Facial Reconstruction after Mohs Surgery

drapes do not interfere with the full path of the harvest and is
useful to perform a practice pass without power on the derma-
tome to ensure there are no obstructions to harvesting. A very
common practice of using a no. 15 blade as a “feeler gauge” to
measure the blade thickness is infeasible, is not accurate, and is
not recommended by the Zimmer dermatome manuals. This is
a habit that is easily discarded with no ill e ect for the patient.
Mineral oil is routinely used on the guard, as well as on the
donor site. After the graft is harvested, initial attention is to be
focused on the donor site. There is literature in support of an
inclusive dressing of either Tegaderm or BioDerm to be placed
directly over the donor site and great care is taken for the accu-
rate placement of this dressing with wide borders and use of a
tissue adhesive on the normal skin borders to maintain this
dressing in place.8 The patient is given postoperative instruc-
tions to leave the adhesive in place for 5 to 7 days and healing
can occur underneath. If the patient develops a large area of
ballotable fluid unexpectedly, we encourage them to make a
small piercing on the Tegaderm with nail scissors and drain it
and make every attempt to leave the occlusive Tegaderm dress-
ing in place until the donor site heals underneath. For surgeons
who are interested in the final aesthetic outcome, some degree
of insight needs to go into the decision-making process of
actually meshing the graft. Although meshing does increase the
volume of usable skin, and also likely increases the graft take, it
will result in an irretrievably abnormal aesthetic result that is
impossible to correct. The common pebble-stoning or screen
door appearance of a meshed skin graft is unmistakable and is
caused by the healing of the meshed interstices by scarring and
not actual primary healing and results with a far inferior result
than a unmeshed sheet graft. Additionally, the practice of
meshing, but not expanding, also results in wound healing that
is inferior to an appropriately inset unmeshed sheet graft.
6.4 Graft Inset
The inset process for large sheet graft relies on continuous fast
or plain gut sutures (never chromic gut) along the border of the
graft and then dependent on the size, as well as the eventual
contours, small areas of the graft, where it is not adhered or
where there are clear air bubbles underneath which are then
sharply incised with a no. 69 Beaver blade and a 5–0 gut suture
is utilized to secure one limb of the interstices to keep this open
and allow the easy egress of any potential seroma fluid. The
graft is then carefully bolstered with a surgical sponge bolster
with ointment on one side and no intervening nonstick gauze.
For large areas of graft, central 3–0 double-armed Prolene
sutures are utilized to improve uniform compression of the
sponge and the remainder of the sponge is sewn in place with
4–0 pop-o Nurolon sutures with no attempts to do a tie-over
bolster, rather utilizing just peripherally placed sutures. The
advantage of peripherally placed suture is the speed of the
bolster inset and also that it prevents the peripheral upturning
that can occur with tie-over bolsters. Postoperatively, the
sponge is kept dry and removed in 5 to 7 days. On bolster
removal and if there is any accumulation of seroma fluid, then
this is carefully expressed on the initial phase and the graft
recompressed and given a chance to continue healing
(Fig. 6.1, Fig. 6.2, Fig. 6.3, Fig. 6.4, Fig. 6.5, Fig. 6.6,
Fig. 6.7, Fig. 6.8, Fig. 6.9, Fig. 6.10, Fig. 6.11, Fig. 6.12,
Fig. 6.13, Fig. 6.14, Fig. 6.15, Fig. 6.16, Fig. 6.17,
Fig. 6.18, Fig. 6.19, Fig. 6.20).
Fig. 6.1 A 32-year-old male patient with very large
dermatofibrosarcoma protuberans tumor of left scalp.

Fig. 6.2 Tumor was resected and wound temporized with Integra until
clear margins were verified.
Introduction
34

Fig. 6.3 Decision was made to proceed with existing Integra as final
wound coverage with required split-thickness skin graft.
Fig. 6.4 Decisions regarding donor site involve ease of harvest and final
color match. For this patient, even though proximal thigh donor site
would provide easier harvest, the split-thickness graft was harvested
from shaved posterior scalp in order to provide final color match.
Fig. 6.5 Although the graft is not meshed, it is handled with a carrier
to facilitate accurate placement on the scalp.
Fig. 6.6 Tegaderm and Mastisol dressings are utilized for the donor
site with stockinette cap for final wound coverage. This dressing is left
in place until postoperative day 5.
Fig. 6.7 Split-thickness graft inset.
Split-Thickness Skin Grafting
35

Fig. 6.8 Sponge bolster applied to graft site with topical antibiotic ointment. Bolster may be stapled in place with cosmetic staples or sewn into place
with 4–0 Nurolon pop-offs. Bolster is removed on postoperative day 5.
Fig. 6.9 Stockinette cap is placed and may be removed on
postoperative day 5.
Fig. 6.10 Final postoperative results shown at 4 months.
Fig. 6.11 Wound site measured and appropriate dimensions drawn onto thigh donor site prior to local anesthetic infiltration of donor site.
Introduction
36

Fig. 6.12 Sponge bolsters measured for final wound coverage.
Fig. 6.13 Mineral oil placed on both the Zimmer dermatome and graft donor site to facilitate harvest.
Fig. 6.14 Skin placed under manual tension and graft harvested at 0.012 inches thickness.
Split-Thickness Skin Grafting
37

Fig. 6.16 Harvested graft spread out on carrier and tacked down with antibiotic ointment.
Fig. 6.15 Tegaderm and Mastisol dressing placed on donor site.
Fig. 6.17 Graft meshed at 1:1.5.
Introduction
38

References
[1] Papa G, Spazzapan L, Pangos M, Delpin A, Arnez ZM. Compared to coverage
by STSG grafts only reconstruction by the dermal substitute Integra® plus
STSG increases TcPO2 values in diabetic feet at 3 and 6 months after recon-
struction*. G Chir. 2014; 35(5–6):141–145
[2] Yi JW, Kim JK. Prospective randomized comparison of scar appearances
between cograft of acellular dermal matrix with autologous split-thickness
skin and autologous split-thickness skin graft alone for full-thickness skin
defects of the extremities. Plast Reconstr Surg. 2015; 135(3):609e–616e
[3] Quilichini J, Benjoar MD, Hivelin M, Lantieri L. Split-thickness skin graft har-
vested from the scalp for the coverage of extensive temple or forehead defects
in elderly patients. Arch Facial Plast Surg. 2012; 14(2):137–139
[4] Khalid K, Tarar MN, Mahmood F, Malik FS, Mehrose MY, Ata-ul-Haq. Scalp as
a donor site for split thickness skin grafts. J Ayub Med Coll Abbottabad. 2008;
20(1):66–69
[5] Weyandt GH, Bauer B, Berens N, Hamm H, Broecker EB. Split-skin grafting
from the scalp: the hidden advantage. Dermatol Surg. 2009; 35(12):1873–
1879
[6] White N, Hettiaratchy S, Papini RP. The choice of split-thickness skin graft
donor site: patients’ and surgeons’ preferences. Plast Reconstr Surg. 2003;
112(3):933–934
[7] Fang P, Engrav LH, Gibran NS, et al. Dermatome setting for autografts to cover
INTEGRA. J Burn Care Rehabil. 2002; 23(5):327–332
[8] Karlsson M, Lindgren M, Jarnhed-Andersson I, Tarpila E. Dressing the split-
thickness skin graft donor site: a randomized clinical trial. Adv Skin Wound
Care. 2014; 27(1):20–25
Fig. 6.19 Graft sewn in place with opposing 4–0 plain gut sutures and
tacked down centrally.
Fig. 6.18 Meshed graft transferred to wound site with carrier.
Fig. 6.20 Bolster placed on wound site with antibiotic ointment and tacked down with 4–0 Nurolon pop-offs.
Split-Thickness Skin Grafting
39

