Local Flaps in Facial Reconstruction

44
SECTION I  FUNDAMENTALS
FIGURE 4-4  ■  Application of mechanical creep.
FIGURE 4-3  ■  Undermining of wound edge by single-prong hook.
Achieving a tension-free wound closure is important in
the short-term to prevent wound dehiscence and to
promote tissue viability. Wound closure tension also plays
a role in the long-term appearance of the scar.10 In soft
tissue surgery, a number of techniques should be used to
decrease wound closure tension. Undermining of the soft
tissue at the wound edge will allow easier approximation.
Depending on the anatomic location and depth of dissec­
tion, a layered closure with deep buried sutures will effec­
tively diminish wound strain. For some procedures, a
series of relaxing incisions, such as galeatomies beneath
the forehead skin, allow the recruitment and advance­
ment of adjacent tissue and reduction of wound closure
tension.
When undermining and layered wound closure fail to
minimize wound closure tension, the surgeon may elect
to alter the mechanical properties of the skin itself.
Because skin is viscoelastic, its intrinsic shape can be
altered by mechanical creep. Mechanical creep is defined
as the elongation of skin beyond the skin’s intrinsic exten­
sibility by a constant load over time. The stretching is
usually performed intraoperatively, and tissue lengthen­
ing is due to collagen realignment, displacement of fluids,
and fragmenting of elastin fibers. The force used to elicit
mechanical creep may be applied with standard instru­
ments, such as towel clamps applied to the skin (Fig. 4-4),
or with a number of commercially available devices. Dis­
advantages of rapid intraoperative skin expansion include
tissue damage and problems with extrusion of the expand­
ing device. A promising technique has been the use of
external tissue expanders. These devices work more
slowly than intraoperative devices. They apply steady and
significant tissue traction around an open wound without
causing tissue trauma. They are effective in assisting in
closure of large wounds that cannot be repaired with
conventional techniques.11
A large variety of needle drivers are available to sur­
geons. The delicate nature of soft tissue work creates a
number of requirements for these instruments. The jaws
of the driver must be able to effectively grasp the small-
caliber needles commonly used for facial skin closure. In
addition, the instrument should accommodate the wrist
pronation required for proper suture placement. The
small-caliber Castroviejo needle driver is an excellent
choice for soft tissue work (Fig. 4-5). With its unique
design, the locking version of the Castroviejo provides
excellent needle traction while allowing more ergonomic
wrist pronation. The result is a more accurate and con­
sistently placed suture.
Wound Apposition
Regardless of the suture material selected to approximate
a skin incision, basic suture techniques are applied to all
wound repairs. A variety of materials, including sutures,
tapes, staples, and adhesives, are available for wound
approximation. The surgeon should make a selection
after carefully analyzing a number of factors including
the characteristics of the tissue surrounding the wound
and the proximity of the wound to critical facial struc­
tures. Wound repairs that impinge on the lip, eyelid, or
eyebrow merit particular attention.
Wound repair should be performed with the least
wound closure tension necessary to approximate the
wound margins. Wound closure tension can be mini­
mized with the placement of proper subcutaneous sutures.
The addition of dermal sutures will also assist with reduc­
tion of dead space and skin edge eversion. The path of

4  WOUND CLOSURE TECHNIQUES
45
results when the needle enters too far from the skin edge
or at an improper angle.
Once the subcutaneous tissue layers of a wound have
been approximated, the method of cutaneous closure
must be determined. Suture remains the “gold standard”
material for repair of skin incisions. Sutures are highly
adaptable to complex wounds and may be tailored to each
individual wound. The limiting aspect for all cutaneous
suture techniques is the time required to perform the
procedure. When suture closure is performed, with or
without deep sutures, the surgeon must use precise tech­
niques to promote skin eversion (Fig. 4-6). At the com­
pletion of an ideal wound closure, the skin edges will be
slightly everted. In time, with wound contraction, the
everted skin edge will retract to leave an aesthetic cutane­
ous scar. In contrast, when skin edges are approximated
without eversion, contractile forces may result in a
depressed or widened scar. Sutures that are placed too far
from the wound edge may result in telltale suture marks
(i.e., train tracks) from pressure necrosis (Fig. 4-7).
The most basic cutaneous suture is the simple inter­
rupted suture (Fig. 4-8). This technique enables the
surgeon to adjust to variations in the level of the wound
edges with each individual suture. Whereas an excellent
wound closure can be achieved with this technique, it is
time-consuming. If the level of the wound edges does not
require many adjustments, they may be approximated
with a simple continuous (running) suture (see Fig. 4-8).
This method provides a rapid wound repair and an even
distribution of wound tension along the length of the
incision. Wounds near an area of increased motion, such
as the lips or medial cheeks, may benefit from an inter­
rupted suture repair. More stress is placed on cutaneous
sutures in these areas compared with other regions of the
face, and as a result, there is a greater risk for sutures to
break. Should this occur to a continuous suture, wound
dehiscence is likely.
The cutaneous suture that creates maximum wound
edge eversion is the vertical mattress suture. This suture
passes in arcs from two opposing points distal to the
wound margin to two opposing points immediately
such sutures should start and end at a point farthest from
the surface of the skin. On placement of dermal sutures,
care must be taken to match the entry and exit points of
the suture on both sides of the wound. Misplaced sutures
will result in uneven wound edges and poor skin edge
eversion. An equal distribution of wound closure tension
is achieved by inserting the suture needle below and par­
allel to the surface of the skin, following the curve of the
needle and exiting below and parallel to skin on the con­
tralateral side of the wound. Poor eversion of skin edges
FIGURE 4-5  ■  Castroviejo needle driver.
FIGURE 4-6  ■  Schematic diagram of deep suture placement. Placement of deep sutures should eliminate dead space and accomplish
wound edge approximation and eversion.
A
B

46
SECTION I  FUNDAMENTALS
FIGURE 4-8  ■  A, Simple interrupted suture. B, Simple continuous suture. C, Horizontal mattress suture. D, Vertical mattress suture.
Simple interrupted Simple continuous
Horizontal mattress Vertical mattress
A
B
C
D
FIGURE 4-7  ■  A, Proper placement of cutaneous suture showing equal distribution of tension along entire wound edge. Everted
surgical wound edges provide aesthetic result. B, Improper placement of cutaneous suture with surgical bite too far from skin edge
and too superficial. This creates vector forces that are greatest in a horizontal direction and produces inverted wound. C, Improper
placement of cutaneous suture farther from skin edge with more superficial surgical bite. Force vectors on wound are greater in a
horizontal direction and create more wound inversion. In addition, permanent suture marks result in areas of pressure necrosis
where wound closure tension is greatest.
A
B
C

4  WOUND CLOSURE TECHNIQUES
47
insertion of the needle. When suture depth varies, the
wound edges will tend to invert and create unfavorable
scarring.
The use of cutaneous sutures allows selective adjust­
ment of wound margin apposition when there is a dis­
crepancy in the thickness of the opposing skin edges (Fig.
4-10). To alleviate disparities in skin thickness on either
side of the wound, deep sutures must first be placed to
align the dermal-subdermal tissue planes along the border
of tissue apposition (Fig. 4-10B, C). Alignment of the
skin edges is accomplished by taking a deeper dermal bite
of the thinner skin and a more superficial dermal bite of
the thicker skin (Fig. 4-10D, E).
Wound repair with tape is effective in properly selected
patients. The ideal wound is one that is located on a flat
body surface. The repair must have no wound closure
tension at the cutaneous level. Rather than achieving cuta­
neous approximation, paper tape essentially maintains an
adjacent to the wound margins (see Fig. 4-8). When it is
tied, this suture provides vectors of force that maximize
wound edge eversion. It also has the benefit of decreasing
dead space compared with a simple interrupted or simple
continuous cutaneous suture. The horizontal mattress
suture does little to decrease dead space, but like the
vertical mattress suture, it provides maximum wound
edge eversion (see Fig. 4-8). A horizontal mattress suture
is placed by taking two equidistant bites of tissue on
either side of the wound in a purse-string fashion.
Depending on the location of the wound and the type
of suture used, intradermal sutures may be beneficial. The
intracuticular technique is a continuous suture that is
placed in alternating loops completely within the dermis
(Fig. 4-9). Because the suture never penetrates the epider­
mis, there are no external suture marks. The technique is
technically difficult because the suture must be placed at
exactly the same depth within the dermis with each
FIGURE 4-9  ■  Intracuticular continuous suture. Cross section of skin shows continuous suture at level of dermis to achieve maximal
wound edge eversion.
Intracuticular continuous

48
SECTION I  FUNDAMENTALS
tape are placed perpendicular to the line of closure
without tension. Tissue forceps should be used to align
skin edges during the process. Once it is complete, the
tape bandage acts to distribute wound closure tension
evenly over the skin-tape interface (Fig. 4-11). When
surgical tape is applied to an improperly approximated
already approximated wound in the form of strips that
traverse the wound. Tape closure offers the advantage of
ease of use and improved patient comfort.
The technique for tape closure begins once the wound
is completely approximated. A skin adhesive is applied
immediately adjacent to the wound edges, and strips of
FIGURE 4-10  ■  A, Schematic diagram illustrating two skin edges of unequal thickness. B, C, Placement of deep sutures in mismatched
tissue to achieve maximal cutaneous alignment. Note that suture is placed in dermis at deeper plane of thinner skin edge.
D, E, Placement of cutaneous sutures in mismatched tissue to achieve maximal tissue eversion.
A
B
D
E
C
FIGURE 4-11  ■  A, Appropriately selected wound for surgical taping. Adequate deep tissue approximation allows minimum and well-
distributed tension between surgical tape and skin surface. B, Poorly selected wound for surgical taping. Inadequate deep tissue
closure creates gaping of wound and increased wound closure tension that is poorly distributed between skin surface and surgical
tape interface. This creates shearing on skin surface, which results in wound edge inversion and epidermolysis.
A
B
Paper tape closure

4  WOUND CLOSURE TECHNIQUES
49
wound, shearing forces create tension at the cutaneous
interface (see Fig. 4-11). The uneven distribution of
tension by the tape closure can result in inversion of skin
edges and poor wound healing.
Staples are an excellent option for repair of certain skin
incisions. The location and characteristic of the wound
must be carefully determined before this option is
selected. The wound surface should be relatively flat and
not located over major bone convexities or concavities.
Staples should not be used with delicate tissue (e.g.,
eyelid) or at the border of certain aesthetic boundaries
(e.g., vermilion border). Furthermore, because of the
relative lack of precise skin edge approximation when
staples are used, there should be minimal disparity in
thickness of the skin at the wound edges. With a properly
selected wound, staples achieve an aesthetic result similar
to that of suture closure.12
As with all cutaneous closures, the staple technique
begins with an appropriate subcutaneous tissue approxi­
mation (Fig. 4-12). The skin edges are then grasped
with a tissue forceps to position them in an everted ori­
entation. Staples are then applied and are placed at inter­
vals necessary to maintain eversion of the wound edge.
Properly applied staples produce a transverse vector force
that maintains wound approximation and eversion.
Postoperative Dressing
If there has been limited undermining of skin and hemo­
stasis has been ensured, no surgical dressing is required.
If the skin closure has been performed with a dissolvable
suture, such as fast-absorbing gut, wound healing is facili­
tated by the application of an antibiotic ointment along
the suture line. If a permanent suture, such as polypro­
pylene, has been used, the wound site can be dressed with
Steri-Strips until the time of suture removal.
After completion of wound closure, a surgical dressing
is usually applied. One of the main considerations is the
risk for postoperative hematoma formation. If this is a
concern, a compression-type dressing should be planned.
A variety of dressing materials are available for compres­
sion of the surgical site. For smaller wound areas, the
combination of a flexible tape with a compressible bolster
will provide adequate direct pressure. Bolster material
may include cotton balls, layered nonadhesive (Telfa)
pads, or other such material. For larger wounds that
require compression, a prefabricated stockinette dressing
is helpful. These dressings, also known as facioplasty gar­
ments, provide even direct pressure to the entire region
of the surgery. Such dressings are an ideal choice for
larger reconstructions with cervicofacial flaps.
When a skin defect is left open to heal by secondary
intention, several strategies may be employed to hasten
the healing process. Foremost is providing a moist healing
environment. If an open skin wound is allowed to dry,
a significant loss of fluids and electrolytes may occur.
Dry wounds develop an eschar. Whereas the eschar
provides an element of protection to the wound, its pres­
ence delays wound healing and usually results in greater
scar tissue formation than when wounds heal in a moist
environment.13 Thus wounds healing by secondary
intention are kept moist by the periodic application of a
petroleum-based ointment. Although this is an effective
strategy, it requires frequent reapplication by the patient.
Hydro­gel products are a new class of semiocclusive dress­
ings that provide a moist environment for optimal re-
epithelialization of the wound. The semipermeable
nature of the dressing prevents maceration of the sur­
rounding tissues and decreases the incidence of infection.
There are multiple commercial hydrogel dressings,
such as Vigilon, CarraDres, and NuGel. Although they
are ideal for wounds that are healing by secondary
intention, the hydrogel dressings are also useful for skin
care after dermabrasion. Application of a hydrogel dress­
ing minimizes postprocedure crusting and speeds
re-epithelialization, resulting in reduced wound healing
time.
SUTURE MATERIAL
Suture Characteristics
The ideal suture material should be easy to handle,
have high tensile strength, and have no tissue reaction
(Table 4-2). A variety of suture material is available for
soft tissue surgery. Selection of a particular type is depen­
dent on the physical characteristics of the material. A set
of common terms and definitions are presented in Table
4-3. Given the multitude of requirements of cutaneous
and reconstructive procedures, there is no single suture
suited for all wound closures. In part, the outcome of
wound repair depends on the type of suture material and
needle architecture selected. Inappropriate needle or
suture material can create tissue damage at the wound
interface and affect the ultimate aesthetic results. One
important characteristic of suture material is its coeffi­
cient of friction. Different types of suture filaments have
varied levels of friction (Fig. 4-13). A higher level of fric­
tion results in increased local tissue damage. In general,
monofilament sutures have the lowest coefficient of fric­
tion. Examples of monofilament sutures are nylon and
polypropylene. Braided sutures with higher coefficients
of friction can be made more “slippery” with coating
agents. Common coating agents include silicone, organic
waxes, and polymers of suture material (such as polygla­
ctin 370 and polycaprolate). Another important suture
characteristic is elasticity. During wound healing, there
is local tissue edema, and the suture material used for
repair of the wound should have sufficient elasticity to
accommodate the change in tissue volume without
TABLE 4-2  Ideal Suture Material
Characteristics
Minimal tissue injury
Minimal tissue reaction
Ease of handling
High tensile strength
Favorable absorption profile
Resistance to infection

