.
CLINICAL RESULTS
The slide-swing flap has proved to be of great practical use. This plasty was used in more than 1,600
patients between 1962 and 1982 at the Department of Plastic Surgery at the University of Cologne. Primary
healing was achieved in almost every patient. Delayed healing as a result of necrosis of the distal portions
of the flap usually was the consequence of poor design in the ratio of length and width, as well as impaired
circulation postoperatively because of pressure. We never observed total flap loss. In case of partial
necrosis, another slide-swing plasty or free skin transplant should be tried. If granulation tissue cannot be
removed completely, as is often the case in bedsores, fistulas may result. Hematomas under large flaps are
not unusual and should be removed completely as soon as possible.
SUMMARY
The slide-swing flap combines the principle of transposition with skin sliding. This permits the closure of
large, round defects with flaps that are smaller than the original defect.
References
1. 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.
2. Limberg AA. Design of local flaps. In: Gibson T, ed., Modern trends of plastic surgery. London:
Butterworth, 1966;38-61.

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Chapter 113
Cervical Skin Flaps to The Cheek
V. Y. BAKAMJIAN
See Chapters 120 and 122. The same cervical skin flaps as are described for intraoral lining can be used to
cover external cheek defects (Figs. 113.1 and 113.2).
FIGURE 113.1 Transverse cervical skin flap to the cheek in a male patient. A: Multicentric pigmented basal cell
carcinoma. B: Result after wide resection and repair.

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FIGURE 113.2 Oblique cervical skin flap to the cheek in a 90-year-old patient. A: Neglected squamous cell
carcinoma. B: Defect after wide resection with outline of the flap. C: The repair with the donor site covered with
a split-thickness skin graft. (Continued)
FIGURE 113.2 (Continued) D: The final result.

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Chapter 114
Transposition Neck-to-Cheek Skin Flaps
C. C. COLEMAN JR.
M. J. TAVIS
The need for an abundance of relaxed tissue lying within the operative field has prompted the use of a
posteriorly based neck flap to cover cheek defects.
INDICATIONS
The posteriorly based flap, when raised, affords a broad exposure for formal neck dissection and also
provides tissue for defects in the cheek and mandibular regions. The posteriorly based neck flap can be
used for various defects, including cancers of the parotid, radionecrosis with persistent cancer invading the
mandible, and skin malignancy involving the jaw and mouth.
ANATOMY
The neck skin has been used as a pedicle-flap donor site by numerous workers (1, 2, 3, 4). Most of the reports
deal with neck flaps that are based inferiorly and are migrated in a clockwise direction (5, 6, 7, 8, 9), primarily by
stretching the posterolateral neck skin. Such flaps will successfully close sizable cheek defects, but their blood
supply is greatly jeopardized by an associated radical neck dissection. The division of the deep fascia requires
that all three branches of the supraclavicular plexus of arteries, veins, and nerves be ligated.
Studies have shown that the blood flow in the cervical skin comes from a lateral direction (10). The posteriorly
based flap is not compromised by an associated radical neck dissection because muscular branches of the
vertebral, occipital, and superior thyroid arteries are not affected by the dissection. Although the posteriorly
based cervical skin flap includes the platysma muscle, the blood supply is random in nature.
FLAP DESIGN AND DIMENSIONS
With the patient supine, the neck is extended and the head is rotated in the opposite direction, thus placing the
deep cervical fascia under maximal tension and thereby facilitating elevation of the flap. The flap is based on the
anterior border of the trapezius muscle. It is outlined roughly parallel to the mandible over as far as the midline of
the neck as a well-rounded structure. The lower border of the flap parallels the clavicle. The degree of rotation
depends on the angle. The lower incision follows over the posteroinferior trapezius (Fig. 114.1A).
OPERATIVE TECHNIQUE
Following surgical delineation of the cheek resection, the neck flap is elevated down to the deep cervical fascia
and reflected posteriorly. The extirpative procedure then is carried out through this ample exposure. When the
composite resection is completed, the adjustment in the lower incision will provide easy relaxed closure of the
face with the rotation neck flap (Fig. 114.1B). Although there are some reports (4, 5, 6, 7, 8, 9) to the contrary,
we believe that closure of the neck defect always requires a split-thickness skin graft (Fig. 114.1C) or, in some
cases, a rotation chest flap (also based posteriorly) (Figs. 114.2, 114.3, 114.4).

FIGURE 114.1 A: Drawing of large round rotation flap extending to or slightly beyond the midline of the neck. As
the inferior part of the incision is carried over the trapezius, the degree of cephalad extension will determine the
amount of rotation. B: The donor wound in the neck gives ample room for radical neck dissection. Occasionally,
two divergent radial incisions in the lower part of the neck skin are necessary in order to gain access to the
insertion of the sternocleidomastoid muscle and internal jugular vein. C: Closure of the neck is accomplished
with a split-thickness skin graft.
CLINICAL RESULTS
In no patient has there been any tissue loss in these flaps, and the associated grafts on the donor site have
been successful in every patient. Because of the position and size of the neck defect in rounded, laterally
based flaps, a skin graft or additional chest rotation flap is always necessary.
Another disadvantage of these flaps is that they are so thin that contour problems are frequently present,
particularly when segments of the facial skeleton are removed in the resection. In such instances, the bulky
pectoralis major island musculocutaneous flap is more desirable.
All neck flaps produce rotation redundancies that necessitate secondary minor surgical procedures. At least
one segment of the facial scar (medial) and the medial edge of the skin graft or second rotation flap will
require Z-plasty release.