7 Cartilage Grafts
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the use of cartilage grafts in soft-tissue
facial reconstruction. Donor sites and grafts include conchal
bowl, septal cartilage, rib, and radiated cartilage (MTF banked
cartilage). This includes the discussion of donor sites, technique
for each donor site, cartilage graft harvest, and cartilage graft
inset.
Keywords: cartilage graft, conchal cartilage graft, conchal bowl,
donor site, septal cartilage, rib cartilage, banked frozen allograft
Summary
● Conchal cartilage is adequate for the majority of nasal recon-
struction.
● The morbidity of graft harvest is not trivial.
● Care must be taken during harvest, especially in elderly
patients, to avoid breaking often brittle cartilage.
● Great care must be taken during cartilage inset to ensure
complete soft-tissue apposition to the cartilage graft
● Banked costal cartilage provides excellent quality and volume
of cartilage for grafting without donor-site morbidity.
7.1 General Considerations
The use of cartilage grafting in nasal reconstruction is liberal
and is used to both replace resected cartilage and reinforce
areas that anatomically lack cartilage but will require support
to prevent deformity in healing. This is most applicable in
partial or total alar reconstruction where both anatomic and
nonanatomic cartilage grafting can prevent irreversible alar
retraction and deformity.1
The requirements for a successful cartilage graft include a
robust vascular bed and firm suture fixation to support its
ingrowth and prevent extrusion and subsequent infection.
The selection of donor site for cartilage grafts is based on the
needed graft size and shape, consideration of the donor-site
surgical access and postoperative morbidity, as well as the
shape and size of the cartilage. The majority of isolated lower
third nasal defects can be managed with conchal cartilage
grafting or MTF cartilage. Defects larger than isolated heminasal
will require rib cartilage grafting or multiple MTF cartilage
grafting.
7.2 Donor-Site Selection
7.2.1 Conchal Bowl Donor Site
The conchal bowl is an excellent donor site and provides robust
flexible cartilage that, if harvested contralateral to the defect,
approximates the shape of the native alar cartilage. Provided
the antihelical fold is not violated, the entire cymba and cavum
conchae can be harvested with minimal donor-site morbidity
and no change in the final appearance of the ear.2 Preopera-
tively, the patient should be asked about any hearing aid
requirements, given this requirement can be a contraindication.
For patients who do require hearing aids, the conchal bowl
donor site is not suitable, given the long-term pain and di -
culty in fitting the expensive prosthetic hearing devices.
When the side that the patient prefers to sleep on has been
determined, then the contralateral side is chosen for harvest as
long as the alar shape requirement is not required. During the
surgical preparation, the external auditory meatus, as well as
the front and back of the external ear, is carefully prepped.
The patient is placed on a sterile towel and great attention is
directed at maintaining sterility throughout the process, which
includes avoiding contact of the patient’s hairnet or nonsterile
head dressing with the ear.
Lidocaine mixed with epinephrine and 0.25% Marcaine is
injected subcutaneously with a 27-gauge needle both anteriorly
and posteriorly on the conchal bowl, and the local anesthetic
injection is used to hydrodissect the skin from the cartilage.
Either an anterior or posterior incision can be made. The advan-
tages of an anterior incision rely on a significantly easier har-
vest, as well as an easier access to the incision for postoperative
care with no sacrifice in donor-site scar appearance. The entire
conchal bowl is sharply dissected with an assistant holding the
dissected skin flap up out of position and then the entire con-
chal bowl is carefully managed with Adson-Brown forceps
versus regular Adson forceps and then sharply dissected free of
the donor site. At this point, careful hemostasis is achieved and
then the donor site is simply closed with a running horizontal
mattress, 5–0 plain gut suture taking care to ensure eversion
approximation of the wound edges. No external bolster dress-
ing is required; however, the dead space must be obliterated to
prevent formation of late hematoma, and multiple through-
and-through 4–0 gut sutures are placed from the front to the
back of the ear with a straight Keith needle and the suture is
tied on the anterior aspect of the ear. The ear is liberally coated
with antibiotic ointment and followed carefully during the
postoperative period to ensure healing without hematoma or
infection. No postoperative antibiotic coverage is provided;
however, if the patient does develop a postoperative infection
at the donor site, wound cultures must be taken and prescribed
antibiotics must include pseudomonas coverage, given this can
be a frequent pathogen.3 In elderly patients, the gradual
increasing in sti ness of the cartilage must be considered and
significant care taken in the graft harvest, given that it is
increasingly brittle and prone to fracture.
The cartilage is harvested w ith perichondrium intact on
both sides and carefully thinned and contoured and sew n in
place with 4–0 Vicryl sutures to a carefully designed and
approxim ated cartilage pocket. Even small toothpick-sized
segm ents of conchal cartilage can be utilized and these can
prevent late alar retraction if placed in a properly designed
subcutaneous pocket in a nonanatomic location along the
alar rim.
The di culty in harvesting conchal cartilage grafts lies only
in harvesting adequate length and this must be ensured prior
Introduction
40

to incision and rarely is the vertical height or width of the graft
a limiting factor ( Fig. 7.1, Fig. 7.2, Fig. 7.3, Fig. 7.4,
Fig. 7.5, Fig. 7.6).
7.2.2 Rib Cartilage Donor Site
For larger cartilage requirements that include complete nasal
defects or heminasal defects with columellar loss, the rib
cartilage is the next choice. Through either a horizontal infra-
mammary incision in females or a horizontal medial incision as
described by Nagata,4 large segments of up to 4 cm of costal
cartilage can be utilized. Advantages of the rib harvest are both
in the size of the graft and the ability to harvest grafts of such
thickness so that balance cross-sectional carving can be
performed to prevent later warping.5 Additionally, both bone
and rib can be harvested simultaneously.
The choice of rib varies from the fifth to the ninth ribs as has
been described by Gibson et al.6 The postoperative pain associ-
ated with costal cartilage grafting is not insignificant and wide
Marcaine blocks should be placed intraoperatively with careful
attention to detection and treatment of inadvertent pneumo-
thorax, particularly in the outpatient setting.6
7.2.3 Septal Cartilage Donor Site
Septal cartilage harvest is advantageous as it leaves no postope-
rative scar, the donor site is already within the surgical field,
and large volumes of cartilage are available.7 However, the
Fig. 7.1 Although conchal cartilage harvested form an anterior approach to the entire conchal bowl constitutes the majority of grafts, the anterior
helical rim is also a suitable donor site. If more cartilage is required, the entire conchal bowl may be harvested.
Fig. 7.2 Wide generous exposure of the conchal bowl is required for adequate cartilage harvest. Cartilage width is rarely an issue, but adequate length
requires precision in harvest.
Cartilage Grafts
41

Fig. 7.4 Final flap appearance with underlying
conchal cartilage graft.
Fig. 7.3 The graft is inset as a nonanatomic alar rim graft secured in place with 5–0 Vicryl through-and-through sutures. This must be apposed with
underlying tissue at host site.
Fig. 7.5 Donor site is closed with 5–0 continuous plain gut with through-and-through 4–0 Keith needles on plain gut to tack down any space between
skin and cartilage and avoid hematoma.
Introduction
42

septal cartilage itself is flat and is di cult to contour for alar
reconstruction.
7.2.4 Banked Frozen Allograft Cartilage
Banked frozen allograft is widely available with the advant-
age of no donor-site m orbidity and the ability to obtain
large pieces of cartilage.8,9,10 The product is easily obtainable
and available as follows ( Fig. 7.7, Fig. 7.8, Fig. 7.9,
Fig. 7.10).
Costal cartilage grafts:
Sheets W/L/T
1–2 cm, 3.5–4 cm, 1.8–2.2 mm # 258223
1–2 cm, 4.1–5 cm, 1.8–2.2 mm # 258224
Fig. 7.6 Final postoperative results of donor site shown at 3 months.
Fig. 7.7 A number of excellent-quality banked MTF costal cartilage
grafts are available and provide superior quality and quantity of graft
material with no donor-site morbidity.
Fig. 7.8 Cartilage is carved on the back table utilizing fresh 10 blades.
Fig. 7.9 Cartilage is secure in place with soft-tissue lining apposition
with 4–0 Vicryl through-and-through sutures.
Fig. 7.10 Cartilage construct in apposition to lining ready for forehead
flap coverage.
Cartilage Grafts
43

References
[1] Selçuk CT, Durgun M, Özalp B, Bozkurt M. Cartilage-supported paramedian
forehead flaps for reconstruction of full-thickness nasal defects. J Craniofac
Surg. 2013; 24(2):425–427
[2] Lee M, Callahan S, Cochran CS. Auricular cartilage: harvest technique and
versatility in rhinoplasty. Am J Otolaryngol. 2011; 32(6):547–552
[3] Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondri-
tis of the auricle and its management. J Laryngol Otol. 2007; 121(6):530–534
[4] Kawanabe Y, Nagata S. A new method of costal cartilage harvest for total
auricular reconstruction: part I. Avoidance and prevention of intraoperative
and postoperative complications and problems. Plast Reconstr Surg. 2006
May; 117(6):2011–2018
[5] Sajjadian A, Naghshineh N, Rubinstein R. Current status of grafts and implants
in rhinoplasty: Part II. Homologous grafts and allogenic implants. Plast
Reconstr Surg. 2010; 125(3):99e–109e
[6] Gibson T, Curran RC, Davis WB. The survival of living homograft cartilage in
man. Transplant Bull. 1957; 4(3):105–106
[7] Murrell GL. Dorsal augmentation with septal cartilage. Semin Plast Surg.
2008; 22(2):124–135
[8] Burke AJ, Wang TD, Cook TA. Irradiated homograft rib cartilage in facial
reconstruction. Arch Facial Plast Surg. 2004; 6(5):334–341
[9] Kridel RW, Ashoori F, Liu ES, Hart CG. Long-term use and follow-up of irradi-
ated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg.
2009; 11(6):378–394
[10] Demirkan F, Arslan E, Unal S, Aksoy A. Irradiated homologous costal cartilage:
versatile grafting material for rhinoplasty. Aesthetic Plast Surg. 2003; 27(3):
213–220
Introduction
44