50
SECTION I  FUNDAMENTALS
FIGURE 4-12  ■  A,
Deep
tissue
approximation
required before placement of surgical staple.
B, Tissue forceps approximating and everting
skin edge during application of surgical staple.
C, Appearance of surgical wound after appropriate
placement of surgical staple. Note equal and well-
distributed horizontal vector forces on tissue edge
after appropriate placement.
Surgical staple closure
A
B
C

4  WOUND CLOSURE TECHNIQUES
51
FIGURE 4-13  ■  Scanning electron micrograph (40×) of various suture materials: A, silk suture; B, nylon suture; C, coated synthetic
braided suture (Vicryl); D, chromic gut suture. In general, monofilament sutures (like nylon) have lowest coefficient of friction.
A
B
C
D

52
SECTION I  FUNDAMENTALS
the greatest memory and require precise handling in cre­
ating a knot.
The tensile strength of suture material is important to
maintain wound approximation. For a given wound
closure, a smaller gauge suture may be used if it possesses
sufficient tensile strength. Conversely, mechanically
weaker suture material must have a larger caliber to close
similar wounds. In repairs in which there is significant
wound closure tension, smaller gauge sutures with high
tensile strength can cut through the wound edges as it
transmits wound closure tension to the local tissue. For
best results, the suture used should be no stronger than
the tissue it is approximating. The strength of individual
tissue types is detailed in Table 4-4.
The United States Pharmacopoeia (USP) classifica­
tion system was established in 1937 for standardization
and comparison of suture materials. The graded system
has a direct correlation to metric measures. Suture size
describes the diameter of the suture strand and is graded
by a series of zeros. Somewhat paradoxically, the more
zeros a suture has, the smaller it is (e.g., 5-0 is smaller
than 4-0). Suture materials are also divided into three
classes: collagen, synthetic absorbable, and nonabsorb­
able. USP specifications for each class are detailed in
Tables 4-5 to 4-7. Review of these specifications reveals
TABLE 4-3  Suture Material: Definition of Terms
Absorbable Suture
Memory
Undergoes progressive loss of mass or volume (does not
correlate with loss of tensile strength)
A suture’s inherent capability to return to or maintain its
original gross morphologic shape; it is a function of
elasticity, plasticity, and diameter
Breaking Strength
Nonabsorbable Suture
Limit of tensile strength at which material (or tissue) failure
occurs
Undergoes no significant loss of mass or volume (does not
correlate with retention of tensile strength)
Capillarity
Plasticity
Extent to which absorbed fluid is transferred along the strand
A measure of a suture’s ability to deform without breaking
and to maintain that new form after relief of the deforming
force
Coefficient of Friction
Straight-pull Tensile Strength
A numeric value that quantifies a material’s surface
characteristics that act to resist motion against another
surface
Linear breaking strength of suture material
Elasticity
Suture Pullout Value
A measure of a suture’s ability to regain its original form and
length after deformation
Limit of strength of a particular tissue as measured by the
force applied to a loop of suture at which tissue failure
occurs
Fluid Absorption
Tensile Strength
Ability to take up fluid after immersion
A material’s or tissue’s ability to resist deformation and
breakage
Knot-pull Tensile Strength
Wound Breaking Strength
Breaking strength of a suture material, which can be 10% to
40% weaker after deformation by knot placement
Limit of tensile strength of a healing wound at which wound
separation occurs
Knot Strength
Amount of force necessary to cause a knot to slip, which is
directly proportional to the coefficient of static friction and
plasticity of a given material
compromising wound approximation. Poliglecaprone 25
(Monocryl) and polybutester (Novofil) are two materials
that have excellent elasticity profiles.
All suture material elicits an inflammatory response in
the tissue where the suture is placed. The response may
be related to the physical nature of the suture material
(coating materials) or a patient’s immune reaction to the
material. Chromic and plain gut sutures are associated
with significant tissue reactions.14 These collagen-based
sutures are absorbed by neutrophil-mediated proteolysis.
A nonspecific inflammatory response accompanies the
arrival of neutrophils, resulting in local tissue reaction.
In contrast, a variety of synthetic absorbable suture fibers
are absorbed by simple hydrolysis, which is associated
with limited inflammation. Nonabsorbable fibers do not
undergo local degradation and elicit the least inflamma­
tory response.
Other important suture characteristics are pliability,
tensile strength, and absorption profile. The pliability of
suture material affects the ease of use. A more pliable
suture will facilitate creation of a knot. In contrast, a
stiff suture material will be more difficult to work with.
Rigid suture material is more resistant to knotting and
has an increased material memory. In general, braided
sutures are the most pliable. Monofilament sutures have

4  WOUND CLOSURE TECHNIQUES
53
TABLE 4-4  A Regional Guide to Suture Selection
Region
Cutaneous Suture
Subcutaneous/
Fascia Suture
Comments
Eyelid and periorbital
6-0, 7-0
4-0, 5-0
Minimal tensile strength requirements
Aesthetic concerns at a premium
Nose and pinna
5-0, 6-0
4-0, 5-0
Small tensile strength requirements
Aesthetic concerns at a premium
Lip and vermilion
6-0
3-0, 4-0
Moderate tensile strength requirements due to highly
active region
Aesthetic concerns at a premium
General facial and
anterior neck
5-0, 6-0
4-0, 5-0
3-0, 4-0
Moderate to high tensile strength requirements due to
regional mobility
Significant aesthetic concerns
Nasal and oral mucosa
3-0, 4-0
3-0, 4-0
Moderate tensile strength required due to tissue mobility
May select on the basis of ease or no need for removal
No aesthetic concern
Scalp and posterior neck
3-0, 4-0
2-0, 3-0
Tensile strength required for moderately heavy tissue
and very mobile region
Minimal aesthetic concern
Superior trunk
2-0, 3-0
2-0, 3-0
Tensile strength required for heavy tissues in a relatively
mobile area
Major musculocutaneous
flaps
4-0, 5-0
1-0, 2-0, 3-0
Maximal tensile strength required because sutures are
often under significant tension
May require long-term tensile strength
TABLE 4-5  USP Specifications for Collagen Suture
USP Size
Metric Size (Gauge No.)
Limits on Average
Diameter (mm)
Knot-Pull Tensile Strength (kgf)
LIMIT ON
AVERAGE MIN.
LIMIT ON
INDIVIDUAL
STRAND MIN.
MIN.
MAX.
9-0
0.4
0.040
0.049
—
—
8-0
0.5
0.050
0.069
0.045
0.025
7-0
0.7
0.070
0.099
0.07
0.055
6-0
1
0.10
0.149
0.18
0.10
5-0
1.5
0.15
0.199
0.38
0.20
4-0
2
0.20
0.249
0.77
0.40
3-0
3
0.30
0.339
1.25
0.68
2-0
3.5
0.35
0.399
2.00
1.04
0
4
0.40
0.499
2.77
1.45
1
5
0.50
0.599
3.80
1.95
2
6
0.60
0.699
4.51
2.40
3
7
0.70
0.799
5.90
2.99
4
8
0.80
0.899
7.00
3.49
USP36-NF31 ©2013 United States Pharmacopeial Convention. Used by Permission.
several inconsistencies of the USP system. The true
metric size and USP size have some variation between
the three classes. In addition, metric size does not per­
fectly correlate with suture knot tensile strength. Last,
whereas the USP specifications set the minimum tensile
strength for a given suture size, they do not set an upper
limit. Therefore, sutures in the same USP class may have
different tensile strengths.
Natural Fiber Suture
Multiple natural fiber sutures are available. The charac­
teristics of natural fiber sutures are listed in Table 4-8.
Natural fiber materials may be absorbable or nonabsorb­
able. Absorbable sutures consist of collagen and varieties
include gut, fast gut, and chromic gut. Collagen suture is
derived from either sheep or beef intestine. Plain gut
suture maintains tensile strength for 7 to 10 days. Absorp­
tion is complete by 70 days. Fast-absorbing gut maintains
tensile strength for 5 days with complete absorption by
60 days. Chromic gut has a longer duration of action and
its tensile strength is maintained for 10 to 14 days. The
treatment of the collagen material with chromium salts
retards absorption, slowing the process to 90 days.
Whereas plain and chromic gut may be used internally,
fast-absorbing gut is intended for external use.

54
SECTION I  FUNDAMENTALS
TABLE 4-6  USP Specifications for Synthetic Absorbable Suture
USP Size
Metric Size
(Gauge No.)
Limits on Average
Diameter (mm)
Knot-Pull Tensile Strength (kgf)
(Except Where Otherwise Specified)*
Limit on Average Min.
MIN.
MAX.
12-0
0.01
0.001
0.009
—
11-0
0.1
0.010
0.019
—
10-0
0.2
0.020
0.029
0.025*
9-0
0.3
0.030
0.039
0.050*
8-0
0.4
0.040
0.049
0.07
7-0
0.5
0.050
0.069
0.14
6-0
0.7
0.070
0.099
0.25
5-0
1
0.10
0.149
0.68
4-0
1.5
0.15
0.199
0.95
3-0
2
0.20
0.249
1.77
2-0
3
0.30
0.339
2.68
0
3.5
0.35
0.399
3.90
1
4
0.40
0.499
5.08
2
5
0.50
0.599
6.35
3 and 4
6
0.60
0.699
7.29
5
7
0.70
0.799
USP36-NF31 ©2013 United States Pharmacopeial Convention. Used by Permission.
*The tensile strength of the specific USP size is measured by straight pull.
TABLE 4-7  USP Specifications for Nonabsorbable Surgical Suture
USP Size
Metric Size
(Gauge No.)
Limits on Average
Diameter (mm)
Limits on Average Knot-Pull (Except Where Otherwise
Specified)* Tensile Strength (kgf)
MIN.
MAX.
CLASS I MIN.
CLASS II MIN.
CLASS III MIN.
12-0
0.01
0.001
0.009
0.001*
—
0.002*
11-0
0.1
0.010
0.019
0.006*
0.005*
0.02*
10-0
0.2
0.020
0.029
0.019*
0.014*
0.06*
9-0
0.3
0.030
0.039
0.043*
0.029*
0.07*
8-0
0.4
0.040
0.049
0.06
0.04
0.11
7-0
0.5
0.050
0.069
0.11
0.06
0.16
6-0
0.7
0.070
0.099
0.20
0.11
0.27
5-0
1
0.10
0.149
0.40
0.23
0.54
4-0
1.5
0.15
0.199
0.60
0.46
0.82
3-0
2
0.20
0.249
0.96
0.66
1.36
2-0
3
0.30
0.339
1.44
1.02
1.80
0
3.5
0.35
0.399
2.16
1.45
3.40←
1
4
0.40
0.499
2.72
1.81
4.76←
2
5
0.50
0.599
3.52
2.54
5.90←
3 and 4
6
0.60
0.699
4.88
3.68
9.11←
5
7
0.70
0.799
6.16
—
11.4←
6
8
0.80
0.899
7.28
—
13.6←
7
9
0.90
0.999
9.04
—
15.9←
8
10
1.00
1.099
—
—
18.2←
9
11
1.100
1.199
—
—
20.5←
10
12
1.200
1.299
—
—
22.8←
USP36-NF31 ©2013 United States Pharmacopeial Convention. Used by Permission.
Limits on knot-pull tensile strength apply to nonabsorbable surgical suture that has been sterilized. For nonsterile sutures of class I and
class II, the limits are 25% higher.
*Tensile strength of sizes smaller than USP size 8-0 (metric size 0.4) is measured by straight pull. Tensile strength of sizes larger than
USP size 2-0 (metric size 3) of monofilament class III (metallic) nonabsorbable surgical suture is measured by straight pull.
←Silver wire meets the tensile strength values of class I sutures but is tested in the same manner as class III sutures.
Class I: composed of silk or synthetic fibers where the coating agent does not significantly affect thickness.
Class II: composed of cotton or linen or synthetic fibers where the coating significantly affects thickness but not strength.
Class III: composed of monofilament or multifilament metal wire.