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SUMMARY
Posteriorly based neck flaps are helpful, time-proven adjuncts to extirpative surgery of the face and jaws.
FIGURE 114.2 In some patients, a second rotation flap in the upper lateral chest is used to close the neck
wound. This obviates placing a skin graft over the carotid axis and transfers skin-graft coverage to a less
vital area.
FIGURE 114.3 A: Composite resection of cheek and parotid outlined. Injudicious open biopsy of tumor
necessitated the cheek resection. B: The exposure of the neck structures affords ample room for radical
neck dissection. Note blood stain on central portion of flap.

FIGURE 114.4 A: Deeply infiltrating basal cell carcinoma extending through full thickness of cheek and oral
commissure. The tumor extended along the gingivobuccal sulcus at the level of the jaw. An anteriorly based
tongue flap was used for lining. B: Rotation neck flap transferred as cover for the operative defect. A split-
thickness skin graft was needed for closure of the defect.
References
1. Hadjistomaff B. Restoration of the cheek by using the skin of the jaw-neck region. Plast Reconstr Surg
1947;2:127.
2. Hoffman G. Full-thickness resection of the cheek with one-stage reconstruction. Am Surg 1968;34:68.
3. Conley J. Regional flaps of the head and neck. Philadelphia: WB Saunders, 1976;176-187.
4. Kaplan I, Goldwyn RM. The versatility of the laterally based cervicofacial flap. Plast Reconstr Surg
1978;61:390.
5. Smith F. Flaps utilized in facial and cervical reconstruction. Plast Reconstr Surg 1951;7:415.
6. Stark RE, Kaplan J. Rotation flaps, neck to cheek. Plast Reconstr Surg 1972;50:230.
7. Crow ML, Crow J. Resurfacing large cheek defects with rotation flaps from the neck. Plast Reconstr Surg
1976;58:196.
8. Juri J, Juri C. Advancement and rotation of large cervicofacial flaps for cheek reconstruction. Plast
Reconstr Surg 1979;64:692.
9. Coleman CC. Flaps for floor of the mouth and cheek reconstruction. In: Grabb WC, Myers MB, eds., Skin
flaps. Boston: Little, Brown, 1975; 337-350.
10. Freeland AP, Rogers J. The vascular supply of the cervical skin with reference to incision planning.
Laryngoscope 1975;85:714.

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Chapter 115
Cervical Rotation Skin Flap for Reconstruction of The Cheek
R. B. STARK
EDITORIAL COMMENT
The radical undermining and elevation of the neck flap to the level just below the eye may cause significant
tension on the eyelid structures. This may be averted by creating an anterior incision so that a rotation flap
would rest more easily in this elevated position, or by providing more tissue by doing preliminary tissue
expansion.
The cervical rotation flap, well vascularized by branches of the external carotid artery, offers a nearly ideal
means of surfacing the aesthetic unit of the cheek (1, 2, 3, 4, 5).
INDICATIONS
Cervical flaps have been used to resurface the cheek when dermatoses have been removed (i.e.,
epitheliomas, hemangiomas, radiodermatitis, superficial melanoma, blue nevus of Ota, and noma) and for
oral-cutaneous fistulas and scarring from burns and lupus erythematosus.
FLAP DESIGN AND DIMENSIONS
The size of the flap is dependent on the surface area of the neck. In the average-sized adult, the rotation flap,
which resembles an acute angle more than it does a hemicircle, may measure 10 cm on each of its two sides
(along the body of the mandible and along the hairline of the neck).
OPERATIVE TECHNIQUE
With rotation superiorly and medially, the side adjacent to the mandibular body shifts to the nasolabial line and
side wall of the nose. The side next to the hairline is elongated by a generous back cut into the base of the flap
(parallel to the clavicle). The flap then shifts up to the infraorbital rim, the zygomatic arch, and along the posterior
hairline. The back-cut incision opens as a V when rotation of the flap begins and is virtually a straight line when it
reaches its final position. A cut a few centimeters proximally on the opposite side of the wound produces a Z that
facilitates wound closure at this point.
As a general principle, the flap should be raised before the lesion is removed to determine adequacy of cover
and vascularity (Fig. 115.1). The flap consists of full-thickness skin and subcutaneous tissue whose thickness is
that of a rhytidectomy flap.
In the postoperative period, tension on the flap can be minimized by positioning. The head is turned toward the
flap, and the ipsilateral shoulder is hunched, with that arm placed across the chest, the hand resting on the
opposite shoulder. This arm-chest relationship is maintained by a padded elastic bandage of Velpeau design. A
head cap of the operating room type is joined to the Velpeau by adhesive bands.
CLINICAL RESULTS