8 Pedicled Flaps
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the use of two pedicle flaps in soft-tissue
facial reconstruction: the paramidline forehead flap and the
nasolabial flap. The design, surgical harvest, surgical inset,
and postoperative care of these flaps are discussed, as well as
indications and postoperative management.
Keywords: paramidline forehead flap, nasolabial flap, pedicle
flap, division and inset, postoperative care, anticoagulation
Summary
● Two distinct flaps, the paramidline forehead flap and the
nasolabial flap, are most suitable for nasal reconstruction.
● Although they should not be considered interchangeable,
either pedicle flap can be considered for the majority of
defects without lining.
● Paramidline forehead flaps should be considered the gold
standard for the majority of nasal reconstruction and the
only flap suitable for nasal reconstruction with lining deficits.
8.1 General Considerations
Two distinct pedicle flaps for nasal reconstruction are
described: the interpolated nasolabial flap and the paramedian
forehead flap. The flap selection between nasolabial flap and
paramedian forehead flap is dictated primarily by surgeon’s
preference, but the flaps should not be considered interchange-
able. Nasolabial flaps are suitable for patients with a distinct
nasolabial fold and cheek redundancy and who have either ala,
tip, or soft triangle defects with intact lining. Advantages of the
nasolabial flap include technically simpler flap harvest, the abil-
ity to harvest under local or intravenous sedation only, and
much easier postoperative wound care.
The disadvantages include a tendency toward pincushioning
and the inability to provide large areas of robust soft-tissue cov-
erage in comparison to the paramidline forehead flap.
The paramidline forehead flap is exceedingly reliable and
predictable and should be the first choice for nasal defects of
any significance. The contraindications to forehead flaps are
few and include current anticoagulation with clopigel and the
inability of the patient to understand or comply with the post-
operative course, including follow-up visits, surgery, and
dressing changes. Forehead flaps can be performed with some
di culty under local or sedation anesthesia, but greater preci-
sion and greater patient comfort result if the initial procedure is
performed under general anesthesia.
8.1.1 Nasolabial Flap (Fig. 8.1a–f)
Flap Design
For the nasolabial flap design, the only sizing decision is the
height of the defect. The vertical height of the defect is trans-
posed to the cheek after placing the cheek under stretch and
marking the vertical height of the flap with calipers and ink. A
reverse Gilles test will confirm su cient flap length, and
remembering that the majority of the nasolabial flap laxity is
obtained from the perioral cheek, the distal extent of the flap
can be positioned lateral to the commissure.1 The absence of a
nasolabial fold is an absolute contraindication to elevation of a
nasolabial flap as the scarring will be unacceptable.2 After the
vertical and horizontal dimension of the flap is determined, the
flap is designed again with the cheek placed under mild stretch
to avoid oversizing. The flap dimensions include a planned dog-
ear excision and this excess skin is utilized as a handle before
being discarded (Fig. 8.2, Fig. 8.3, Fig. 8.4, Fig. 8.5,
Fig. 8.6, Fig. 8.7, Fig. 8.8).
Pedicled Flaps
45

Fig. 8.1 (a,b) The vertical height of the defect is transferred to the cheek with the inferior margin being the nasolabial fold. General traction is placed
to prevent oversizing the flap. (c) The flap is sharply elevated to the level of the ala. (d) Bovie cautery is utilized at the flap corners and proximal defect.
(e,f) The cheek is meticulously closed, but care is taken to avoid compression of the pedicle. (g) The flap is sharply divided at 3 to 5 weeks. (h) The flap
is elevated up to 80% of its volume and aggressively thinned prior to final inset. (i,j) The flap is inset under slight tension. (k,l) No attempt is made to
keep any of the pedicle remnants; it is excised and discarded and the resulting incision closed. No attempt is made to keep any of the pedicle
remnants; it is excised and discarded and the resulting incision closed.
Introduction
46

Fig. 8.2 A 72-year-old female patient status post Mohs excision for
basal cell carcinoma at right ala.
Fig. 8.3 Alar rim cartilage graft is harvested from anterior conchal
bowl incision.
Fig. 8.4 The anterior portion of the graft is placed within a previously dissected subcutaneous tunnel and then the remainder of the graft is
meticulously inset to the lining soft tissue.
Pedicled Flaps
47

Fig. 8.5 Graft is inset with 5–0 Vicryl.
Fig. 8.6 The vertical height of the nasal defect is transposed to the cheek.
Fig. 8.7 Measurements verified by repeat measurement of flap design following transposition to cheek while cheek is under slight tension.
Introduction
48

Elevation and Inset
Elevated sharply in the deep subcutaneous plane and then
approaching medially, it is elevated with either scissors or
bluntly with cotton-tipped applicators, taking care to identify
the angular perforating vessels and maintain them as the
medial extent of the incision is approached. The most medial
corners of the inset flap will then undergo electrocautery, as
these frequently bleed postoperatively. The flap is always
rotated medially, trimmed on inset, and inset under slight
tension with 6–0 black nylon sutures. The donor site is meticu-
lously closed with 3–0 Vicryl deep sutures followed by 4–0
subcuticular Monocryl followed by 6–0 black nylon sutures.
The flap is trimmed on inset (Fig. 8.9, Fig. 8.10, Fig. 8.11,
Fig. 8.12, Fig. 8.13, Fig. 8.14).
Postoperative Care
The flap is dressed with fibrillar collagen immediately postop-
eratively and the pedicle donor site deliberately packed with
either fibrillar collagen or sterile cotton for hemostasis and the
patient is instructed to simply shower away the dressings on
the third postoperative day and then the flap is treated with
just petroleum ointment until it is divided between the third
and fourth weeks.3 The patient is allowed to return to full activ-
ity and as long as the pedicle is not compressed, the patient can
wear a CPAP mask (Fig. 8.15).
Fig. 8.8 Reverse Gilles test is performed to ensure adequate flap length.
Fig. 8.9 Flap is sharply elevated to the level of the nasal ala. Care is taken to protect any perforating vessels at the base of the flap.
Pedicled Flaps
49

Fig. 8.10 Hemostasis is achieved at the base of the flap.
Fig. 8.11 Flap is accurately marked for inset.
Fig. 8.12 Flap is inset with 6–0 nylon.
Introduction
50

Fig. 8.13 Cheek is meticulously closed with 3–0 Vicryl and care is taken to avoid compression of the flap pedicle.
Fig. 8.14 Final cheek closure achieved with 5–0 nylon.
Fig. 8.15 The flap is coated in nitropaste and wrapped in oxidized cellulose, with care taken to avoid compression of the pedicle.
Pedicled Flaps
51

Division and Inset
At the time of division and inset, the pedicle is excised and dis-
carded and the cheek is closed as a linear incision with no
attempt to reinsert the pedicle. The cheek scar undergoes initial
dermabrasion and the flap is re-elevated over 70 to 80% of its
maximal length and is inset under slight tension with 5 and
6–0 black nylon suture ( Fig. 8.16, Fig. 8.17, Fig. 8.18,
Fig. 8.19, Fig. 8.20, Fig. 8.21, Fig. 8.22, Fig. 8.23,
Fig. 8.24).
8.1.2 Paramidline Forehead Flap
The contraindications to paramidline forehead flaps are few
and include widespread forehead scars, severe patient comor-
bidity, and the inability of the patient to meet the postoperative
wound care requirements. Ongoing anticoagulation is only a
relative contraindication.
Unquestionably, a patient fully anticoagulated on any agent,
even as simple as aspirin, makes the very vascular forehead flap
more di cult to harvest, inset, and manage postoperatively.4
However, we do not consider either aspirin or Coumadin as
absolute contraindications against paramidline forehead flaps.
Clopigel is considered a contraindication given its irreversibility
without transfusion.4 In all cases, it is preferred if the surgeon
is able to place an initial temporizing wound dressing and the
patient is able to safely hold anticoagulation for the flap
elevation as well as the inset.3
Fig. 8.16 Four weeks following initial flap elevation and inset.
Fig. 8.17 Pedicle is sharply divided.
Introduction
52