4  WOUND CLOSURE TECHNIQUES
55
TABLE 4-8  Natural Fiber Suture
Name
Source
Special
Processing
Filament
Relative
Tensile
Strength*
Tensile
Strength
Profile†
Absorption
Profile
Tissue
Reaction‡
Ease of
Use§
Absorbable
Plain gut
Highly
purified
(nearly
100%)
collagen
derived
from
submucosa
of sheep
intestines
or serosa
of beef
intestine
None
Twisted
“virtual”
monofilament
2
75% at 7
days
70 days
proteolysis
Chromic
gut
Chromium
salt
treatment
resists
breakdown
2
75% at 14
days
90 days
proteolysis
5
4
Fast-
absorbing
gut
Heat treated
to speed up
degradation
2
75% at 5
days
60-70 days
proteolysis
Plain
collagen
Beef Achilles
tendon
Chromium
salt
treatment
75% at 7
days
70 days
proteolysis
Chromic
collagen
Chromium
salt
treatment
Twisted
“virtual”
monofilament
35% at 14
days
90 days
proteolysis
4
3
Nonabsorbable
Silk
Silkworm
Coating with
beeswax or
silicone;
dyed
Braided
1
Progressive
loss
during 1
year
Significant at
2 years
proteolysis
4
1 (gold
standard)
Cotton
Cotton seed
Twisted
1
2
Linen
Flax seed
Twisted
2
2
Surgical
steel
Braided or
monofilament
5
Significant
loss only
if kinked
1
5
*Relative tensile strength scale: 1 = least, 5 = greatest strength. When accompanied by ( ), indicates relative rank within a relative
strength class: (1) = greatest, (5) = least.
†Represents percentage of original dry, out-of-package tensile strength.
‡Represents relative tissue reaction: 1 = least, 5 = greatest reaction.
§Represents relative overall ease of use: 1 = easiest, 5 = most difficult.
Natural fiber suture that is nonabsorbable is less com­
monly used in facial plastic surgery. Available materials
include silk and cotton. Surgical silk is made from the
natural raw product of silkworms. For many years, silk
suture was considered the ideal material, given its ease of
handling. Silk is classified as a nonabsorbable material,
but in many cases it is absorbed by 2 years. Tensile
strength of silk suture decreases over time and is lost
by 1 year. Surgical cotton is rarely used. Because it is
nonabsorbable, in time it becomes an encapsulated
foreign body. The tensile strength decreases over time
and is reduced to one-third of its original strength by 2
years.
Synthetic Fibers
Absorbable synthetic sutures are polymers that are
degraded by hydrolysis, which causes less inflammation
than with natural fiber sutures. Popular synthetic absorb­
able sutures include Vicryl, Monocryl, and polydioxa­
none (PDS). These products are detailed in Table 4-9.
Vicryl is a braided multifilament suture coated with
lactide and glycolide. These copolymers are hydropho­
bic, which prolongs the life of the suture. Nearly two-
thirds of the tensile strength remains at 14 days.
Absorption is not complete until 60 to 70 days after
implantation. Vicryl is an ideal suture for approximating
the depths of wounds, including fascia and muscle.
Monocryl is a synthetic monofilament that is composed
of glycolide and ε-caprolactone. Initial tensile strength
is maintained during the first week, with subsequent
rapid degradation by 3 weeks. The pliable nature of
Monocryl makes it ideal for delicate subcuticular clo­
sures. PDS is another monofilament and is a polyester
derivative. This suture has a pliability similar to that of
Monocryl but with a longer duration of tensile strength.
Tensile strength is maintained for up to 6 weeks. PDS is
used for repairs that may have increased wound closure
tension.
Synthetic nonabsorbable sutures, such as nylon and
Prolene, have long been the standard for cutaneous
approximation. Other synthetics, such as Mersilene, are
used for deep permanent sutures. The characteristics of

56
SECTION I  FUNDAMENTALS
TABLE 4-9  Absorbable Synthetic Suture
Name
Source
Special
Processing
Filament
Relative
Tensile
Strength*
Tensile
Strength
Profile†
Absorption
Profile
Tissue
Reaction‡
Ease of
Use§
Poliglecaprone
25
(Monocryl;
Ethicon)
Synthetic
copolymer
glycolide and
caprolate
Undyed
Monofilament
4 (1)
50%-60% at
1 week
20%-30% at
2 weeks
20% at 3
weeks
90-120 days
hydrolysis
2
1, very
pliable
elastic
Polydioxanone
(PDS II;
Ethicon)
Synthetic polymer
polydioxanone
Undyed
Monofilament
4 (4)
70% at
3 weeks
50% at
4 weeks
25% at
6 weeks
180-210 days
hydrolysis
2
3
Polyglactin 910
(Vicryl;
Ethicon)
Synthetic
copolymer
glycolide lactide
Dyed violet or
undyed,
coated
galactin 370
Braid
4 (2)
65% at
2 weeks
40% at
3 weeks
8% at
4 weeks
56-70 days
hydrolysis
3
2
Polyglycolic
acid (Dexon
II, Dexon S;
Davis &
Geck)
Synthetic polymer
Dyed or undyed,
coated
polycaprolate
Braid
4 (3)
65% at
1 week
35% at
2 weeks
5% at
4 weeks
90-120 days
hydrolysis
3
2
Polyglyconate
(Maxon;
Davis &
Geck)
Synthetic polymer
polytrimethylene
carbonate
Dyed
Monofilament
4 (1)
75% at
2 weeks
50% at
4 weeks
25% at
6 weeks
180-210 days
hydrolysis
2
2
*Relative tensile strength scale: 1 = least, 5 = greatest strength. When accompanied by ( ), indicates relative rank within a relative
strength class: (1) = greatest, (5) = least.
†Represents percentage of original dry, out-of-package tensile strength.
‡Represents relative tissue reaction: 1 = least, 5 = greatest reaction.
§Represents relative overall ease of use: 1 = easiest, 5 = most difficult.
these sutures are noted in Table 4-10. Nylon is a poly­
amide polymer and is available in a monofilament and
braided formulation. The suture has a high level of elas­
ticity and is useful for cutaneous closures. When it is
used as an internal permanent suture, nylon has an
impressive duration of tensile strength. As much as two-
thirds of the original tensile strength is present at 10
years after implantation. Although nylon undergoes
eventual hydrolysis, this is minimized by the foreign
body encapsulation that occurs. Polybutester (Novofil)
is a true permanent suture that does not lose tensile
strength or become absorbed. Another polyester fiber
(polyethylene terephthalate) is a multifilament braided
fiber that is available in coated (Ethibond) and uncoated
(Mersilene) versions. This suture has an indefinite per­
manence. With its ease of use and long life, the suture
is ideal for use with implants and in procedures requir­
ing cartilage sculpting, such as otoplasty. Prolene is a
propylene polymer monofilament suture. As a monofila­
ment, Prolene has excellent pliability and minimal fric­
tion. Of all the synthetic monofilaments, Prolene is the
best for holding a knot.
Suture Needles
Similar to the large selection of sutures, a number of
suture needles are also available in a variety of styles.
Commonly used nomenclature for needles is listed in
Table 4-11. The basic architecture of the needle is noted
in Figure 4-14. All needles have the same three basic
elements: point, body, and swage. The point is the
portion of the needle that begins at the tip and ends
when the needle reaches its full diameter. The body
forms the majority of the needle and ends at the contour
change that is the start of the swage. The swage
continues to the end of the needle where the suture is
attached.
The point of the needle represents the initial interface
of the structure with the tissue through which it passes.
A silicone coating on the stainless steel of the needle
determines the level of friction that occurs with each pass
through tissue. An improved quality of steel and silicone
coating maximizes the durability of the needle point.
There are multiple styles of needle points. The three
most common types are taper, cutting, and reverse cutting
(Fig. 4-15; Table 4-12).

4  WOUND CLOSURE TECHNIQUES
57
TABLE 4-10  Nonabsorbable Synthetic Suture
Name
Source
Special
Processing
Filament
Relative
Tensile
Strength*
Tensile
Strength
Profile†
Absorption
Profile
Tissue
Reaction‡
Ease of
Use§
Nylon
  Dermalon
(Davis &
Geck)
  Ethilon
(Ethicon)
Synthetic
polyamide
Clear or
dyed
Monofilament
3
81% at
1 year
72% at
2 years
66% at
11
years
Slow
hydrolysis
stable at 2
years
2
2, low
coefficient
of friction
  Nurolon
(Ethicon)
  Surgilon
(Davis &
Geck)
Dyed,
silicone
coated
Braided
2
Same as
above
Same as
above
2+
1
Polybutester
  Novafil
(Davis &
Geck)
Synthetic
copolymer of
polyglycol
terephthalate
and
polytrimethylene
terephthalate
Dyed blue
Monofilament
3
—
None
1
2, very
elastic,
very low
coefficient
of friction
Polyester
  Ticron
(Davis &
Geck)
  Ethibond
extra
(Ethicon)
Synthetic Dacron
polyester
Dyed,
silicone
coated
Braided
3
—
None
2
2
  Dacron
(Davis &
Geck)
  Mersilene
(Ethicon)
Synthetic Dacron
polyester
Dyed,
uncoated
Braided
2
—
None
2
3
Polypropylene
  Prolene
(Ethicon)
  Surgilene
(Davis &
Geck)
Synthetic polymer
propylene
Dyed blue
Monofilament
2
—
None
1
3, very low
coefficient
of friction
*Relative tensile strength scale: 1 = least, 5 = greatest strength. When accompanied by ( ), indicates relative rank within a relative
strength class: (1) = greatest, (5) = least.
†Represents percentage of original dry, out-of-package tensile strength.
‡Represents relative tissue reaction: 1 = least, 5 = greatest reaction.
§Represents relative overall ease of use: 1 = easiest, 5 = most difficult.
TABLE 4-11  Commonly Used Nomenclature of Suture Needles
BV
Blood vessel
TE
Three-eighths
P
Plastic surgery
PS
Plastic surgery
CPS
Conventional plastic surgery
PC
Precision cosmetic
OPS
Oculoplastic surgery
M
Muscle
J
Conjunctiva
FS
For skin
FSL
For skin large
X
Exodontial
KS
Keith straight
SC
Straight cutting
FN
For tonsil
SH
Small half
MH
Medium half
CT
Circle taper
ST
Straight taper
CP
Cutting point
T
Taper
E
Three-eighths
O
One-fourth
SC
Standard cutting
S
Straight
CTE
Cutting taper three-eighths
PR
Plastic reconstructive
PRE
Plastic reconstructive three-eighths

58
SECTION I  FUNDAMENTALS
FIGURE 4-14  ■  Schematic diagram of needle anatomy.
POINT
SWAGE
Chord length
(Bite width)
Radius
BODY
Chord
diameter
(bite depth)
Chord length
(Bite width)
Ar
c l
en
gt
h

4  WOUND CLOSURE TECHNIQUES
59
use in soft elastic tissues, such as muscle and subcutane­
ous fat.
Cutting needles function by dividing the tissue as they
pass through. A typical cutting needle has a tip with three
sharpened edges. The standard cutting needle has the
third cutting surface on the inner curve of the point. In
contrast, the reverse cutting needle has the third edge on
the outer curve of the point. The standard cutting needle
must be used with care. Unintended upward traction on
the needle may create a shallower than intended bite. At
the extreme, the needle can inadvertently cut through the
tissue. The reverse cutting needle will tend to take deeper
bites of tissue when downward pressure is applied. Either
style of cutting needle is ideal for penetrating tough tissue
such as skin.
The body of the needle plays a role in the function of
the needle. Its greatest importance is in the interaction
with the needle holder (Fig. 4-16). The geometry of the
needle body determines the amount of force transmitted
to the needle point. Round-bodied needles have limited
surface contact area with a needle holder and thus trans­
mit the least force to the needle tip. Ovoid bodies have
greater surface contact area with the needle holder and
transmit greater force to the needle point. For this reason,
most needles have an ovoid contour. A needle holder of
appropriate size is important when a specific needle is
selected. Needle holder jaw width should be no wider
than 30% to 50% of the needle radius (Fig. 4-17). A
needle holder that is too large straightens the needle, and
a holder that is too small allows the needle to rotate
around the needle’s long axis.
In addition to the cross-sectional design of the needle
body, the arc of the needle body is also highly variable.
The arc or shape of the needle body influences its appli­
cations in surgery (Table 4-13). The most common design
used in facial surgery is semicircular. This allows optimum
distribution of tension on the suture and a favorable skin
edge eversion. The arc of a needle body is described
by the fraction of a complete circle that it approximates
(Fig. 4-18). A standard suture bite that enters and exits
FIGURE 4-15  ■  Schematic diagram of commonly used suture needles. Cross-sectional geometry of needle point, needle body, and
needle swage is shown in inset drawings.
Taper Conventional cutting Reverse cutting
TABLE 4-12  Needle Point Types and
Applications
Type
Application
Taper
Aponeurosis
Biliary tract
Blood vessels
Dura
Fascia
Gastrointestinal tract
Muscle
Nerve
Peritoneum
Pleura
Subcutaneous fat
Urogenital tract
Conventional or reverse cutting
Dermis
Ligament
Nasal cavity
Oral cavity
Pharynx
Skin
Tendon
Tapercut (tapered cutting point,
very sharp)
Bronchus
Dermis
Ligament
Nasal cavity
Oral cavity
Ovary
Perichondrium
Periosteum
Pharynx
Sclerotic vessels
Tendon
Trachea
Uterus
The tapered needle is round and works by spreading
the tissue as it passes through it. Its sharpness is directly
related to the rapidity of its taper. This is known as the
taper ratio. Most tapered needles have a taper ratio of 8 : 1
to 12 : 1.The higher the ratio, the sharper is the needle
tip. The function of the taper needle makes it suitable for

60
SECTION I  FUNDAMENTALS
FIGURE 4-17  ■  Schematic diagram of interaction between needle holder and suture needle. A, Needle holder of appropriate size.
B, Needle holder too large for needle shown, which creates inadvertent straightening of needle. C, Needle holder too small for
needle shown, which allows needle rotation around long axis of needle holder.
A
B
C
FIGURE 4-16  ■  Profile of typical needle holders grasping three different geometric-shaped needle bodies. B, Oval needle maximizes
surface contact with holder, transmitting greatest force to needle tip.
A
B
C

4  WOUND CLOSURE TECHNIQUES
61
equidistant from the wound edge requires a 12 circle
needle. As the depth of the bite increases, the fraction of
a circle required increases. For example, a 5
8 circle needle
will place a suture at the same equidistant points as a 12
circle needle but with deeper tissue penetration. Table
4-14 lists the definition of terms that play a role in the
characteristics of a suture needle in relationship to the
needle holder and the interaction of a needle with tissue
it encounters.
The swage of the needle is where the suture material
is attached. In the past, suture needles had an eye through
which the suture material was threaded. Modern needles
have the suture swaged. This is achieved by two different
methods: channel or drill swaging. In channel swaging, a
press is used to create a channel in which the suture mate­
rial is laid and crimped. The drill swaging method creates
a tunnel in the needle in which suture material is placed,
and then the tunnel is crimped. The main difference is
that the channel method does not remove any steel from
the needle swage so that when it is crimped, there is no
net change in swage diameter. The majority of modern
needles are drill swaged.
TISSUE SEALANTS
Fibrin Sealants
The use of fibrin-based tissue sealants has a long history.
Their initial use was as early as the First World War.
Pooled human plasma was used as the source for fibrin
and associated factors. Commercial production was
FIGURE 4-18  ■  Schematic diagram of various suture needle configurations.
1/4 Circle
3/8 Circle
1/2 Circle
5/8 Circle
1/2 Circle compound curve