In a series of 27 patients, there was one incident of a postoperative hematoma when the flap replaced a
hemangioma, necessitating evacuation and resuture. In three instances, the distal end of the flap failed to
survive. The remaining flap was later rerotated successfully.
SUMMARY
The cervical rotation skin flap is ideal for reconstructing cheek defects.
FIGURE 115.1 The area of scar tissue (shaded) is excised, and the cervical flap is undermined completely
and rotated to cover the defect.
References
1. Gonzalez-Ulloa M, Castillo A, Stevens E, et al. Preliminary study of total restoration of facial skin. Plast
Reconstr Surg 1954;13:151.
2. Stark RB. The pantographic expansion principle as applied to the advancement flap. Plast Reconstr Surg
1955;15:222.
3. Stark RB. Plastic surgery. New York: Hoeber, 1962;106,146.
4. Stark RB, Kaplan M. Rotation flaps neck to cheek. Plast Reconstr Surg 1972;50:230.
5. Stark RB. Resurfacing the face. Clin Plast Surg 1975;2:577.

Chapter 116
Cervicofacial Skin Flap to The Cheek
R. M. GOLDWYN
EDITORIAL COMMENT
This flap should be compared with that described in Chapter 114 because there are some similarities.
The cervicofacial flap involves the lower cheek and upper neck. It is based laterally not medially, as is usually
described (1).
INDICATIONS
The cervicofacial flap is particularly suitable for patients who are middle-aged or older because of the laxity
of the cervical skin that allows a primary closure of the donor area. It has been used without difficulty in
younger patients; however, a skin graft may be required in the neck to prevent excessive pulling on the
lower lid. The flap can be used, with or without lining, for closure of a cheek defect that also requires a
radical neck dissection because the opening on the neck can be approximated without resorting to a distant
flap. In my experience, this flap has its greatest usefulness for closure of cheek defects ranging from 4 × 4
cm to 6 × 7 cm.
ANATOMY
Although random, the cervicofacial skin flap is richly supplied, primarily by the external maxillary artery and vein
and their branches. It is not necessary to include the platysma for blood supply.
FLAP DESIGN AND DIMENSIONS
No flap delaying procedure is required. The skin portion of this laterally based flap usually measures 9.5 cm wide
at its base and 12 cm long.
OPERATIVE TECHNIQUE
Flap dissection on the cheek usually follows or parallels the nasolabial fold and then goes across the mandible
down to the midcervical region or lower, where dissection is maintained superficial to the platysma muscle to
avoid injury to the mandibular branch of the facial nerve. In the midneck, the flap is cut transversely to a point
over the sternocleidomastoid muscle and then superiorly and posteriorly to the earlobe or mastoid area.
If the flap is rotated into the lower eyelid, it is advisable to anchor it to the deep tissues of the orbit and the nose
to avoid ectropion from its weight. Similarly, the excision should be carried laterally beyond and above the outer
canthus onto the temporal region, where the flap also can be fastened to provide a supportive sling under the
lower lid.
Closure of the donor area in the neck can be accomplished usually by beginning posteriorly and laterally and
going medially, ending with a Y. If necessary, a split-thickness skin graft can be taken from an inconspicuous
donor area and used in the neck to decrease tension on the flap, thereby lessening the possibility of ectropion. A
few months later, the skin graft can be excised on an outpatient basis under local anesthesia.

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At completion of the operation, a Penrose drain can be placed inferiorly and posteriorly, extending upward for the
length of the flap. It is removed in 36 to 48 hours. If the patient's head is kept slightly flexed postoperatively, the
flap will be subjected to less pull (Figs. 116.1, 116.2, 116.3).
CLINICAL RESULTS
If the flap is contemplated in male patients, they should be warned that their beard line will be slightly higher
than normal. This discrepancy has not caused any complaints in my patients. In none of the 17 patients for
whom this flap has been used within the past 4 years has there been a problem with necrosis, infection, or
failure to achieve adequate closure of the defect and donor site. One patient had the sensation of “pulling”
of his lower lid but no evidence of actual
ectropion. In 6 months, this discomfort disappeared. Two patients for whom a skin graft was used for
closure of the donor site later had their graft excised and a Z-plasty used to avoid a straight-line
hypertrophic scar under the neck. No patient has reported any functional deficit from the use of the flap.
FIGURE 116.1 Diagram of patient at time of operation. A: After excision of tumor and development of the
cervicofacial flap. B: Rotation of flap. C: Closure.
FIGURE 116.2 A 46-year-old man with sclerosing basal cell carcinoma of 2 years' duration. A: After
excision of tumor and development of the cervicofacial flap. B: Flap rotated. C: Primary closure of recipient
and donor sites. (From Kaplan, Goldwyn, ref. 1, with permission.)

FIGURE 116.3 A,B: Appearance 3 years postoperatively. (From Kaplan, Goldwyn, ref. 1, with permission.)
SUMMARY
The cervicofacial flap is a useful, well-tolerated flap for closing cheek defects with or without an associated
radical neck dissection.
Reference
1. Kaplan I, Goldwyn RM. The versatility of the laterally based cervicofacial flap for cheek repairs. Plast
Reconstr Surg 1978;61:390.