Fig. 8.18 Pedicle on cheek is completely excised and resulting wound closed with 3–0 Vicryl and 6–0 nylon.
Fig. 8.19 Flap is elevated up to 80% of its maximal volume and inset under slight tension.
Fig. 8.20 The border of the defect is marked to determine flap outline for inset and flap is then sharply cut to size and shape.
Pedicled Flaps
53

Fig. 8.21 Flap is then inset with 5–0 nylon.
Fig. 8.22 Flap is coated in nitropaste. Following dermabrasion with Bovie scratch pad of cheek scar, it is coated in bacitracin ointment.
Fig. 8.23 Xeroform is placed over stitches as final dressing.
Introduction
54

The remaining contraindications including forehead scars
require decisions made on a case-by-case basis. Often times
forehead scars will be superficial and the arterial pedicle
beneath will be intact by Doppler examination. However,
elevated flaps with scars across the majority of the pedicle can
develop significant venous stasis despite adequate inflow 5
(Fig. 8.25a–m ).
Flap Design
The vertical dimensions of the forehead are important and great
care is to be taken to avoid transporting hair into the nasal
reconstruction itself. For patients with large flap volume
requirements and a low hairline, preoperative tissue expansion
is considered.6,7,8 The indications for tissue expansion can be
determined by measuring simply from the flap arc of rotation
at the eyebrow up vertically to the hairline, that is, a modified
reverse Gilles test, and if it is insu cient for the required flap
dimensions, then a tissue expander can be placed across the
entire forehead.7,8 The endpoint for tissue expansion is based
on the understanding that the tissue expander is not placed to
allow closure of the forehead. It is just placed to provide su -
cient reach of the flap from the eyebrow to the hairline.8 There
are many discussions and illustrations of forehead flap design
with many descriptions, including ipsilateral, contralateral,
“up-down” flap, or, even worse, a transverse flap across the
forehead. Both the “up-down” and the transverse flap really are
only mentioned to be condemned. They provide absolutely no
advantage to a properly designed paramidline forehead flap, as
described by Menick which remains an ipsilateral axial pattern
or vertical flap.6,9 The “Dallas” design with a medial right angle
extension at the hairline is felt to provide adequate soft tissue
for the reconstruction but with a reduced arc of pedicle rota-
tion. Although the flap design does provide su cient soft tis-
sue, the reduced pedicle arc of rotation provides no practical
benefit and the medial flap design destroys the contralateral
side for possible revision or a second flap.
Great care is taken to remain out of the hairline. The flap
pedicle width is dependent on the venous requirements of the
flap. Very large flaps will require a pedicle width beyond 1.5 cm
to maintain venous outflow. For thin, single subunit (ala or iso-
lated tip), the width of the flap can be narrowed to as small as
1.2 cm wide. The forehead donor-site scar is improved with a
thinner, narrower flap and the narrower pedicle provides an
easier arc of rotation. With proper flap design, which includes
the Doppler identification of the pedicle, and centering the
pedicle on the identified artery, the flap can be safely narrowed.
The actual sizing of the flap, whether it be subunit or defect
only, takes a significant amount of the operative time. Multiple
techniques have been described, but the easiest is a foil suture
pack that is placed with printed side down over outlines of
the contralateral nose and then simply reversed which can pro-
vide the most expedient and accurate detail. The foil is allowed
to be cratered in the concavities and very accurately contoured
along the convexities. Oftentimes 5–0 silk is utilized to suture
tack it along the defect site borders as the flap template is being
designed. If there is significant three-dimensional tissue loss,
then bone wax with overlying constructs of Steri-Strips and
Dermabond to create a three-dimensional moulage has also
been utilized and these are transposed to suture foil to provide
the correct volume requirements. The malleable tin foil wrap-
pers of traditional wine bottles also contour very nicely to the
convexities of ala and tip and if sterilized ahead of time are
useful for flap design. In all cases when an accurate sized foil
pattern template is designed, it can be saved, labeled, and
re-sterilized for use during any subsequent inset and revision
procedure.
The flap dimensions are designed with very accurate tem-
plating as either a defect or a subunit with no regard to final
closure of the forehead. The length of the flap is determined by
a reverse Gilles test, understanding that the arc of rotation is
below the eyebrow, the takeo of the vascular pedicles. Intra-
operative pencil Doppler is utilized to identify the pedicle
below the eyebrow and this provides safety in maintaining the
vertical and axial design.1 For defects that have large lining
requirements, such as isolated hemialar and heminasal defects,
it is allowable to develop a lateral transition of the flap main-
taining axial flow as much as possible in patients with a sparse
or thinning hairline, as illustrated in Fig. 8.26, Fig. 8.27,
Fig. 8.28, Fig. 8.29, Fig. 8.30, Fig. 8.31).
Fig. 8.24 Final results at 3 months.
Pedicled Flaps
55

Fig. 8.25 (a,b) Combined nasal tip, ala, and soft triangle defect. The remaining tip and ala are excised for subunit-based reconstruction. (c,d) Foil
template is carefully made of nasal tip and contralateral ala to aid in symmetrical reconstruction of affected side. (e) Foil outline is transposed to
forehead with planned medial rotation. Standing cone excision is planned superior to template. Great care is taken to maintain axial pattern of
forehead pedicle. Avoid violating the hairline if at all possible and if additional length is required, a short cant can be made ipsilaterally. (f) The flap is
initially sharply elevated subcutaneously and is grasped only at the soon-to-be discarded standing cone triangle. Dissection eventually transitions to
the subfrontalis.
Introduction
56

Fig. 8.25 (continued) (g) Proximally 1–2 cm above eyebrow the plane of dissection is developed underneath the periosteum. (h) To prevent
postoperative bleeding, the medial and lateral flap edges as well as the superior aspect of the defect are aggressively cauterized. (i) For planned two-
stage flaps, the distal 30% of the flap that will never be re-elevated is aggressively thinned. (j) The flap is inset with simple 5–0 nylon sutures. The
forehead is closed with 3–0 Vicryl and simple 4–0 and 5–0 nylon sutures. If the forehead cannot be fully closed due to tension, it may remain open and
allowed to heal in secondarily. (k) At 4 weeks following initial flap elevation and inset for a two-stage flap, the pedicle is sharply divided and
dermabrasion on the forehead scar is done with a Bovie scratch pad. (l) Great care must be taken to restore eyebrow symmetry. The forehead pedicle
is either completely excised and closed in a linear or incision or a small remnant of pedicle is saved and inset as a small upside down V with 6–0 nylon
sutures. (m) Nasal pedicle is trimmed accurately for inset and is inset with simple 5–0 nylon sutures.
Pedicled Flaps
57

Fig. 8.26 A 62-year-old male patient status post Mohs excision of basal
cell carcinoma at right nasal tip and partial ala.
Fig. 8.27 Through an anterior conchal bowl incision, a nonanatomic
cartilage graft is harvested. The graft is carefully inset with 5–0 Vicryl,
ensuring close apposition of the cartilage to the intact lining.
Fig. 8.28 Following inset of cartilage graft to defect, a foil pattern
template is designed based on the contralateral normal side.
Fig. 8.29 The vascular pedicle is identified with Doppler at a single
point inferior to the eyebrow. The 1.5-cm flap pedicle is centered over
the identified vascular pedicle.
Fig. 8.30 The flap remains axial pattern and template is transposed to
the ipsilateral forehead with planned medial rotation.