62
SECTION I  FUNDAMENTALS
TABLE 4-14  Suture Needle and Needle Holder:
Definition of Terms
Angle of Needle Failure
Angle of deformation at which a needle rapidly loses
resistance to plastic deformation
Bending Moment
Force applied to needle creating angular deformation
Needle Ductility
Resistance to needle breakage
Needle Holder Clamping Moment
Force applied to a suture needle by a needle holder; this
applied force may cause deformation of a curved needle
Taper Ratio
Length-to-width ratio of the needle point; a measurement
of the sharpness of a needle point
Tip Angle
Angle described by two straight lines drawn from the tip of
the needle toward the body that best match the slightly
curved contour of the taper; a measurement of the
sharpness of a needle point
Ultimate Moment
Greatest bending moment at which the limits of
nonreversible (plastic) deformation are reached
Yield Moment
Greatest bending moment at which reversible (elastic)
deformation occurs
TABLE 4-13  Needle Body Shapes and
Applications
Shape
Application
14 circle
Eye
Microsurgical
38 circle
Aponeurosis
Biliary tract
Blood vessel
Dura
Eye
Fascia
Gastrointestinal tract
Muscle
Myocardium
Nerve
Perichondrium
Periosteum
Peritoneum
Pleura
Tendon
Urogenital tract
12 circle
Biliary tract
Eye
Gastrointestinal tract
Muscle
Nasal cavity
Oral cavity
Pelvis
Peritoneum
Pharynx
Pleura
Respiratory tract
Skin
Subcutaneous fat
Urogenital tract
58 circle
Cerebrovascular system
Nasal cavity
Oral cavity
Pelvis
Urogenital tract
Compound curved (J shaped)
Cleft palate repair
Eye
Keith (straight)
Gastrointestinal tract
Nasal cavity
Oral cavity
Pharynx
Skin
Tendon
Vessels
achieved soon after, but further development was limited
by concern for safety.15 Improvement in viral screening
and safety in the 1970s has prompted re-examination of
these useful surgical adjuncts. Production of fibrin seal­
ants has occurred in Europe and Canada. A more pro­
tracted approval process culminated with the approval of
the Food and Drug Administration (FDA) for fibrin-
based sealants in 1997.
The basic model for fibrin-based sealants involves the
combination of two distinct components, which results
in rapid coagulation. The primary components are puri­
fied fibrinogen, factor XIII, and various plasma-derived
proteins. The secondary component, which acts as the
catalyst, is concentrated thrombin and calcium chloride.
The mixing of these components induces activation of
the coagulation cascade. The result is conversion of
individual fibrin molecules to a cross-linked polymer of
fibrin.16
The physiology of this basic reaction can be altered by
producing fibrin and thrombin products with variable
properties. In general, these products are classified as
either tissue sealants or glues. Sealants provide moderate
tissue adhesion and excellent hemostasis. Fibrin glues have
greater tensile strength for improved tissue adhesion.17 A
third class of products uses a collagen base with activated
thrombin to produce a significantly hemostatic agent.
This combination is commercially available as Floseal
(Baxter) and has a much stronger hemostatic profile with
the ability to inhibit active arterial hemorrhage.
There are many indications for fibrin-based sealant
products in facial plastic and reconstructive surgery. For
soft tissue procedures that involve the use of full- or split-
thickness skin grafts, studies have demonstrated a signifi­
cant improvement in outcome when a fibrin sealant is
used.18 Fibrin glue has been shown to improve the sur­
vival rate of skin grafts. The improved survival rate is
particularly notable at grafting sites that involve an
element of unavoidable motion. Bacterial wound infec­
tions have also been reduced by the hemostatic properties
of fibrin products. Experimental studies demonstrate that
fibrin sealants are an ideal delivery vehicle for exogenous
growth factors.19 This strategy may be used in the near
future to accelerate wound healing.
Fibrin sealants have also proved useful in local flap
techniques. Improved flap adhesion and accelerated
hemostasis contribute to the long-term success of these
procedures. Early flap adhesion reduces soft tissue

4  WOUND CLOSURE TECHNIQUES
63
shearing forces that can delay neovascularization. Fibrin
sealants help reduce surgical dead space. Thus, the use of
fibrin sealants may be particularly useful when creating
large local flaps, such as cervicofacial rotation flaps. A
significant decrease in postoperative drainage as well as
in hematoma formation has been demonstrated when
fibrin sealants are used during rhytidectomy.20
After reagent preparation is complete, the surgical
technique for the use of a fibrin sealant depends on the
location and nature of the procedure. In all cases, the
basic delivery device is the same: a syringe with dual
chambers and a single ejection port. The reagents
combine and begin the coagulation cascade as they are
ejected. For delivery in small-volume areas (e.g., small
full-thickness skin grafts, small local flaps), an angiocath­
eter style tip is adequate for coating the graft or flap
recipient site. For larger procedures (e.g., cervicofacial
flaps), the delivery system can be combined with a forced-
air system to produce an aerosol delivery. This is ideal
for coating of a large area with a thin volume of fibrin
sealant (Fig. 4-19). After application is complete, the flap
or graft should be stabilized in the desired location with
gentle pressure. The time required for complete adhe­
sion varies from 60 seconds to several minutes, depend­
ing on the concentration of the reagents. The surgeon
can modify the rapidity of the adhesion on the basis of
the surgical procedure. The sealant is adjusted for rapid
onset for simple grafts and flaps. For larger or more
complex local flaps, the sealant should be at a slower
mixture setting to allow ideal tissue positioning.
A new type of wound healing reagent introduced in
recent years is a starch compound that is purified from
potatoes and has been FDA approved for enhancement
of intraoperative hemostasis. Branded as Arista, the com­
pound has a number of advantages: it is significantly less
expensive than fibrin-based products, it has minimal
tissue reactivity because of its chemical nature, and it is
effective in promoting hemostasis in an open wound.21
Tissue Adhesives
The development of tissue adhesives parallels the history
of fibrin sealants.22 The chemical compounds (cyano­
acrylates) were discovered in the 1940s, but complete
commercialization was delayed until FDA approval in
1998. These compounds demonstrate excellent adhesion
and tensile strength. The initial formulation of these sub­
stances was not suited for medical use because of the brisk
inflammatory reaction that they induced. Industrial use
in the 1950s became popular. A modification to the
formula in the early 1970s created a more useful com­
pound that, although off-label, was used for wound
closure during the Vietnam War. During the 1980s and
early 1990s, the cyanoacrylates were used widely in vet­
erinary medicine. Initial successes in studies with human
wounds eventually led to commercialization and FDA
approval for human use.23
The cyanoacrylate tissue adhesives combine cyanoac­
etate and formaldehyde and a base to form a liquid
monomer. Moisture on the skin’s surface then chemically
induces a polymerization. Once it is fully polymerized,
the cyanoacrylate is bound to the top epithelial layer. The
polymerized cyanoacrylate bridges the wound edges
together, and normal healing occurs at the subepithelial
level. It is essential that wound edges be well apposed to
avoid contamination of the subepithelial portions of the
wound, which can lead to foreign body reaction and
wound failure.24
The mechanical requirement for well-apposed wound
edges can limit the utility of the cyanoacrylate tissue
adhesives. The commercialized formulations are intended
to replace suture of only 5-0 or smaller. Wounds that
require a layered closure should still be approximated
with the appropriate deep sutures; cyanoacrylate glue
may then provide the superficial skin closure. Wounds
that can be closed with a single-layer skin closure may be
closed with cyanoacrylate alone. After adequate wound
approximation, the cyanoacrylate adhesive is painted
directly on the line of closure. Complete polymerization
will usually occur in 30 seconds. Two additional layers are
then applied in separate stages. Once it is completely
sealed, the cyanoacrylate serves as a watertight bandage
with no further dressing required. The dried adhesive
will detach from the epithelium in 5 to 10 days. Antimi­
crobial ointments should be avoided as they may cause
premature polymer breakdown.
CONCLUSION
Successful execution of wound closure in local flap pro­
cedures requires a complete understanding of wound
physiology. Proper surgical technique can improve
healing, leading to improved aesthetic outcomes. Multi­
ple choices are available for suture materials, and a famil­
iarity with the various alternatives allows the surgeon to
choose the right material for each individual case. New
advances in tissue sealants and glues increase the sur­
geon’s options for wound repair.
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Wound Repair Regen 2004;12:134.
FIGURE 4-19  ■  Application of fibrin glue by an aerosol delivery
system.

64
SECTION I  FUNDAMENTALS
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keloids. Facial Plast Surg 2001;17:263.
11. Topaz M, Carmel NN, Silberman A, et al. The TopClosure 3S
System, for skin stretching and a secure wound closure. Eur J Plast
Surg 2012;35:533–43.
12. Edlich RF, Becker DG, Thacker JG. Scientific basis for selecting
staple and tape skin closures. Clin Plast Surg 1990;17:571.
13. Svensjo T, Pomahac B, Yao F, et al. Accelerated healing of full-
thickness skin wounds in a wet environment. Plast Reconstr Surg
2000;106:602.
14. Swanson NA, Tromovitch TA. Suture materials, 1980s: properties,
uses and abuses. Int J Dermatol 1982;21:373.
15. Reece TB, Maxey TS, Kron IL. A prospectus on tissue adhesives.
Am J Surg 2001;182(Suppl):40S.
16. Spotnitz WD. Commercial fibrin sealants in surgical care. Am J
Surg 2001;182(Suppl):8S.
17. Clark RA. Fibrin glue for wound repair: facts and fancy. Thromb
Haemost 2003;90:1003.
18. Currie LJ, Sharpe JR, Martin R. The use of fibrin glue in skin grafts
and tissue-engineered skin replacements: a review. Plast Reconstr
Surg 2001;108:1713.
19. Greiling D, Clark RA. Fibronectin provides a conduit for fibroblast
transmigration from collagenous stroma into fibrin clot provisional
matrix. J Cell Sci 1997;110:861.
20. Oliver DW, Hamilton S, Figle AA, et al. A prospective, random­
ized, double-blind trial of the use of fibrin sealant for face lifts. Plast
Reconstr Surg 2001;108:2101, discussion 2106.
21. Sindwani R. Use of novel hemostatic powder MPH for endoscopic
sinus surgery: initial impressions. Otolaryngol Head Neck Surg
2009;140:614.
22. Mobley SR, Hilinski J, Toriumi DM. Surgical tissue adhesives.
Facial Plast Surg Clin North Am 2002;10:147.
23. Toriumi DM, O’Grady K, Desai D, et al. Use of octyl-2-cyanoac­
rylate for skin closure in facial plastic surgery. Plast Reconstr Surg
1998;102:2209.
24. Edmonson MB. Foreign body reactions to dermabond. Am J
Emerg Med 2001;19:240.

65
C H A P T E R 5 
PREPARATION OF THE PATIENT
Sam Naficy  •  Shan R. Baker
PREPARATION OF THE PATIENT
Surgical restoration of the face may require a multistage
procedure with a potentially protracted healing period
before the final aesthetic outcome is evident. The initial
reconstructive procedure is usually the most influential
in predicting the aesthetic and functional result. Mucosa,
cartilage, and facial skin are limited commodities. If the
initial reconstructive effort squanders these resources
through poor planning or surgical execution, subsequent
options for surgical restoration are more limited. The
surgeon must carefully analyze the facial defect and
develop a cohesive surgical plan.
For many patients, the diagnosis of facial skin cancer
and the perceived potential for unsightly scarring and
distortion of facial features are traumatizing and create a
great deal of anxiety. The patient must be prepared, emo­
tionally and medically, through detailed explanation of
the surgical plan. A thorough discussion of the required
reconstructive procedure is helpful in creating a trusting
relationship between patient and surgeon.
PREOPERATIVE CONSULTATION
Most of our patients undergo micrographic (Mohs)
surgery for a cutaneous malignant neoplasm. We work
with the referring dermatologic surgeon to provide an
efficient and convenient coordination of care. Every
attempt is made to schedule reconstruction on the day
after micrographic surgery. To enable a smooth transition
between the two procedures, all patients are seen preop­
eratively by the dermatologic surgeon and the facial
plastic surgeon. The consultation provides the opportu­
nity to anticipate the extent of the defect to be repaired,
to assess the aesthetic demands of the patient, and to
discuss the reconstructive options. Depending on the
location and anticipated size of the defect, patients may
be provided with several reconstructive options.
Consideration is given to the patient’s age, occupation,
and aesthetic demands. As a general rule, younger patients
have the highest aesthetic concerns and are more willing
to tolerate a complex, multistage operation to obtain an
optimal aesthetic result. Many older patients also have
high aesthetic standards, but some are willing to compro­
mise the outcome in return for a single-stage operation
with a more rapid recovery. The occupation of the patient
may influence the choice of reconstructive procedures.
For example, patients having occupations that require
considerable public interaction are unable to perform
their duties during the initial stage of reconstruction in
which an interpolated forehead flap is used. The interpo­
lated cheek flap, however, may be covered with a surgical
bandage and allow the patient an earlier return to his or
her occupation. Occupational use of corrective or protec­
tive eyewear or protective headwear should be considered
when an interpolated paramedian forehead flap is required
because the patient may not be able to use these items
during the interval between flap transfer and pedicle
detachment.
Factors are considered that may influence the extent
of the facial defect. These include tumor size and depth,
histologic features, and whether the tumor represents a
recurrence. Recurrent tumors or those with aggressive
histologic features often require significantly larger exci­
sions of tissue than may be anticipated.
Most patients have a difficult time visualizing flaps
used in facial reconstruction. This is especially true in the
case of interpolated cheek and paramedian forehead flaps.
To prepare patients, they are shown a photograph album
displaying representative preoperative and postoperative
photographs of their anticipated operation. For staged
repairs, such as with interpolated flaps, photographs are
shown that display an individual at each stage of the
reconstruction. We have found this to be especially useful
for younger patients, for whom the shock of the initial
deformity caused by an interpolated flap, without prior
visual preparation, can be devastating and may create in
the patient a feeling of hostility or resentment toward the
surgeon. Photographs also allow patients to view the
outcome of representative examples of different recon­
structive techniques. The scar and differences in skin
color and texture in the area of reconstruction are pointed
out, particularly to those patients with the greatest aes­
thetic concerns. For realistic expectations to be devel­
oped of the outcome, patients with fair to average surgical
results are included in the photograph album. A realistic
estimate of when the patient may return to work and
social activities is discussed, aided by photographs of rep­
resentative reconstructive sequences.
The average number of surgical procedures and length
of time required to complete all stages of the reconstruc­
tion are discussed with the patient (Table 5-1). In cases
of repair of the nose, when an interpolated covering flap
is planned, the reconstructive sequence includes initial
flap transfer, pedicle division 3 weeks later, a contouring
procedure 2 or 3 months after pedicle division, and
possibly dermabrasion in the office 2 months after