Fig. 8.31 Adequate flap length is ensured with revers Gilles test.
Introduction
58

Elevation and Inset
When the flap has been accurately templated and the volume
requirements have been determined and drawn out on the
forehead with surgical marker, a no. 69 beaver blade is utilized
to score the flap borders, given surgical markings can be
obscured and even erased by bleeding during elevation. The
entire forehead is infiltrated with lidocaine containing epi-
nephrine and then the flap is elevated with a small distal exten-
sion or “handle” where a dog-ear excision can be extended into
the hairline and then the flap is elevated initially in the subcu-
taneous plane transitioning to the subfrontalis. Caution must be
exercised particularly in elderly patients, as it is quite easy to
inadvertently score the periosteum and expose the calvarium
which can result in a full-thickness defect on the forehead that
can be di cult to heal.10 If this occurs, Integra can be placed at
the initial flap elevation and grafted during the inset. The flap
continues to be elevated sharply without using Bovie cautery
until 1.5 cm above level of the eyebrow and then the cautery is
turned up significantly and both the lateral borders of the flap
and the native forehead undergo electrocautery identifying all
the bleeding vessels. For vigorous well-isolated bleeders, they
can either be suture ligated or even clip ligated if required. After
the flap is elevated to the level of the eyebrow and bleeding
is controlled, the periosteum is scored approximately 1.5 cm
above the eyebrow and the flap is elevated bluntly to below the
eyebrow if required. There is significant clinical discussion of
the utility of elevating the flap below the periosteum. Detrac-
tors feel the periosteum limits the reach of the flap, while sup-
porters feel it captures periosteal perforating vessels.1 Anatomic
studies support the elevation below the periosteum with the
perforating vessel supporting the vascularity of the flap, which
provide a safe rapid plane of dissection. If further flap length is
required and it is tethered by the periosteum, under loop mag-
nification, the periosteum itself can be scored to provide further
lengthening. The flap vessel origin and the arc of rotation are
below the eyebrow. After the flap is fully elevated, taking care
not to over-elevate it and create a redundant pedicle, the flap is
wrapped in warm moist lap pad and hemostasis is achieved on
the forehead and attention is placed to forehead closure. The
forehead is closed only to the point of no distortion on the
brow, and surrounding areas and any areas of remaining open
forehead are allowed to heal in secondarily. If required dermal
regeneration templates can be utilized for very thick defects or
acellular dermis can be utilized to facilitate healing.11 No
attempts are made at color-matched full-thickness grafting on
the forehead defects because ultimately the forehead that is
allowed to heal in secondarily will have a better final outcome
than full-thickness grafting. After forehead closure, attention is
then returned to the nose. The flap inset portion is actually the
easiest portion of the case, provided it has been accurately tem-
plated. Border sutures are placed at the alar border and if it is a
defect that does not require lining, it is significantly thinned
with great care taken to the distal 30% of the flap and it is
thinned without plans for further re-elevation and very accu-
rately inset with 5–0 black nylon simple sutures. If the lining
portion is included in the reconstruction, a simple scoring of
the alar rim is made, as this allows a more rapid turn in or
decreases the tension on the skin and allows rapid turn in with
no real loss of vascularity and then the lining portion itself can
be significantly thinned. For axial pattern flaps, these can be
thinned safely to skin only. As the flap is turned in on itself, 3–0
Prolene tacking sutures are utilized for the distal portion of the
flap and these are placed on the designed alar groove to secure
the lining portion over the cartilage construct. Chromic gut
sutures are used internally to attach the recreated lining to the
native nasal lining and these can often be placed externally
with retraction on the inset flap. The remainder of the flap is
carefully inset with 5–0 black nylon ( Fig. 8.32, Fig. 8.33,
Fig. 8.34, Fig. 8.35, Fig. 8.36, Fig. 8.37).
Dressing and Management of Flap Pedicle
Management of the exposed flap pedicle is surgeon dependent.
Numerous authors have described skin grafting of the back
portion of the flap; unquestionably it does provide a great
improvement in postoperative wound care and reduces peri-
operative bleeding. However, to raise a skin graft with an
additional donor site with the plans to discard it within 3 to
6 weeks is often not well received by the patient. Alternatively,
the back portion of the flap is carefully dressed with oxidized
cellulose to stop bleeding and the entire flap is wrapped in
sheet collagen (Surgical)3 (Fig. 8.38 and Fig. 8.39).
Postoperative Care
The patient is allowed to shower o the dressing on the third
postoperative day and Vaseline and nonstick gauze is then used
as the wound dressing. The patient is returned to normal activ-
ity as much as possible. With care, they are allowed to wear
eyeglasses taking care to avoid compression on the flap pedicle.
With the understanding of paramidline forehead flaps, there is
no real ability to camouflage it with a dressing and the patient
is counseled on this preoperatively. The timing of flap division
and inset is never made at less than 3 weeks and if the patient
has significant flap fullness or edem a at 3 weeks, the procedure
is delayed. Any planned two-stage flaps can be converted to a
three-stage flap if there is need to improve the contour, reduce
the flap volume, or manipulate cartilage grafts.
Pedicled Flaps
59

Fig. 8.32 Template outline is lightly scored with a beaver blade.
Fig. 8.33 Flap is sharply dissected with care being taken to grasp only
standing cone portion of flap that will be discarded during inset. The
flap is initially elevated subcutaneously and this is later transitioned to
the subfrontalis when it is assured that the donor site can be closed
directly.
Fig. 8.34 Corners of the flap are aggressively cauterized to prevent late
postoperative bleeding. Approximately 1–2 cm above eyebrow, bluntly
dissect to subperiosteal plane. This can be extended to well below the
eyebrow if needed.
Fig. 8.35 Distal portion of flap can be aggressively thinned.
Fig. 8.36 The forehead is closed directly with 3–0 Vicryl with care
being taken to avoid compression of the pedicle.
Fig. 8.37 Forehead is then closed with simple 4–0 and 5–0 nylon
sutures. Flap is trimmed and inset with simple 5–0 nylon sutures.
Introduction
60

Conversion to Three-Stage Flap
If the decision is made to perform a three-stage flap, the pedicle
is left intact and the flap is elevated from distally to proximally
as thin as the final inset will be (Fig. 8.40, Fig. 8.41,
Fig. 8.42).
Division and Inset
At the time of division and inset, which usually occurs between
the third and fourth weeks for two-staged flaps, a significant
amount of elevation and thinning can safely be performed.
In nonsmoking patients, 80% of the flap can be routinely
elevated and thinned safely. Immediately after the flap pedicle
is divided, a good indication of the vascularity of the flap is
the amount of back bleeding from the flap pedicle. With
experience, this can be used to gauge the safety of the flap ele-
vation and thinning. In a robustly vascular flap, tacking sutures
can be placed at and superior to the alar groove to contour the
inset flap along the new alar groove. Nitropaste is routinely
Fig. 8.38 Flap is covered with nitropaste.
Fig. 8.39 Flap is carefully wrapped in oxidized cellulose.
Pedicled Flaps
61

placed as a single application on inset flaps12 ( Fig. 8.43 and
Fig. 8.44).
Forehead Scar Optimization
After flap inset and contouring, attention is directed to optimiz-
ing the forehead donor-site closure.13
The vertical forehead incision scar is released from periosteal
and bony attachments by blunt elevation with the elevator in
place and the scar is dermabraded with a Bovie scratch pad.
Autologous fat grafting is performed if needed to improve
scar contour. The fat is harvested from the abdomen with a
syringe and blunt tip cannula. The harvested fat is placed on
Telfa to remove the e uent and then injected using 1-mL Luer
Lock syringes and a 21-gauge needle or a 1-mm blunt cannula
in a crosshatch pattern.
After the forehead incision scar is optimized, the eyebrow
containing the flap pedicle is reoriented to match the contrala-
teral normal side. After the eyebrow alignment, the pedicle
remnant is either excised directly and closed with a linear inci-
sion or debulked aggressively and the remainder is carefully
inset as a small inverted V at the medial eyebrow (Fig. 8.45,
Fig. 8.46, Fig. 8.47).
8.2 Postoperative Care
After suture removal at 5 days, the patient is changed from anti-
biotic ointment to scar management oil or silicone gel and
sheeting for no less than 8 weeks.14 At 8 weeks, the patient is
reexamined and o ered a revision procedure to be done at
about 3 months after the division and inset.
Fig. 8.40 Flap is elevated thinly.
Introduction
62

Fig. 8.41 (a,b) The tissue remaining on the nose is very carefully carved into the final desired contours to match contralateral side.
Fig. 8.42 The maximally thinned forehead flap is returned to the soft-tissue construct on the nose and carefully inset with 5–0 black nylon border
sutures. Through-and-through contour tacking sutures are placed for the ala.
Pedicled Flaps
63

Fig. 8.43 Four weeks after the second stage inset, the pedicle is
divided sharply.
Fig. 8.44 The flap is elevated over 60% of its volume and aggressively
thinned and inset.
Fig. 8.45 The forehead scar is elevated off of the
calvarium and undergoes dermabrasion with a
folded Bovie scratch pad.
Fig. 8.46 Final inset with simple 6–0 black nylon
sutures.
Introduction
64