66
SECTION I  FUNDAMENTALS
to the standard medications, those patients requiring a
forehead flap are prescribed a 2-day supply of antiemetic
suppositories.
Patients are encouraged to visit the office on the day
of their micrographic surgery after completion of tumor
resection. This visit enables the surgeon to examine and
photograph the defect and to confirm or modify the sur­
gical plan. This visit is often reassuring to the patient and
allows the surgeon sufficient time to make adjustments
and alterations of the surgical plan and the operative
schedule.
PHOTOGRAPHY
The senior author’s technique for photography has been
consistent during the past 12 years. Most photographs in
the chapters he has authored in this book were obtained
by the following setup. For in-office photographs, the
system uses two Canon EOS Digital Rebel XT camera
bodies, each outfitted with Canon zoom 18-55mm
contouring of the flap. We therefore advise patients that
up to 6 months may be necessary for the restoration to
be completed.
Preoperative consultation with the patient is ideally
scheduled 4 to 6 weeks before surgery, allowing adequate
time for the patient to stop anticoagulant agents. Medica­
tions to be avoided beginning up to 3 weeks before
surgery include all nonsteroidal anti-inflammatory drugs
and vitamin E supplements (Table 5-2). Coumadin should
be discontinued 3 to 5 days before surgery. A number of
herbal supplements also possess anticoagulant properties
and should be avoided.
A medical history is obtained from the patient, and
a physical examination is performed as part of the con­
sultation. The general health of the patient is noted, with
special attention given to hypertension, symptomatic
coronary artery disease, and smoking history. Smokers
are strongly encouraged to quit and are instructed on the
higher risk of complications for users of tobacco products.
An electrocardiogram is obtained for all men older than
40 years and women older than 50 years. All patients older
than 60 years are tested for hematocrit and blood levels
of urea nitrogen, creatinine, and glucose (Table 5-3).
During the physical examination, note is made of prior
facial cutaneous surgery or ear surgery involving the
cartilage. The patient is examined for scars on the face
that may potentially influence the design of flaps. The
redundancy of the facial skin is assessed, particularly in
the area of the anticipated cutaneous defect. The position
of the anterior hairline is noted when a paramedian fore­
head flap for nasal reconstruction is anticipated. Patients
with low hairlines are informed about the possibility of
the flap’s extending to hair-bearing scalp and the need for
subsequent depilation procedures on the nose.
We provide patients with prescriptions for medica­
tions at the time of preoperative consultation (Table 5-4).
Oral diazepam (5 to 10 mg) is prescribed for patients
younger than 70 years with instructions to take it the
evening before and 1 hour before the operation. Benzo­
diazepines help reduce preoperative anxiety and counter­
act the toxic effects of local anesthetics used during the
procedure. In instances in which skin or composite graft­
ing is planned or cartilage and bone grafting is antici­
pated, patients are given a postoperative course of an
oral antistaphylococcal antibiotic for 5 to 7 days. A taper­
ing dose pack of prednisone is prescribed for those
patients undergoing composite grafting. An analgesic of
choice is prescribed in appropriate quantity. In addition
TABLE 5-1  Estimated Number of Surgical
Procedures and Recovery Periods
Type of Procedure
Number of
Procedures
Initial Recovery
Local flap
1-2
1-2 weeks
Skin graft
2
1-2 weeks
Interpolated flap
2-4
4 weeks
From Naficy S: Preparation of the patient. In Baker SR, editor:
Principles of nasal reconstruction, 2nd ed, New York, Springer,
2011.
TABLE 5-2  List of Medications to Avoid
Before Surgery
Nonsteroidal Anti-Inflammatory Drugs (Stop 2-3 Weeks
before Surgery)
Aspirin
Celecoxib
Diclofenac
Diflunisal
Etodolac
Fenoprofen
Flurbiprofen
Ibuprofen
Indomethacin
Ketoprofen
Naproxen
Ketorolac
Rofecoxib
Sulindac
Tolmetin
Coumadin (Stop 3-5 Days before Surgery)
Natural Supplements (Stop 2-3 Weeks before Surgery)
Asian ginseng
Bromelain
Cayenne fruit
Chinese skullcap root
Dan Shen root
Feverfew
Garlic
Ginger rhizome
Ginkgo biloba
Horse chestnut bark
Papain
Sweet clover plant
Sweet-scented bedstraw plant
Sweet vernal grass
Tonka bean seeds
Vanilla leaf leaves
Woodruff plant
Vitamin E (Stop 3 Weeks before Surgery)
From Naficy S: Preparation of the patient. In Baker SR, editor:
Principles of nasal reconstruction, 2nd ed, New York, Springer,
2011.

5  PREPARATION OF THE PATIENT
67
are obtained in the office photography suite if the patient
is seen on the day before repair. Otherwise, photographs
are obtained in the holding area or operating suite with
proper regard for light and background.
ANESTHESIA
Monitored anesthesia care is appropriate for the majority
of facial reconstructive procedures, including all skin
grafts, local or regional flaps, and cartilage grafts. The
patient is placed on a head/neck surgery stretcher with
the head of the stretcher turned 90° to 120° from the
anesthetist but near enough to the anesthetist to allow
manipulation of the airway if necessary (Fig. 5-1). The
patient is positioned supine without a special headrest. A
doughnut-shaped foam pillow is placed under the patient’s
head, and a towel roll supports the shoulders. A standard-
sized pillow is placed under the knees to provide flexion
and to reduce back strain. The stretcher is placed in an
appropriate degree of reverse Trendelenburg’s position to
reduce venous pooling in the face. Oxygen is adminis­
tered at the rate of 2 to 4 L/min by nasal cannula tubing
either nasally or orally. Preoxygenation reduces the toxic
effects of local anesthetics and accommodates brief
periods of apnea caused by intravenous sedation. To
prevent the risk of fire, it is important to reduce or to
stop the flow of oxygen when cautery is performed in the
area of the nasal cannula openings.
f/3.5-5.6 lenses. Two ceiling-mounted strobe flashes are
aimed at an angle of 25° to 30°, 6 feet from the subject.
The strobe flashes are hard-wired to the camera bodies
for synchronization. A backlight illuminates a blue back­
ground to eliminate shadow. Blue is chosen as the back­
ground color as it provides an excellent contrast to the
color of flesh and hair.
Photography in the operating room is accomplished
with a Nikon D90 12.3-megapixel digital camera body
attached to a Nikkor AF-S Micro 60mm f/2.8G ED lens.
The camera is equipped with a built-in flash for close-up
photography. The operating room lights are turned away
from the subject because they give an undesirable yellow
color to the photograph. In the operating room, a blue
or green surgical towel often serves as an adequate sub­
stitute for the photographic background.
Photographic documentation includes those views
that illustrate the facial defect. These typically consist of
a full-face frontal view, with oblique and lateral views on
the side of the defect. If the defect involves the nose, a
base view is also obtained. Close-up views of the defect
may be obtained when it is appropriate. For nasal cutane­
ous malignant neoplasms, we have found it helpful to
obtain photographs of the lesion at the time of initial
consultation, before surgery. Photographs of the defect
TABLE 5-3  Preoperative Requirements
Age
Men
Women
<40 years
None
None
>40 years
ECG
None
>50 years
ECG
ECG and HCT
>60 years
ECG, HCT, BUN/
Cr, Glu
ECG, HCT, BUN/
Cr, Glu
Special Circumstances
1. Childbearing potential—puberty through menopause
(1 year without a period). Obtain a pregnancy test if
the patient
a. has missed or has late period or irregular periods.
b. is having unprotected intercourse.
c. has any of the symptoms of pregnancy—breast
tenderness, nausea, bloating, etc.
d. believes there is a chance she might be pregnant.
2. Diabetics—fasting glucose on day of surgery.
3. Patients on digitalis (Lanoxin) or diuretics—potassium
level is required.
4. Bleeding problems
a. Patient is on anticoagulants—obtain PT.
b. Patient complains of bleeding disorder—obtain PT/
PTT, complete blood cell with platelet count, and a
bleeding time.
5. Kidney disease—for patients with known renal
insufficiency or on dialysis, obtain electrolytes, BUN,
creatinine, and HCT.
6. Chest radiograph or radiograph report—required if the
patient has been hospitalized for treatment of CHF,
pneumonia, or other lung disease (chronic obstructive
pulmonary disease, asthma) within the last 6 months.
From Naficy S: Preparation of the patient. In Baker SR, editor:
Principles of nasal reconstruction, 2nd ed, New York, Springer,
2011.
BUN, blood urea nitrogen, CHF, congestive heart failure;
Cr, creatinine, ECG, electrocardiogram; Glu, glucose;
HCT, hematocrit; PT, prothrombin time; PTT, partial
thromboplastin time.
TABLE 5-4  Recommended Medications
Local Flap
Diazepam (preoperative)
Narcotic analgesic with acetaminophen
Local Flap and Cartilage Graft
Diazepam (preoperative)
Cephalexin (5-7 days)
Narcotic analgesic with acetaminophen
Skin Graft
Diazepam (preoperative)
Cephalexin (5-7 days)
Narcotic analgesic with acetaminophen
Composite Graft
Diazepam (preoperative)
Cephalexin (5-7 days)
Prednisone dose pack
Narcotic analgesic with acetaminophen
Interpolated Forehead Flap
Diazepam (preoperative)
Phenergan suppositories (postoperative)
Narcotic analgesic with acetaminophen
Interpolated Forehead Flap and Cartilage or Bone Grafts
Diazepam (preoperative)
Cephalexin (5-7 days)
Phenergan suppositories (postoperative)
Narcotic analgesic with acetaminophen
From Naficy S: Preparation of the patient. In Baker SR, editor:
Principles of nasal reconstruction, 2nd ed, New York, Springer,
2011.

68
SECTION I  FUNDAMENTALS
LOCAL ANESTHESIA
The four methods of local anesthesia applicable to local
flap surgery are topical, local infiltration, field block (ring
block), and peripheral nerve block. Topical anesthesia
and vasoconstriction of nasal mucosa are performed for
all procedures in which the inside of the nose is manipu­
lated. In such instances, 12 × 3-inch surgical cottonoids
moistened with an equal mixture of topical lidocaine 4%
and oxymetazoline hydrochloride are used to apply the
mixture to nasal mucosa. The topical medicine is left in
contact with the nasal mucosa for a few minutes before
injection of the mucosa with local anesthetic. The septum
is injected in the subperichondrial plane with a 27-gauge
needle and a 3-mL syringe for adequate hydraulic force.
It may be useful to perform nerve blocks before local
infiltration of the face (Fig. 5-2). An anesthetic block of
the midface can be obtained by infiltrating the infraor­
bital (V2) nerve as it exits the maxilla. The nerve exits the
infraorbital foramen 1 cm below the level of the inferior
orbital rim, vertically aligned with the pupil. The nerve
is blocked by injecting 1 mL of lidocaine (1% with
1 : 100,000 concentration of epinephrine) just above the
After adequate oxygenation, the patient is given a
bolus of intravenous sedatives and narcotics, achieving an
adequate depth of anesthesia to enable the surgeon to
infiltrate the local anesthetic. It is not uncommon for the
patient to require a chin thrust at this point to prevent
transient apnea. After infiltration of the local anesthetic,
the patient is maintained at an appropriate level of intra­
venous sedation for the duration of the procedure.
General anesthesia is used when cranial bone grafting
is performed or when large septal mucoperichondrial
flaps are required to repair full-thickness nasal defects.
An oral RAE tube taped in the midline to only the lower
lip and chin offers the least amount of obstruction and
distortion of the surgical field. An alternative is the use
of laryngeal mask ventilation. The nose and face are
painted with iodine, and a surgical drape is wrapped
around the head in a turban fashion, exposing the entire
face and donor sites if applicable. The eyelids are taped
closed, and moistened eye pads are placed over the eyes
to protect them from the intense overhead light and
accidental injury. A preoperative intravenous dose of an
antistaphylococcal antibiotic is administered when graft­
ing is performed.
FIGURE 5-1  ■  Operating room setup for facial reconstruction using monitored anesthesia care. (From Naficy S: Preparation of the patient.
In Baker SR, editor: Principles of nasal reconstruction, 2nd ed, New York, Springer, 2011.)
Surgeon
5
4
2
1
3
Assistant
Scrub tech/RN
Anesthesiologist
Anesthesia machine

5  PREPARATION OF THE PATIENT
69
may be obtained by use of lidocaine (2% with 1 : 100,000
concentration of epinephrine). One of our preferred
local anesthetic formulations prepared just before injec­
tion is an equal (1 : 1) mixture of lidocaine (1% with
1 : 100,000 concentration of epinephrine) and bupiva­
caine (0.25% to 0.5% without epinephrine). The lido­
caine provides immediate anesthesia and vasoconstriction,
whereas the longer acting bupivacaine provides an addi­
tional 3 to 6 hours of anesthesia. The lidocaine compen­
sates for the longer onset of action of bupivacaine. The
diluted epinephrine in the mixture is just as effective for
hemostasis because there is no additional vasoconstrictive
benefit with concentrations of epinephrine greater than
1 : 200,000.
POSTOPERATIVE CARE
Written postoperative instructions that cover general
wound care (Table 5-5) are provided. Patients are pro­
vided with an adequate supply of cotton-tipped applica­
tors, hydrogen peroxide, and antibiotic ointment. Patients
periosteum around the site of exit of the nerve from the
foramen. The injection may be performed percutane­
ously with a 30-gauge needle or through the gingivobuc­
cal sulcus with a 27-gauge needle. The external nasal
branch of the anterior ethmoidal nerve supplies the skin
of the caudal half of the nasal dorsum and most of the
tip. This nerve is blocked by injection of anesthetic in the
subfascial plane of the nasal sidewall at the junction of
nasal bone and upper lateral cartilage approximately 1 cm
lateral to the midline. The infratrochlear nerve supplies
the skin of the upper nasal vault. This nerve is blocked
by infiltration of anesthetic under the thin skin of the
lateral bony nasal sidewall, medial to the medial canthus.
Bilateral blocks of all of the nerves discussed will result
in anesthesia of the majority of the skin and soft tissue of
the nose, medial cheek, and upper lip. The forehead can
be anesthetized by a nerve block of the supraorbital and
supratrochlear nerves. The supraorbital nerve exits its
foramen and extends superiorly toward the scalp in a line
that is directly vertical to the pupil. The supratrochlear
nerve ascends toward the scalp in a line that is a vertical
tangent to the medial limits of the eyebrow. This line is
1.5 cm lateral to the midline. The skin of the lower lip
and chin can be anesthetized by blocking the mental
nerve. This nerve exits the mental foramen, which is
located at the midpupillary line.
In addition to any specific nerve block, local anesthetic
solution is injected in the planned plane of dissection and
more superficially to the level of the subdermis by mul­
tiple punctures with a 30-gauge needle. A longer,
27-gauge needle is used for injection of the septum and
turbinates and for infraorbital nerve blocks.
Choice of local anesthetic depends on the length of
the procedure and the desired amount of postoperative
analgesia. Procedures lasting less than 1.5 hours are per­
formed with lidocaine (1% with 1 : 100,000 concentration
of epinephrine). Longer anesthesia of up to 2.5 hours
FIGURE 5-2  ■  Nerve blocks for nasal surgery.
(From Naficy S: Preparation of the patient. In
Baker SR, editor: Principles of nasal reconstruc­
tion, 2nd ed, New York, Springer, 2011.)
Supraorbital nerve
Supratrochlear nerve
Infratrochlear nerve
External nasal branch of
anterior ethmoidal nerve
Infraorbital nerve
TABLE 5-5  General Wound Care Instructions
• Remove compression dressing the day following the
procedure.
• Clean sutures with cotton-tip applicators and hydrogen
peroxide or soap and water 3 times a day.
• Apply bacitracin ointment 3 times a day for 3 days.
• Patient may shower the day following the operation
using lukewarm water on the face and avoiding a direct
forceful spray to the operative site. Patient should apply
ointment to the sutures after showering.
From Naficy S: Preparation of the patient. In Baker SR, editor:
Principles of nasal reconstruction, 2nd ed, New York, Springer,
2011.

70
SECTION I  FUNDAMENTALS
procedure. Patients requiring hinged septal mucoperi­
chondrial flaps are often admitted for observation and to
decrease risk of early postoperative bleeding. Patients
requiring cranial bone or rib grafting are admitted for
pain control and because of the prolonged duration of
such operations. Patients requiring interpolated para­
median forehead flaps are occasionally admitted for
control of pain and nausea. Nausea and vomiting are not
uncommon after use of wide (3 cm or greater) forehead
flaps and are presumably due to tension on the galea
aponeurotica.
are instructed to avoid heavy lifting, bending, straining,
and nose blowing if nasal reconstruction has been
performed. There are other postoperative instructions
specific to each procedure.
HOSPITALIZATION
The majority of cases of facial reconstruction are
performed on an outpatient basis. There are two catego­
ries of patients who are admitted overnight after the

71
C H A P T E R 6 
FLAP CLASSIFICATION AND DESIGN
Shan R. Baker
INTRODUCTION
The author defines a local cutaneous flap as an area of skin
and subcutaneous tissue with a direct vascular supply that
is transferred from its in situ position to a site located
immediately adjacent to or near the flap. This is in contrast
to a graft, which is tissue that is moved from one site to
another and without a direct vascular supply immediately
re-established. Optimal wound repair requires an under­
standing of the physiology and biomechanics of cutaneous
flaps. These topics are discussed in detail in other chapters
of this book, but key concepts are reviewed here. The
purpose of this chapter is to introduce the terminology
used in this textbook and to provide a classification of local
cutaneous flaps. A discussion of flap design and the author’s
preferred flap for a given location is also included.
TERMINOLOGY
The primary defect is the wound to be closed by a local
cutaneous flap. In this book, the majority of wounds
shown have resulted from employing the micrographic
(Mohs) surgical techniques to remove skin cancer. A
secondary defect is the wound created when a skin flap is
transferred to repair the primary defect (Fig. 6-1). The
transfer of every cutaneous flap from its in situ position
results in a secondary defect. The challenge of recon­
structive surgery is to design a flap that places the second­
ary defect in the most advantageous location. This usually
translates into harvesting of the flap from areas of the face
and neck that have greater skin laxity.
When a skin flap is transferred to a defect, the motion
of the flap is considered the primary tissue movement of
the repair. This usually occurs by sliding or pivoting
of tissue. Secondary tissue movement is the displacement of
skin surrounding the defect toward the center of the
primary defect. The vector of movement is typically in
the opposite direction of the vector of movement of the
flap. By necessity, there is also skin movement toward the
donor site of the flap to close the secondary defect.
Therefore, a combination of primary and secondary
tissue movement occurs when a wound is repaired with
a skin flap (Fig. 6-2). In a region where a primary defect
is adjacent to a mobile facial structure, secondary tissue
movement may result in distortion of these structures.
Facial structures that have visible margins, such as the
eyelids, lips, and nostrils, are particularly susceptible to
distortion by secondary tissue movement. The stronger
the attachments of facial structures to the underlying
bone, the less propensity for distortion. For example, the
earlobe is more likely to be deformed by secondary tissue
movement than the tragus is.
Wound closure tension is the amount of stress (per unit
area) along the suture line of a repaired wound. This
tension is dependent on the vector forces of the tissue
involved with primary and secondary movement. The
greater the wound closure tension, the more likely it is
that there will be distortion of facial features resulting
from secondary tissue movement. It is therefore impor­
tant to understand primary and secondary tissue move­
ment in designing cutaneous flaps.
In part, the degree of wound closure tension is related
to skin extensibility. Skin extensibility is the lengthening
of skin under tension due to stretching of elastic fibers.
There are directional variations in skin extensibility.1
That is, skin is more extensible when the vector of strain
is in a certain direction. For this reason, it is advantageous
to recruit skin for repair of a wound in areas of maximum
skin extensibility. These areas are identified by the lines of
maximum extensibility (LME).
Relaxed skin tension lines (RSTLs) are intrinsic to facial
skin. RSTLs result from orientation of collagen fibers of
the skin and are manifested in the aging face as skin
creases and wrinkles (Fig. 6-3). RSTLs are perpendicular
to LME. The orientation of skin excisions and repair of
wounds are usually made parallel to RSTLs when possible
(Fig. 6-4). Orienting them this way places the maximum
wound closure tension parallel to LME and perpendicular
to RSTLs. This orientation results in wound repair that
is performed with the least amount of wound closure
tension. Minimal wound closure tension is extremely ben­
eficial in minimizing the appearance of facial scars. A
converse of this is that incisions made at right angles to
RSTLs usually heal with wider and more visible scars.
Skin extensibility is sometimes referred to as mechani­
cal creep. Mechanical tissue creep results in reduction of
wound closure tension over time because tension is
reduced when skin is held under a constant strain.
Mechanical creep is different from the ability of skin to
expand, which is known as biologic creep. Skin expansion
is a secondary phenomenon in which there is augmenta­
tion of skin surface area as a result of applying constant
tension to the skin for a prolonged time. Biologic creep
occurs in the abdomen skin during pregnancy and over
tissue expanders placed beneath the skin.
  Videos available online

72
SECTION I  FUNDAMENTALS
The pedicle of a flap is that portion, together with
adjacent tissue, responsible for providing vascularity to
the flap. The pedicle may consist of skin and subcutane­
ous fat, muscle, or a combination of all three. A pedicle
may also consist only of subcutaneous tissue or, on occa­
sion, an individual artery and vein unencumbered by sur­
rounding tissue. When a local flap has no cutaneous
connections with surrounding skin and is supplied by
only subcutaneous tissue or an individual artery and vein,
the flap is referred to as an island flap. Nearly all island
local flaps in the face are based on a subcutaneous tissue
pedicle. Local skin flaps should be designed with a pedicle
that will provide ample vascularity.
Flap delay is a means of increasing the blood flow to a
flap. Delay is accomplished by incising all or a portion of
the flap and elevating all or a portion before returning
An important factor that may limit skin expansion is
the attachments of the skin to underlying structures, such
as fascial or aponeurotic connections to the skin. Skin
expansion is resisted by structures that anchor the skin
by aponeurotic or tendinous insertions in bone. Examples
of these include medial and lateral canthus, bony orbital
rim, zygomatic arch, and malar eminence. Undermining
of the skin reduces wound closure tension and more
widely distributes skin deformation. Undermining
releases the attachments of the skin to the underlying
fascia, allowing the skin to become more expansible.
Moderate skin undermining is beneficial in reducing
wound closure tension. However, extensive skin under­
mining is not usually helpful in further reducing the
wound tension, although it may assist with tissue draping
and reduction in secondary tissue movement.
FIGURE 6-1  ■  Movement of cutaneous flap used to repair primary defect creates secondary defect. (From Swanson NA: Classification,
definitions, and concepts in flap surgery. In Baker SR, Swanson NA, editors: Local flaps in facial reconstruction, St. Louis, Mosby, 1995.)
Primary defect Secondary defect
Maximum
wound closure
tension
FIGURE 6-2  ■  Combination of primary and secondary tissue movement occurs when a wound is repaired with a skin flap.
SECONDARY
MOVEMENT
PRIMARY
MOVEMENT

6  FLAP CLASSIFICATION AND DESIGN
73
number of components known as aesthetic units, which are
separated by borders somewhat less discrete than those
that delineate aesthetic regions. The forehead may be
divided into central and temporal units. The cheek is
divided into infraorbital, zygomatic, buccal, and parotid
masseteric units. The upper lip is divided into philtrum
and paired lateral units. The lower third of the face is
divided into labial and mental units. The nose is particu­
larly suited for division into aesthetic units because of its
complex topography. It may be divided into nine aes­
thetic units that include dorsum, paired sidewalls, tip
lobule, paired nasal facets, paired alae, and columella.
These units are highlighted when incident light is cast on
the nasal surface, creating shadows along the borders of
each unit and topographic landmarks.2 As with facial aes­
thetic units, the framework of the nose supporting the
overlying skin is primarily responsible for variations in
light reflections and gives rise to the aesthetic border
between the nasal units.
The concept of facial aesthetic regions, and the borders
that separate them, is important in designing local flaps
for facial reconstruction. The preferred flap for recon­
struction is frequently one that can be designed within
the same aesthetic region as that containing the primary
defect. Scars are best camouflaged by placing incisions
along aesthetic borders. When a defect involves two or
more aesthetic regions, it is usually best to compartmen­
talize the repair. Individual skin flaps are designed to
construct the separate components of the defect that are
located within separate aesthetic regions. This may
ensure likeness of skin quality but, more important,
places scars in the aesthetic borders. It is often a benefit
to enlarge the primary defect by extending the defect to
an aesthetic border or even to enlarge the defect to
occupy an entire aesthetic unit. Repair of the defect with
a local flap will then position a border of the flap in an
aesthetic border for improved scar camouflage.
LOCAL FLAP CLASSIFICATION
Cutaneous flaps may be classified by the nature of their
blood supply (random vs. arterial), by configuration
(rhomboid, bilobe), by location (forehead, cheek, lip),
and by the method of transferring the flap. Flaps classi­
fied by location are identified by the region of the body
from which they are harvested. This location may be near
or considerably removed from the primary defect. When
they are removed from the defect, such flaps are trans­
ferred either by microvascular surgery or by staged
movement of the flap toward the recipient site. On the
basis of location, flaps are classified as local, regional, or
distant. A local flap is one in which tissue immediately
adjacent to or near the primary defect is used to cover
the defect. The majority of skin flaps discussed in this
textbook are local flaps. In regard to facial reconstruction,
a regional flap is one in which tissue is harvested from a
site not located on the face, scalp, or neck. However, the
pedicle is sufficiently long to enable the flap to reach the
primary defect. An example of a regional flap for facial
repair is a deltopectoral flap transferred from the anterior
chest wall to repair a defect of the lip or cheek. A distant
the flap to its in situ position. The incisions are sutured,
and the flap is left in place usually for 10 to 14 days before
the flap is transferred to a recipient site. Delay results in
an enhanced circulation to the flap, probably by the
closing of arteriovenous shunts and the realignment of
the vasculature in the subdermal plexus. Delay is rarely
used with local flaps of the face because of the overall rich
blood supply to facial skin. Delay is reserved for particu­
larly large flaps used to repair major facial defects in situ­
ations in which skin vascularity has been compromised
by irradiation or previous surgery and, on occasion, in
patients using tobacco.
The face can be divided into specific areas or aesthetic
regions, which are covered by skin that has common char­
acteristics. These skin characteristics include thickness,
quantity of subcutaneous fat, degree of adherence to
underlying fascia, color, texture, and hair growth. Coin­
cidentally, these facial areas are separated from each other
by ridges or valleys in the skin created by the facial skel­
eton or musculature. These ridges and valleys are known
as aesthetic borders and are identified by facial landmarks
including eyebrows, melolabial creases, mental crease,
philtral crests, vermilion borders, and anterior hairline.
Aesthetic regions and their accompanying borders
provide form, character, and individual uniqueness to the
face. The principal aesthetic regions of the face are fore­
head, eyelids, cheeks, nose, lips, mentum, and auricles
(Fig. 6-5). Some aesthetic regions may be divided into a
FIGURE 6-3  ■  Relaxed skin tension lines (RSTLs) of face. Lines of
maximal extensibility (LME) are perpendicular to RSTLs.
R
S
T
L
LME

74
SECTION I  FUNDAMENTALS
FIGURE 6-4  ■  A, B, Orientation of skin excisions and repair of wounds are made parallel to RSTLs when possible.
GRE
ATES
T
EXTE
NS
IBI
LIT
Y
LME
RSTL
A
LME
RSTL
B

6  FLAP CLASSIFICATION AND DESIGN
75
Forehead
Brow
Periorbital
Temple
Zygomatic
Nasal
Mandibular
Chin
Upper lip
Lower lip
Infraorbital
Ear
A
FIGURE 6-5  ■  A-C, Facial aesthetic regions and aesthetic units of nose and upper lip.
flap is one that is harvested from sites so removed from
the face that the pedicle is not sufficiently long to enable
the flap to reach the face. Distant flaps are usually trans­
ferred to the face as free flaps, sometime referred to as
microsurgical flaps. The blood vessels of their pedicle are
connected to vessels in the head or neck by microvascular
surgical techniques. Another way of transferring distant
flaps to the face is by staging tubed flaps, in which the
pedicle is “walked” toward the recipient site. This method
has been abandoned since the development of micro­
surgical techniques.
The most common way to classify flaps on the basis
of blood supply is to categorize them as random or axial
pattern flaps. This is discussed in detail in Chapter 2.
Random pattern flaps are based on the rich perforating
vascular plexus of the skin (Fig. 6-6). They do not have
a named blood vessel providing vascularity to the flap. In
contrast, axial pattern flaps depend on a named artery for
the majority of their blood supply (Fig. 6-7). These
vessels parallel the linear axis of the flap and are usually
located in the subcutaneous fat directly beneath the skin
of the flap. Most axial pattern flaps have a degree of
random pattern vascularity to their distal portion. The
majority of cutaneous flaps of the face are random pattern.
The most common axial pattern flap harvested from the
face is the paramedian forehead flap based on the supra­
trochlear artery and vein.
Classifying flaps by method of transfer, which is to say
method of tissue movement, is usually the most conve­
nient way of discussing flaps relative to their use in repair
Continued