References
[1] Correa BJ, Weathers WM, Wolfswinkel EM, Thornton JF. The forehead flap:
the gold standard of nasal soft tissue reconstruction. Semin Plast Surg. 2013;
27(2):96–103
[2] Bi H, Xing X, Li J. Nasolabial-alar crease: a natural line to facilitate transposi-
tion of the nasolabial flap for lower nasal reconstruction. Ann Plast Surg.
2014; 73(5):520–524
[3] Sabel M, Stummer W. The use of local agents: Surgicel and Surgifoam. Eur
Spine J. 2004; 13 Suppl 1:S97–S101
[4] Calafiore AM, Iacò AL, Tash A, Mauro MD. Decision making after aspirin,
clopidogrel and GPIIb/IIIa inhibitor use. Multimed Man Cardiothorac Surg.
2010; 2010(1103)
[5] Stigall LE, Bramlette TB, Zitelli JA, Brodland DG. The paramidline forehead
flap: a clinical and microanatomic study. Dermatol Surg. 2016; 42(6):764–
771
[6] Menick FJ. An approach to the late revision of a failed nasal reconstruction.
Plast Reconstr Surg. 2012; 129(1):92e–103e
[7] Kheradmand AA, Garajei A, Motamedi MH. Nasal reconstruction: experience
using tissue expansion and forehead flap. J Oral Maxillofac Surg. 2011; 69(5):
1478–1484
[8] Weng R, Li Q, Gu B, Liu K, Shen G, Xie F. Extended forehead skin expansion
and single-stage nasal subunit plasty for nasal reconstruction. Plast Reconstr
Surg. 2010; 125(4):1119–1128
[9] Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;
36(3):443–459
[10] Richardson MA, Lange JP, Jordan JR. Reconstruction of full-thickness scalp
defects using a dermal regeneration template. JAMA Facial Plast Surg. 2016;
18(1):62–67
[11] Singh M, Godden D, Farrier J, Ilankovan V. Use of a derm al regeneration tem-
plate and full-thickness skin grafts to reconstruct exposed bone in the head
and neck. Br J Oral Maxillofac Surg. 2016; 54(10):1123–1125
[12] DeLorenzi C. Complications of injectable fillers, part 2: vascular complica-
tions. Aesthet Surg J. 2014; 34(4):584–600
[13] Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on postsurgical
scar management. Semin Plast Surg. 2016; 30(3):122–128
[14] Alberti LR, Vicari EF, De Souza Jardim Vicari R, Petroianu A. Early use of CO2
lasers and silicone gel on surgical scars: prospective study. Lasers Surg Med.
2017 Aug;49(6):570-576
Fig. 8.47 Final result at 4 months.
Pedicled Flaps
65

9 Local Flaps
James F. Thornton and Jourdan A. Carboy
Sum m ary
This chapter discusses the use of local flaps in soft-tissue facial
reconstruction after Mohs excision. The general considerations,
classifications of flaps, and broad flap descriptions are dis-
cussed. This includes linear closure, rotation flaps, advancement
flaps, and interpolated flaps. Specific flaps discussed include
the bilobed flap, the note flap, the dorsal nasal flap, the melola-
bial flap, and linear closure.
Keywords: local flaps, geometric flaps, linear closure, rotation
flap, advancement flap, bilobed flap, dorsal nasal flap, melola-
bial flap, note flap, rhombic flap
Summary
● Local flaps can provide immediate definitive wound closure
but at the expense of distant incisions and increased repair
complexity.
● Although geometric flaps are well described and popular, the
human face has no inherent right angle geometric patterns.
● Simple linear closure frequently provides the best outcome
and should always be considered.
9.1 General Considerations
The numerous classification systems for local flaps do not nec-
essarily contribute to their clear understanding. Flaps may be
classified by the native blood supply (random or axial pattern),
the geometric configuration (i.e., rhombic, bilobed, trilobed),
the location of either the defect or the pedicle (regional,
pedicled), and by the method of transfer of the flap. The method
of the transfer seems to provide the most clear representation
of the flap and that will be utilized in this chapter. Three types
of local flaps will be described: rotation, advancement, and
transposition flaps. All of these flaps are confined to head and
neck facial reconstruction.
The advantages of the local flaps are their ability to provide
vascularized color- and texture-matched skin for reconstruc-
tion. The majority of the repairs can be done as a single stage.
The disadvantages to local flaps are not trivial and include often
extensive incisions distant from the site of the defect and the
opportunity for wide and irreversible anatomic component dis-
tortion. The most obvious example of this is a poorly designed
or executed bilobed flap that can irreversibly distort the nasal
ala. Additionally, the consequences of a flap failure, all or par-
tial, are not insignificant. The potential disaster for a complex
local flap being performed in the case of an incompletely
excised or recurrent skin cancer and the subsequent provisions
that have to be made for cancer clearance after the formation
and inset of a flap are tremendous. Appropriate planning for
local flap reconstruction includes a very careful assessment of
the defect, but more importantly the flap donor site. As an
example, the limitations on use of a bilobed flap in nasal recon-
struction are most dependent on the site of the secondary lobe
and its subsequent closure and possible distortion of the lower
eyelid versus the initial lobe placement. Appropriate recon-
struction planning must always include alternatives to flap
reconstruction and the placement of flap incisions, as they
relate to any “lifeboat” provisions for a failed flap.
9.2 Linear Closure
Although not technically a local flap, simple linear closure con-
stitutes the majority of nongraft repairs and merits discussion
on proper execution.
The advantages include unmatched simplicity, reliability, and
speed. Properly performed, it can yield the “best” result in all
small and many large defects. Understand that ideal relaxed
skin tension lines facilitate final incision placement.1 Meticu-
lous and complete standing cone or dog-ear excision is
required, given that standing cone rarely “settles” completely.
Skin undermining is rarely indicated and its benefit is overrated
on inset, as it contributes to seroma or hematoma formation
and devascularizes the inset.
For proper performance of linear closure, the surgeon will
place a single silk tacking suture in the center, but 90 degrees
from the estimated ideal closure orientation. The wound is tai-
lor tacked closed and then the suture is now placed at the new
best guess of the ideal closure orientation. Any retraction of
anatomic features, especially eyelid, is evaluated. As a rule, any
eyelid retraction or nasal alar retraction is a firm contraindica-
tion to linear closure, but mild lip retraction almost always
resolves. The single central suture location is marked and the
standing cones are marked for excision with surgical marker.
The suture is removed and the standing cones meticulously
excised. It is very important to conceptually understand that
the standing cones must be excised to the depth of the central
defect. This is not simply a skin-only excision, but rather a skin
and soft-tissue debulking to result in a symmetric depth
throughout the closure. The process is somewhat akin to “dig-
ging a ditch” with each end symmetric to the middle. Under-
mining is rarely required and meticulous linear closure to the
level of the skin is performed. There really is no perceptible
di erence in final outcomes based on final skin closure
techniques. As long as the skin is reached in closure with
elimination of all deep dead space without any undue tension,
any choice of skin closure can yield an equivalent result.1 Other
issues regarding skin closure can be considered, including
surgeon’s preference, need for patient follow-up, as well as the
patient’s preference. It seems prudent for the beginning
surgeon to try a number of di erent skin closure techniques to
determine what works best for his practice and patients
(Fig. 9.1, Fig. 9.2, Fig. 9.3).
9.3 Rotation Flaps
Rotation flaps are a type of pivotal flap where the flap is
designed so that the leading edge of the flap is also bordering
the defect. They are the most commonly utilized, the most
Introduction
66

anatomically correct, and easiest to visualize. A rotation flap
relies on the conversion of any defect into a triangular defect,
where the base of the triangle forms a portion of the circumfer-
ence of the flap arc rotation circle.2,3 The base of the flap then
becomes the radius of the flap rotation circle and these flaps
are very easily designed and executed, particularly on large flat
featureless areas such as the scalp or the cheek.2,3 Two provi-
sions to provide safe inset are caution in the back cut that cuts
into the base of the flap at the consequence of decreased flap
vascularity and a meticulous Burrow’s triangle which is
required to eliminate the standing cone that arises from the
mismatched flap radius (Fig. 9.4, Fig. 9.5, Fig. 9.6,
Fig. 9.7).
9.4 Advancement Flaps
Advancement flaps are useful on featureless and flat areas, such
as the cheek and scalp. One detractor is the required long linear
incisions which ideally are placed within natural soft-tissue
borders. The most common and useful example of advancement
flaps is the V-Yadvancement flap, where planned incisions can
usually be placed within soft-tissue borders and ideal contour
as well as color-matched skin and soft tissue can be advanced
into the wound. If a V-Y advancement flap design includes a
single perforator vessel identified by Doppler, the entire flap
can be safely elevated on that single vessel. This allows for
significant dissection up to the identified pedicle and permits
generous and safe flap advancement.
Fig. 9.1 Standing cones are meticulously excised. This includes skin
and subcutaneous fat.
Fig. 9.2 When the depth of the wound is the same, deep load-bearing
sutures are placed at the vertex of each dog-ear excision, avoiding
deep sutures placed in the central, most tissue-deficient portion of the
wound.
Fig. 9.3 A wide variety of skin closure techniques will yield similar
results, as long as the final layer of closure is performed under little or
no tension.
Local Flaps
67