76
SECTION I  FUNDAMENTALS
Alar lobule
Soft tissue
facet
Columella
Tip
Lateral wall
Dorsum
B
60% 40%
C
FIGURE 6-5, cont’d

6  FLAP CLASSIFICATION AND DESIGN
77
tension greater than the natural tension of the remaining
facial skin, although the repair of the donor site of the
flap is subjected to increased skin tension. However, in
most circumstances in which pivotal flaps are used, tissue
movement is achieved through a combination of pivoting
and advancement. That is, movement of most pivotal
flaps is aided by stretching (advancement) of the flap
skin. Surgeons often speak of combined mechanisms of
tissue movement, such as “advancement rotation flap.”
For clarity, the major mechanism of tissue movement
should dictate the term given to describe a particular flap,
unless both mechanisms are of approximately equal
importance.
PIVOTAL FLAPS
There are four types of pivotal flaps: rotation, transposition,
interpolated, and island. All pivotal flaps are moved toward
the defect by pivoting the flap around a fixed point at the
of facial cutaneous defects (Table 6-1).3-5 This classifica­
tion divides local flaps into pivotal, advancement, and
hinge. Advancement in the majority of situations depends
on stretching the flap skin in the direction of flap move­
ment. Such flaps are subjected to an increase in wound
closure tension. In contrast, pivotal flaps rotate about a
point at their base and in their purest form are not
stretched. Thus they are not subjected to wound closure
FIGURE 6-6  ■  Random pattern flaps based on subcutaneous and intradermal vascular plexuses that supply blood to skin. (From
Swanson NA: Classification, definitions, and concepts in flap surgery. In Baker SR, Swanson NA, editors: Local flaps in facial reconstruction,
St. Louis, Mosby, 1995.)
Subcutaneous fat
Deep cutaneous
fascia
Fascia of muscle
Muscle
Dermal plexus
Subdermal plexus
Perforating
subcutaneous artery
Perforating
muscular artery
Segmental artery
FIGURE 6-7  ■  Axial pattern flaps based on
named artery for blood supply. Most axial
pattern flaps have a degree of random
pattern to the distal portion. (From Swanson
NA: Classification, definitions, and concepts in
flap surgery. In Baker SR, Swanson NA, editors:
Local flaps in facial reconstruction, St. Louis,
Mosby, 1995.)
Direct cutaneous artery
Paired venae comitantes
TABLE 6-1  Classification of Local Cutaneous
Flaps by Method of Transfer
Pivotal
Rotation
Transposition
Interpolated
Island
Advancement
Unipedicle
Bipedicle
V-Y and Y-V
Island
Hinge

78
SECTION I  FUNDAMENTALS
Rotation Flaps
Rotation flaps are pivotal flaps with a curvilinear configu­
ration. They are designed immediately adjacent to the
defect and are best used to close triangular defects. In
such instances, the triangle-shaped defect is covered by a
portion of the standing cutaneous deformity, thus facili­
tating the pivotal movement of the flap (Fig. 6-9). This
flap usually makes use of some advancement, and when
it does, the vector of greatest wound closure tension is
along a line from the base of the flap to a distal point of
the curvilinear border. When no advancement is used in
movement of the flap, animal studies have shown the
greatest wound closure tension to be at the closure site
perpendicular to the periphery of the flap, not across the
long length of the flap.1 These studies have also demon­
strated minimal mechanical benefit at the defect site in
extending the arc of rotation flaps beyond 90° from the
axis of the primary defect. However, there may be benefit
in extending the incision to accommodate redraping of
skin. A back cut at the base of the flap shifts the position
base of the pedicle. Except for island flaps skeletonized
to the level of their nutrient vessels, the greater the pivot,
the shorter is the effective length of the flap (Fig. 6-8).
Pivoting a flap with a cutaneous pedicle 45° from its in
situ position reduces the effective length 5%. A 90° and
180° pivot reduces effective length by 15% and 40%,
respectively.6 The reduction in effective length must be
accounted for when pivotal flaps are designed so that
greater pivoting requires a longer design of the flap. As
the flap turns in an arc around its relatively fixed pivotal
point, redundant tissue, known as a standing cutaneous
deformity (dog ear), develops at the base. Similar to effec­
tive length, there is a positive correlation between the
degree of pivoting and the size of the standing cutaneous
deformity. The greater the pivot of the flap, the larger
the deformity that occurs. Thus, increasing the flap’s
pivot will change the flap’s shape, shorten the effective
length, increase wound closure tension, and deform the
flap’s base by development of a standing cutaneous defor­
mity. To limit these restricting factors, a flap’s arc of pivot
should not exceed 90° whenever possible.
FIGURE 6-8  ■  As transposition flap pivots, flap changes shape and shortens as standing cutaneous deformity increases. As flap pivots
about point A, effective length of flap decreases along circumference B rather than C. Approximate percentage of shortening as
related to degree of pivotal movement is in parentheses. (From Panje WR, Minor LB: Reconstruction of the scalp. In Baker SR, Swanson
NA, editors: Local flaps in facial reconstruction, St. Louis, Mosby, 1995.)
A
B
C
45° (5%)
90° (15%)
135° (25%)
180° (40%)

6  FLAP CLASSIFICATION AND DESIGN
79
Disadvantages of rotation flaps are relatively few. The
defect itself must be somewhat triangular or must be
modified by removal of normal tissue to create a triangular
defect. The configuration of the flap includes a right angle
at the distal tip, and the surgeon must take care in posi­
tioning the tip so that it is not subjected to excessive wound
closure tension and vascular compromise. The curvilinear
incision necessary to create the flap does not easily lie in
RSTLs (see Fig. 6-3). As with all pivotal flaps, rotation
flaps develop standing cutaneous deformities at their base
that may not be removed without compromising vascular­
ity. A second-stage revision in which the standing cutane­
ous deformity is removed may be necessary.
Transposition Flaps
In contrast to rotation flaps, which have a curvilinear
configuration, transposition flaps have a linear configura­
tion. Both are pivotal flaps moving about a pivotal point.
Both flaps develop standing cutaneous deformities at their
bases, and as a consequence, their effective length
decreases as they pivot. This reduction in effective length
must be considered in designing such flaps. Rotation
flaps must be designed in such a way that one border of
the flap is also a border of the defect for which it is
intended for repair. Like rotation flaps, transposition flaps
may be designed so that one border of the flap is also a
border of the defect (see Fig. 6-1); however, it may
also be designed with borders that are removed from
the defect (Fig. 6-10). In this circumstance, only the base
of the flap is contiguous with the defect. The area of
greatest wound closure tension is at the closure site of the
secondary defect adjacent to the base of the flap. Depend­
ing on whether the flap is stretched and the degree of
stretching, the greatest wound closure tension may be
along a vector from the pivotal point to the most periph­
eral border of the flap. The ability to construct a flap some
of the pivotal point and thus changes the wound closure
tension vector as well as the location of the standing
cutaneous deformity.
Inherent with rotation flaps is the unequal length of
the flap’s border compared with the length of the primary
and secondary defect. To equalize this discrepancy, it
may be necessary to excise an equalizing Burow triangle
at some point along the periphery of the curvilinear inci­
sion. Ideally, the triangle should have the same width as
the width of the primary defect. Excision of a Burow
triangle has the effect of equalizing the lengths of the two
sides of the incision. Another solution that may avoid the
need for an equalizing triangle is to change the move­
ment of the flap from one that is purely pivotal to one
that is both pivotal and advancement. Stretching the flap
in essence lengthens the peripheral border of the flap so
that it approaches the sum length of the primary and
secondary defect. As a general rule, in designing rotation
flaps on the face, the length of the incision should be four
times the width of the defect. With this 4 : 1 ratio, exci­
sion of a Burow triangle is usually not necessary. To
avoid a standing cutaneous deformity at the base of the
flap, the defect’s shape ideally should have a triangular
configuration with a height-to-width ratio of 2 : 1. In
addition, if the arc of the flap’s incision is to be a com­
pletely symmetric curve, the height of the triangular
defect should be 0.5 to 1 times the radius of the curve of
the flap.
There are several advantages of the rotation flap. The
flap has only two sides; thus it lends itself to placement
of one side in a border between aesthetic regions of the
face. The flap is broad based, and therefore its vascular­
ity tends to be reliable. There is great flexibility in the
design and positioning of the flap. When it is possible,
the flap should be designed so that it is inferiorly based,
which promotes lymphatic drainage and minimizes flap
edema.
FIGURE 6-9  ■  Rotation flaps are pivotal flaps with curvilinear configuration. They are designed immediately adjacent to defect and
are best used to repair triangular defects. Opposing arrows indicate greatest wound closure tension.

80
SECTION I  FUNDAMENTALS
FIGURE 6-10  ■  Transposition flaps are pivotal flaps with linear axes. The base of the flap is contiguous with the defect. Greatest
wound closure tension is at closure site of donor defect (opposing arrows).
A
SCD removed here
B
C
FIGURE 6-11  ■  A-E, Transposition flaps are common reconstructive options for small to medium-sized cutaneous cheek defects.
A, Lentigo maligna outlined by sutures. Transposition flap designed. B, Skin lesion excised, standing cutaneous deformity (SCD)
marked for excision at base of flap. C, Flap in place.

6  FLAP CLASSIFICATION AND DESIGN
81
D
E
D, E, At 1 year after surgery. No revision surgery performed.
FIGURE 6-11, cont’d  ■
distance from the defect with its axis independent from
the linear axis of the defect is one of the greatest advan­
tages of transposition flaps. This fact enables the surgeon
to recruit skin at variable distances from the defect, select­
ing donor sites with the greatest skin elasticity or redun­
dancy. In addition, the ability to select a variable site for
harvest of a flap may allow the selection of a donor site
that will provide the best possible scar camouflage or even
the ability to hide the scar in aesthetic boundaries.
Transposition is the most common method of trans­
ferring local flaps to skin defects of the head and neck. A
transposition flap is a reconstructive option for small to
medium-sized defects of almost any conceivable configu­
ration or location, thus making it the most useful of local
flaps in facial reconstruction (Fig. 6-11).
Two types of transposition flaps frequently used are
rhombic flaps and bilobe flaps. Rhombic flaps depend on
advancement for part of their tissue movement, but the
majority of movement is pivotal. A rhombus is an equi­
lateral parallelogram. A rhombus defect may be thought
of as two equilateral triangles placed base to base to form
a rhombus with adjacent angles of 60° and 120°. All sides
and the short diagonal of the defect must be equal in
length in a 60°–120° rhombus defect and flap (Fig. 6-12).
Once the 60°–120° rhombus defect has been created with
all sides equal in length, the flap is designed by directly
extending the short diagonal a distance equal to all other
sides. This creates the first side of the flap. The second
side of the flap, again equal in length to all other sides,
is drawn parallel to one of the adjacent borders of the
defect.7
The greatest wound closure tension with a rhombus
flap is at the donor site and has been calculated to be 20°
from the short diagonal line across the base of the flap.7
Wide undermining of the surrounding tissue has minimal
effect on the wound closure tension. Thus, in designing
the flap, skin mobility and extensibility are important.
Understanding the vector of the resultant wound closure
tension is critical to avoid distortion of surrounding
structures. For every rhombus defect, four potential flaps
may be designed (Fig. 6-12). The surgeon can quickly
visualize the resulting scar configuration and approximate
vector of maximum wound closure tension by drawing
the flap and then covering the two parallel sides of the
flap with his or her fingers.
The design of the rhombus flap is more complex than
that of most other facial skin flaps because of the geom­
etry and option of placing the flap in four separate loca­
tions about a rhombus defect. The author does not use
the rhombus flap or its variations frequently, primarily
because approximately half of the entire length of the scar
that results from use of the flap is not parallel or does not
lie within RSTLs. This disadvantage is most important
in the area of the forehead, where skin creases are more
prominent. RSTLs are less important in the cheek, where
creases are not as prominent, the skin is thinner, and the

82
SECTION I  FUNDAMENTALS
resulting scar from the use of a rhombus flap tends to
blend better with adjacent skin.
The bilobe flap is a double transposition flap that
shares a single base. Each lobe of the flap has a separate
pivotal point, and thus each has a standing cutaneous
deformity.8 It was originally designed for repair of nasal
defects but has frequently been used to reconstruct cheek
defects as well. In the classic design of the bilobe flap, the
axes of the first and second lobes as well as the defect
FIGURE 6-12  ■  For every rhombus defect, four potential flaps may be designed. Greatest wound closure tension is at donor site
(opposing arrows).
a
b
c
d
a
60°
120°
FIGURE 6-13  ■  Classic design of bilobe flap. Axes of first and second lobes and defect, separated by 90° angles. Design transferred
wound closure tension through 90° arc, compared with 45° to 60° arc of single transposition flap. Opposing arrows indicate greatest
wound closure tension.
90°
90°
were all separated by an angle of 90° (180° total) (Fig.
6-13). This design transferred the tension of the wound
closure through a 90° arc, which is more than the usual
45° to 60° arc of a single transposition flap. This greater
movement about a pivotal point, together with the use of
two tissue flaps, assists in minimizing wound closure
tension of the primary and secondary defects.
The major disadvantage of the bilobe flap is that the
majority of the incision necessary to create the two lobes

6  FLAP CLASSIFICATION AND DESIGN
83
vascularity of the pedicle or create a contour deformity
along its path.
The paramedian forehead flap used to repair large
defects of the nose is the archetype of interpolated flaps
(Fig. 6-15). This flap is exceedingly reliable because of its
axial blood supply based on the supratrochlear artery and
vein. The flap is designed so that the vessels located
in the subcutaneous tissue plane extend along the axis of
the flap, providing an ample blood supply to the skin.9
Because of this, the portion of the flap cephalic to the
level of the eyebrow and extending up to the level of the
anterior hairline can be trimmed of its frontalis muscle
and most of the subcutaneous fat without harming the
blood supply to the skin of the flap.10
Similar to the interpolated paramedian forehead flap
used for nasal reconstruction, the melolabial interpolated
flap transferred from the cheek to the nose is a reliable
flap for reconstruction of alar defects. The flap may be
based on a cutaneous pedicle (Fig. 6-16) or subcutaneous
tissue pedicle (Fig. 6-17). Regardless of the nature of the
pedicle, it is divided and the flap is inset at the nose 3
weeks after the flap is transferred to its recipient site.
Unlike the forehead flap, the cheek flap has a random
of the flap produces scars that do not parallel RSTLs.
However, the configuration of the lobes may often be
designed to have an angular shape that may conform to
RSTLs better than curvilinear designs. The resulting scar
of bilobe flaps is also lengthy because of the requirement
of elevating two lobes.
Interpolated Flap
The interpolated flap, like the transposition flap, is trans­
ferred by pivotal movement and has a linear configura­
tion, but it differs from transposition flaps in that its base
is not contiguous with the defect. Thus the pedicle must
cross over or under intervening tissue (Fig. 6-14). If the
pedicle passes over intervening tissue, the pedicle must
subsequently be divided in a second surgical procedure.
This is referred to as insetting the flap. Two surgical
stages are thus required, and this is the greatest dis­
advantage of such flaps. On occasion, the pedicle can
be de-epithelialized or reduced to subcutaneous tissue
only (island flap) and brought under the intervening skin
to allow a single-stage reconstruction. Passing flaps
through a subcutaneous tunnel may compromise the
FIGURE 6-14  ■  Base of interpolated flap is not contiguous with defect. Pedicle passes over or under intervening tissue. If it is over
intervening tissue, the pedicle is divided in a second surgical stage. Opposing arrows indicate greatest wound closure tension.
FIRST STAGE
SECOND STAGE

84
SECTION I  FUNDAMENTALS
A
B
FIGURE 6-15  ■  A, Interpolated paramedian forehead flap. B, Pedicle divided and flap inset during second-stage procedure.
blood supply and cannot safely be thinned of as much of
its subcutaneous fat as the forehead flap. Interpolated
flaps have the advantage of crossing over rather than
through the intervening tissue between flap donor site
and the defect, so they do not distort boundaries between
aesthetic regions of the face. This ensures a completely
natural-appearing border between the cheek or forehead
and the nose. Another advantage of an interpolated flap
is that it can be harvested in regions of redundant tissue,
which may be at sites removed from the immediate area
of the defect. That is, the base of the flap is not immedi­
ately juxtaposed to the defect as required by the use of
transposition and rotation flaps.
Island Flaps
An island flap is incised on all borders so that there are
no cutaneous attachments between the skin of the flap
and the adjacent skin of the donor site. This creates an
island of skin that constitutes the flap. The pedicle of the
flap consists only of subcutaneous tissue or an individual
artery and vein unencumbered by surrounding tissue.
Island flaps may be transferred to a defect by pivoting or
by stretching (advancement). Thus, depending on their
method of transfer, island flaps may be classified as pivotal
or advancement. An island flap may be designed with any
configuration, depending on the requirements of the
defect it is used to repair. It may be of a circular, rectan­
gular, or triangular configuration. Depending on its
shape, it may have a linear or nonlinear axis. Provided
the flap has the exact dimensions of the defect, island
flaps transferred in a pivotal movement will not manifest
increased wound closure tension at the recipient site. In
contrast, island flaps transferred by advancement (except
V-Y flaps) will have the greatest wound closure tension
perpendicular to the leading border of the flap. Pivotal
island flaps are rarely used for facial reconstruction.
However, advancement island flaps are commonly used
and are discussed in other sections of this chapter. Pivotal
island flaps are most often used for nasal reconstruction
and consist of either cheek or forehead skin. When they
are harvested from the cheek, they are transferred on a
subcutaneous tissue pedicle from the area of the melola­
bial fold. When they are harvested from the forehead,
they are transferred as an axial flap with a pedicle of soft
tissue containing the supratrochlear artery and vein.
ADVANCEMENT FLAPS
Advancement flaps have a linear configuration and are
moved by sliding toward the defect. This involves

6  FLAP CLASSIFICATION AND DESIGN
85
C
D
E
F
C-F, Preoperative views of nasal tip defect and postoperative views after reconstruction with interpolated para­
median forehead flap shown in A. No revision surgery performed.
FIGURE 6-15, cont’d  ■
stretching the skin of the flap (Fig. 6-18). Thus advance­
ment flaps work best in areas of greater skin elasticity.
The most basic advancement flap is the simple linear
layered closure, which involves undermining and direct
advancement of tissue side-to-side to close the defect
primarily. This closure does not create a secondary defect,
and additional incisions are made only for the removal of
standing cutaneous deformities (Fig. 6-19). However, the
term advancement flap usually refers to a flap created by
incisions that allow a “sliding” movement of tissue. Tissue
transfer is achieved by moving the flap and its pedicle in
a single vector. The greatest wound closure tension is
perpendicular to the distal border of the flap. Advance­
ment flaps may be categorized as unipedicle, bipedicle,
V-Y, Y-V, and island. Except for the V-Y and island flaps,
all other advancement flaps form two standing cutaneous

FIGURE 6-16  ■  A, A 2 × 0.6-cm skin defect of alar rim after micrographic surgery for skin cancer. Internal lining provided by bipedicle
vestibular skin advancement flap. Donor site of bipedicle flap closed with thin full-thickness skin graft. Structural support provided
by auricular cartilage rim graft. B, Cutaneous pedicled interpolated cheek flap secured over auricular cartilage graft positioned along
nostril margin. C, One week after second-stage division of pedicle and flap inset. D, Six months later. Critical alar facial sulcus
preserved. No revision surgery performed. (From Fader DJ, Baker SR, Johnson TM: The staged cheek to nose interpolated flap for
reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol 37:614, 1997.)
A
B
C
D

6  FLAP CLASSIFICATION AND DESIGN
87
A
B
C
D
FIGURE 6-17  ■  A, Cutaneous defect of anterior alar groove. B, Auricular cartilage graft in place for structural support. Subcutaneous
tissue pedicle interpolated melolabial flap designed for repair of defect. C, Flap elevated on pedicle of fat. Standing cutaneous
deformity forming at superior aspect of donor site transferred with flap to nose. Standing cutaneous deformity forming at inferior
aspect of donor site excised and discarded. D, Flap transferred to recipient site. Pedicle crosses over alar facial sulcus.
Continued

88
SECTION I  FUNDAMENTALS
E, Three weeks later, pedicle divided and
flap inset at nose.
deformities, one on either side of the base of the flap.
This is in sharp contrast to pivotal flaps, which form only
one standing cutaneous deformity.
Unipedicle Advancement Flap
A unipedicle advancement flap is created by parallel inci­
sions that allow a sliding movement of tissue in a single
vector toward a defect. The movement is in one direc­
tion, and the flap advances directly over the defect. As a
consequence, the flap must be developed adjacent to the
defect, and one border of the defect becomes the leading
border of the flap. Repair with an advancement flap
involves both primary and secondary tissue movement
(see Fig. 6-2). Complete undermining of the advance­
ment flap as well as of the skin and soft tissue around the
pedicle is important to enhance tissue movement. The
two standing cutaneous deformities forming at the base
of advancement flaps may require excision or may be
eliminated by a halving suture technique. This involves
dividing in half the length of the wound repair with each
consecutive suture. This evenly distributes the redundant
tissue of the standing cutaneous deformity as small
puckers along the entire length of the wound. Thus the
redundancy is “sewn out” without the need for excision
of skin. Excision of standing cutaneous deformities
(Burow triangles) may facilitate movement of the flap
(Fig. 6-18). Unlike with the pivotal flap, in which the
standing cutaneous deformity must be dealt with at the
base of the flap, the deformities that develop from
advancement can be excised anywhere along the length
of the flap and not necessarily juxtaposed to the base.
This is because of the mechanism of tissue movement.
Excision of standing cutaneous deformities of advance­
ment flaps is predicated on the most optimal site for
E
FIGURE 6-18  ■  Advancement flaps have linear configuration and are moved by sliding toward defect. Greatest wound closure tension
is perpendicular to distal border of flap (opposing arrows). Removal of the Burow triangles at base of flap equalizes wound border
length and length of primary plus secondary defect.
FIGURE 6-17, cont’d  ■

6  FLAP CLASSIFICATION AND DESIGN
89
A
B
SCD excised here
SCD excised here
C
FIGURE 6-19  ■  A-C, Cheek advancement flaps often take the form of primary wound closure with excision of standing cutaneous
deformities (SCD). A, A 4 × 2-cm lentigo maligna of medial cheek marked for excision and repair by advancement of cheek skin.
Anticipated standing cutaneous deformities marked for excision. B, Cutaneous lesion excised. C, Standing cutaneous deformities
excised and wound closed.
excision. Typical excisions are placed in RSTLs or in
borders between aesthetic regions of the face.
Unipedicle advancement flaps and rotation flaps have
one characteristic that is inherent only in these two flap
designs. Owing to their specific design and use, when
either type of flap is transferred to its respective recipient
site, it results in a situation in which there are unequal
lengths to the borders of the wound. This is because the
peripheral border of the wound (flap incision plus defect
length) is longer than the length of the flap. Triangular
skin excisions along the periphery of the wound (Burow
triangle) in essence have the effect of reducing the length
of the peripheral wound so that its length matches the
length of the border of the flap. These excisions are
referred to as equalizing triangles. In the case of rotation
flaps, a single Burow triangle excision is required, whereas
unipedicle advancement flaps require two excisions, one
on either side of the flap. An alternative to the technique
of Burow triangle excision is to invert the triangular exci­
sion and to close the skin defect by advancing the trian­
gular flap created by the inverted excision (Fig. 6-20).11
This is referred to as an inverted Burow triangle excision.
When it is used, the technique results in an irregular
suture line. Although this technique results in a longer
scar than in a standard Burow triangle excision, the irreg­
ular scar pattern may create a less conspicuous and less
contracting scar.
In certain locations on the face, unipedicle advance­
ment flaps work particularly well: the forehead (par­
ticularly in the vicinity of the eyebrow), helical rim,
upper and lower eyelids, and medial cheek. Unipedicle
mucosal advancement flaps are useful for vermilion
reconstruction.
Bilateral unipedicle advancement flaps are commonly
combined to close various defects, resulting in H- or
T-shaped repairs, depending on the configuration of the
defect. Repair in this manner is often referred to as an
H-plasty or T-plasty (Fig. 6-21). In both cases, advance­
ment flaps are designed on opposite sides of the defect
and advance toward each other. Each flap is responsible
for covering a portion of the defect. The resulting stand­
ing cutaneous deformities are often excised in the area of
the defect or along the linear axes of the flaps. The two
flaps do not necessarily have to be of the same length.
Flap length is determined primarily by the elasticity and
redundancy of tissue at the donor site.
Continued

90
SECTION I  FUNDAMENTALS
D
E
G
F
FIGURE 6-19, cont’d  ■D-G, Preoperative and 2-month postoperative views. No revision surgery performed.

6  FLAP CLASSIFICATION AND DESIGN
91
FIGURE 6-20  ■  A, B, Alternative to technique of excising Burow triangles to adjust for unequal wound lengths is excision of inverted
triangle of skin at peripheral margin of wound. An inverted Burow triangle excision can be used for unipedicle advancement and
rotation flaps.
A
B
FIGURE 6-21  ■  Bilateral unipedicle advancement flaps combined to repair defect, resulting in horizontally oriented H-shaped wound
closure (H-plasty). Opposing arrows indicate greatest wound closure tension.

92
SECTION I  FUNDAMENTALS
such as the vermilion or eyelids. The affected area of
distorted vermilion or eyelid is incorporated into the
V-shaped flap and advanced toward the lip or eye to
restore natural topography. The skin borders adjacent to
both sides of the secondary defect are then advanced
toward each other and sutured. The suture line becomes
the vertical or common limb of the Y configuration. The
V-Y advancement flap may also be designed as an island
flap based on a subcutaneous tissue pedicle. In this case,
the flap is stretched toward the defect rather than allowed
to recoil. This type of flap is discussed in detail in a later
portion of this chapter.
The Y-V advancement flap has a similar principle to
the V-Y flap except that the V-shaped flap is stretched or
pulled toward a linear incision made at the apex of the
triangular flap (Fig. 6-23). The borders of this incision
are allowed to spread apart, creating a tissue void. The
flap is advanced into the void and sutured in place. The
wound closure suture line assumes a V configuration.
The maximum wound closure tension is at the apex of
V-Y and Y-V Advancement Flaps
The V-Y advancement flap is unique in that the V-shaped
flap is not stretched or pulled toward the recipient site
but rather achieves its advancement by recoil or by being
pushed forward. Thus the flap is allowed to move into
the recipient site in a nearly tension-free fashion. The
secondary triangular donor defect is then repaired with
wound closure tension by advancing the two borders of
the remaining wound toward each other. In so doing, the
wound closure suture line assumes a Y configuration,
with the common limb of the Y representing the suture
line resulting from closure of the secondary defect (Fig.
6-22). The flap is optimally designed so that the common
limb of the Y falls in the boundary of neighboring aes­
thetic regions or within a natural crease, fold, or wrinkle.
V-Y advancement is particularly useful when a structure
or region requires lengthening or release from a con­
tracted state. For instance, V-Y advancement is helpful in
releasing contracted scars that are distorting structures
FIGURE 6-22  ■  A, B, V-Y advancement flap: V-shaped flap not stretched or pulled toward defect. It achieves advancement by recoil
or by being pushed forward. C, Wound closure suture line assumes Y configuration. Greatest wound closure tension is at closure
site of donor defect (opposing arrows).
A
B
C
FIGURE 6-23  ■  A, B, Y-V advancement flap stretched or pulled toward linear incision made at apex of triangular flap. C, Wound closure
suture line assumes V configuration. Greatest wound closure tension is at apex of flap (opposing arrows).
A
B
C