Fig. 9.4 The flap begins with conversion of defect
to a triangular configuration so that base
of triangle forms a portion of the flap
circumference.
Fig. 9.5 As the flap rotates to fill the defect, a
standing cone develops.
Fig. 9.6 A true Burow’s triangle excision of the
standing cone is performed.
Introduction
68

During flap design, a single tacking suture can be placed
within the defect and the leading edge of the planned V-Y
advancement flap. If this closes, even with significant distor-
tion, one can be assured that after flap elevation, there will be
enough laxity to a ect closure without distortion (Fig. 9.8,
Fig. 9.9, Fig. 9.10).
9.5 Transposition Flaps
The last flap design is transposition flaps. Basically, a transposi-
tion flap is created where the donor site is remote from the
defect and the flap is moved about the pedicle or transposed
over intervening normal tissue and into the defect. It is a
Fig. 9.7 Final flap inset.
Fig. 9.8 The leading edge of the V-Y flap is designed slightly larger
than the defect.
Fig. 9.9 The flap can be elevated and advanced based on a single
arterial perforator.
Local Flaps
69

commonly used flap for head and neck reconstruction. We
will discuss three examples of it. It provides the advantage of
immediate flap inset of color-matched and texture-matched
tissue with often a direct linear closure of the donor site. The
di culties of transposition flaps also involve obscuring natural
contours or providing distortions at site distant to the defect.
Two examples of these would be a melolabial transposition flap
that distorts the contour of the cheek–nose junction or a poorly
designed bilobed flap, which distorts the medial eyelid4,5,6,7
(Fig. 9.11, Fig. 9.12, Fig. 9.13).
Fig. 9.10 Final flap inset.

Fig. 9.11 Transposition flap differs from a rotation flap in that the flap
tissue is transposed over intervening tissue and into the defect. This
allows the transfer of tissue from a relatively tissue lax region to a
region of tissue deficit.
Fig. 9.12 The first lobe is designed identical in size to the defect. The
dog-ear is excised and the flap elevated in the deep subcutaneous
plane. The second lobe is closed primarily prior to inset of the flap.
Fig. 9.13 Flap inset.
Introduction
70

9.6 Bilobed Flap
The bilobed flap, classic transposition flap, was originally
described by Esser in 1918 for nasal reconstruction and made
more workable by Zitelli, who limited the arc of rotation to
45 degrees of each limb versus 180 degrees in the original
design.6,8,9 Like most transposition flaps, the bilobed flap allows
the ability to recruit tissue from a distant site and thus recruit
from an area of relative tissue laxity to an area of relative tissue
scarcity, which makes it theoretically ideal for transition of
tissue from the more lax upper two-thirds of the nose to the
less mobile lower third of the nose.
There are, however, significant disadvantages to bilobed flap
reconstruction, including complex incision lines that are, by
definition, impossible to be placed within relaxed skin tension
lines.9 There is no opportunity to follow principles of subunit
nasal reconstruction and an inadequate flap design or execu-
tion can result in irreversible nasal deformities of both contour
and symmetry. For these reasons, even within the best hands, a
bilobed flap reconstruction is never a “perfect” reconstruction,
but may well be the most appropriate given the defect.
Modern bilobed flap design is based on the Zitelli modifica-
tion that limits the arc of rotation of each limb.8 The first lobe is
always designed exactly the same size as the defect and is
rotated in position in a relaxed easy fit. The arc of rotation can
either be geometrically drawn or free drawn and is a fixed con-
stant based on the diameter of the defect. The donor site of the
second lobe actually determines whether the flap design will
be successful. Understand that the second lobe is not made 50%
of the first lobe size, but is essentially made as large as can be
closed without distortion of the second lobe donor site.6,8,10
This determines the suitability of the flap, that is, if the closure
of the second lobe is going to result in medial lower eyelid dis-
tortion to recruit tissue on the nasal sidewall, the flap design is
unsuitable for this location. Zitelli also described a planned
dog-ear excision or a standing cone excision on the first lobe
that is excised prior to flap elevation.6,8,10
Dermatologist Joel Cook has made multiple observations and
provisions for successful flap design, including the preference
for a submuscular flap dissection; however, this decision can
mostly be left to surgeon preference, as a submuscular dissec-
tion provides only a theoretical decrease in pincushioning and
is significantly more involved in flap elevation and inset.9,10
Principals of successful bilobed flap reconstruction include
the initial marking of the arc of rotation for the entire flap and
then very careful anatomic measurement of the initial lobe size,
which is transposed along the previously drawn arc of rotation.
The planned dog-ear excision is outlined and then excised prior
to the remainder of the flap elevation. Then, decisions are made
regarding the second lobe, which is designed as large as possi-
ble to permit primary closure. The second lobe is elevated and
the defect is closed with the remaining lobe rotated into posi-
tion on the inset and then tacking sutures can be utilized even
along the pedicle of the flap to improve in particular alar con-
tour. Initial flap sutures are removed at 5 days and dermabra-
sion o ered at 5 weeks. Unfortunately, pincushioning is not an
infrequent complication of this flap and is initially managed
with sequential low-dose (10%) triamcinolone. If the pincush-
ioning does not resolved after a reasonable period of intrale-
sional management, flap re-elevation, thinning, and re-inset
are indicated (Fig. 9.14, Fig. 9.15, Fig. 9.16, Fig. 9.17,
Fig. 9.18, Fig. 9.19, Fig. 9.20, Fig. 9.21, Fig. 9.22,
Fig. 9.23, Fig. 9.24, Fig. 9.25, Fig. 9.26, Fig. 9.27).
9.7 Dorsal Nasal Flap
The dorsonasal flap is a rotation flap that is very useful for
defects of the distal half of the anatomic nasal dorsum. The flap
Fig. 9.14 The arc of rotation for both lobes is drawn as well as the
planned standing cone excision.
Fig. 9.15 An identical size foil pattern template is used to design the
first lobe adjacent to the defect.
Local Flaps
71

itself has a transposition, as well as a rotation component, and
may result in a degree of tip elevation, which is acceptable, in
elderly patients. The flap was popularized and the design uti-
lized based on Rieger and presented in 1967.11 It is essentially a
random pattern flap based on a broad ipsilateral nasal pedicle.
Rohrich et al in 1999 very accurately defined limitation of
the flap that includes only nasal tip defects that are above the
tip-defining points, the defect at least 1 cm from the alar rim,
and less than 2 cm wide.12 The flap is elevated in the deep
submuscular plane and is a relatively bloodless dissection ini-
tially, with arterial inflow, based on the contralateral side. It is
important that the dog-ear is marked out and elevated and
excised so that there is a symmetrical flap inset. The study of
Rohrich et al describes avoidance of the classic Rieger excision,
which extends onto the forehead with a preference for a dorso-
nasal incision; however, having experience based on over 100
sequential flaps, it is felt that the Rieger incision does provide a
degree of additional soft tissue for inset and the dorsal incision
Fig. 9.16 The second lobe is drawn as large as the soft-tissue laxity will
allow closure. The dog-ear excision of the second lobe is included.
Fig. 9.17 Each lobe’s arc of rotation does not exceed 45 degrees.
Fig. 9.18 The flaps are elevated in the subcutaneous or submuscular
plane.
Fig. 9.19 As the first lobe is rotated into position, the donor site is
closed.
Introduction
72

is almost always unnoticeable if properly executed and closed.12
Great care on flap elevation and inset needs to be made with
regard to hemostasis, as well as contouring the thick forehead
skin as it is inset onto the thinner glabellar area and often vigo-
rous direct thinning is required on proximal inset. The flap is
robust with rarely any issues (Fig. 9.28 and Fig. 9.29).
9.8 Melolabial Flap
The melolabial transposition flap is, in its simplest form, a
transposition flap of cheek skin crossing the cheek–nose junc-
tion to re-create nasal defects. Its advantages include ideal
incision line placement along the cheek–nose junction and the
Fig. 9.20 Final flap inset.
Fig. 9.21 A 45-year-old female status post Mohs resection. Defect is
thick and near nasal tip.
Fig. 9.22 Arc of rotation of bilobed flap and standing cone are drawn and foil patterned template is transferred adjacent to the defect.
Local Flaps
73

Fig. 9.23 Second lobe is drawn at least 75% diameter of first lobe, standing cone excision included.
Fig. 9.24 Flap is elevated in deep subcutaneous plane and rotated for inset. Second lobe closed as first lobe is inset into the defect.
Fig. 9.25 Standing cone excised from second lobe as last step in inset.
Introduction
74

transfer of color-matched skin from the cheek to the nose,
often with su cient volume to fill in significant contour
defects.4,5,13,14,15,16 The disadvantages are extensive and they
include partial or complete obliteration of the cheek–nose junc-
tion, as well e acement of the alar groove, which can be quite
di cult to re-create.4,5,13,14,15,16 The flap is elevated in the deep
subcutaneous plane and a single tacking suture is placed to
facilitate incision line closure with deepithelialization of the
normally turned-in or discarded portion of the nasolabial flap if
additional bulk is required. A preoperative discussion is often
had with the patient regarding the need for late “division and
inset” with the understanding that this is not a true division
and inset, but rather an attempt to re-create the cheek–nose
junction, as well as the alar groove. This procedure performed
at no less than 6 weeks after initial flap design requires signifi-
cant re-elevation and thinning of the cheek–nose junction, as
Fig. 9.26 Final flap inset.
Fig. 9.27 Postoperative results show slight alar distortion, even with
suitable flap design and inset. Final results shown at 4 months.
Fig. 9.28 A 61-year-old female with thick 2 cm nasal tip Mohs defect above tip-defining points. Dorsal nasal flap designed with Reiger incision onto the
forehead. Flap is elevated in the deep submuscular plane and advanced into position. Care is taken in thinning the superior portion of the flap to match
the thin nasal sidewall skin.
Local Flaps
75

well as the nasal sidewall superior to the ala with tacking
sutures or even direct alar rim incision to re-create the alar
groove (Fig. 9.30, Fig. 9.31, Fig. 9.32, Fig. 9.33,
Fig. 9.34, Fig. 9.35, Fig. 9.36, Fig. 9.37, Fig. 9.38).
9.9 Note Flap
The note flap is a versatile flap for smaller defects. Ideally, it
permits the closure of common circular defects with a triangu-
Fig. 9.29 Final results show favorable nasal and forehead scar healing at 5 months.
Fig. 9.30 The melolabial flap is essentially a cheek transposition flap to
repair small posterior nasal side wall or alar defects in continuity with
the cheek. The flap is designed with the standing cone excision on the
nasal sidewall.
Fig. 9.31 Flap is elevated in the deep subcutaneous plane and
advanced into position to fill the defect.
Introduction
76

lar flap, given the donor site is able to be closed primarily. It
was probably first described in early India around 300 BC and it
was popularized and given significant geometric analysis by
Walike and Larrabee in 1985.17 The note flap is a classic trans-
position flap and it would be useful in many areas where a sur-
geon would originally consider a rhombic flap, but with the
advantage of not requiring conversion of a circular defect into
an unnatural square or rhombic shape. Ideally, the note flap is
placed within natural folds where the donor site is able to be
placed in a natural crease. The advantage of the flap is by trans-
posing a triangular flap to fill in a circular defect, and the donor
tissue of the flap is maximally used. However, the disadvantage
Fig. 9.32 The standing cone defects on both the nasal side wall and
cheek are both simultaneously closed as the flap is inset into the
defect.
Fig. 9.33 Final flap inset demonstrates the unavoidable disruption of
the cheek–nose junction and the alar groove.
Fig. 9.34 A 59-year-old male with combined cheek, nasal sidewall, and
nasal ala defect. Patient refused forehead flap nasal reconstruction due
to his requirements for nighttime CPAP use.
Fig. 9.35 Nonanatomic alar cartilage graft placed along alar rim and
secured along intact nasal lining. Melolabial flap designed with planned
standing cone excision at nasal side wall and cheek.
Local Flaps
77

Fig. 9.36 Flap is elevated in deep subcutaneous plane and advanced into position. As cheek is closed primarily, flap is inset along alar rim.
Fig. 9.37 Final flap inset shows unavoidable effacement of cheek–nose
junction as well as flattening of the alar groove.
Fig. 9.38 Final results shown at 4 months.
Introduction
78

is that the inset flap is actually smaller than the defect and a
small amount of laxity is required of the surrounding defect to
a ect closure. The flap is designed as illustrated with the maxi-
mal limb approximately one and a half times the diameter of
the circular defect with the “note” portion of the flap (this
resembles a musical eighth note) placed at the exact diameter
of the defect. The flaps are uniformly elevated in the deep
subcutaneous, but not submuscular, plane and rotated into
position. Some deepithelialization of the inset portion is some-
times required to minimize contour abnormalities and the
donor site is closed directly and then the remainder of the flap
is inset, again, taking advantage of some of the laxity from the
surrounding tissue. The flap unfortunately does not have a triv-
ial learning curve, but when mastered, it becomes a very useful
adjunctive flap for circular defects ( Fig. 9.39, Fig. 9.40,
Fig. 9.41, Fig. 9.42, Fig. 9.43).
Fig. 9.39 The note flap is an undersized triangular flap inset into a
circular defect. Consideration needs to be made regarding laxity at
defect site as well as placement of triangular flap incision.
Fig. 9.40 Flap is elevated in deep subcutaneous plane and donor site
closed primarily.
Fig. 9.41 Because the triangular flap is undersized compared to the
defect, some recruitment in flap tailoring is required.
Fig. 9.42 Final flap inset rarely requires standing cone excision.
Local Flaps
79

References
[1] Sobanko JF. Optimizing design and execution of linear reconstructions on the
face. Dermatol Surg. 2015; 41 Suppl 10:S216–S228
[2] Lo CH, Kimble FW. The ideal rotation flap: an experimental study. J Plast
Reconstr Aesthet Surg. 2008; 61(7):754–759
[3] Boggio P, Annali G, Pertusi G, et al. “Opposite semilunar” variant of Burow tri-
angle in rotation and advancement flaps. J Craniofac Surg. 2011; 22(6):2193–
2194
[4] Carucci JA. Melolabial flap repair in nasal reconstruction. Dermatol Clin.
2005; 23(1):65–71, vi
[5] Yellin SA, Nugent A. Melolabial flaps for nasal reconstruction. Facial Plast Surg
Clin North Am. 2011; 19(1):123–139
[6] Zoumalan RA, Hazan C, Levine VJ, Shah AR. Analysis of vector alignment with
the Zitelli bilobed flap for nasal defect repair: a comparison of flap dynamics
in human cadavers. Arch Facial Plast Surg. 2008; 10(3):181–185
[7] Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol. 1989; 125
(7):957–959
[8] Cho M, Kim DW. Modification of the Zitelli bilobed flap: a comparison of flap
dynamics in human cadavers. Arch Facial Plast Surg. 2006; 8(6):404–409, dis-
cussion 410
[9] Cook JL. Reconstructive utility of the bilobed flap: lessons from flap successes
and failures. Dermatol Surg. 2005; 31(8, Pt 2):1024–1033
[10] Cook JL. A review of the bilobed flap’s design with particular emphasis on the
minimization of alar displacement. Dermatol Surg. 2000; 26(4):354–362
[11] Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;
40(2):147–149
[12] Rohrich RJ, Muza ar AR, Adams WP, Jr, Hollier LH. The aesthetic unit dorsal
nasal flap: rationale for avoiding a glabellar incision. Plast Reconstr Surg.
1999; 104(5):1289–1294
[13] Park BC, Gye JW, Hong SP, Kim MH. Modified three-point rotation-advance-
ment flap for the repair of the melolabial groove and a peri-alar C-shaped
defect. Dermatol Surg. 2013; 39(3, Pt 1):468–471
[14] Lindsey WH. Reliability of the melolabial flap for alar reconstruction. Arch
Facial Plast Surg. 2001; 3(1):33–37
[15] Shipkov H, Stefanova P, Pazardzhikliev D, Djambazov K. Superiorly based
nasolabial island flap: indications and advantages in upper lip reconstruction.
J Craniofac Surg. 2014; 25(5):1928–1929
[16] Torroni A, Longo G, Marianetti TM, et al. The use of a superiorly based melola-
bial interpolated flap for reconstruction of anterior oronasal fistulas: an easy
and practical solution. Ann Plast Surg. 2015; 75(2):163–169
[17] Walike JW, Larrabee WF, Jr. The ‘note flap’. Arch Otolaryngol. 1985; 111(7):
430–433
Fig. 9.43 A 59-year-old male status post Mohs resection with thick posterior left ala defect. Note flap design with flap limb placement along
alar groove.
Introduction
80

2
Part 2
Techniques for Specific
Anatomic Location
10 Scalp Reconstruction

83
11 Forehead Reconstruction

91
12 Introduction to Nose and Simple
Nasal Defects

96
13 Complex Nasal Defects

105
14 Nasal Reconstruction Based on
Subunits

118
15 Eyelid Reconstruction

131
16 Cheek Reconstruction

143
17 Chin Reconstruction

151
18 Lip Reconstruction

154
19 Ear Reconstruction

166

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