Local Flaps in Facial Reconstruction

94
SECTION I  FUNDAMENTALS
method of reconstruction of the majority of small to
intermediate-sized defects (defined as those that can be
repaired with the remaining scalp tissue) is by use of two
or more rotation flaps. Rotation flaps have curvilinear
configurations, and as such they are ideally suited for
spherical contours such as the scalp. Rotation flaps are
transferred by a pivoting movement rather than depend­
ing on stretching of the flap for movement as required
by advancement flaps. Because of the inelasticity of scalp
tissue, advancement flaps are poorly suited for scalp
reconstruction.
Whenever possible, multiple rotation flaps are pre­
ferred to the use of a single flap for scalp reconstruction.
Each flap is designed to pivot on an independent pivotal
point. When two rotation flaps are used, the flaps may
be designed to pivot in opposite directions, creating an
O-T configuration of the wound repair, or in the same
direction, as an O-Z repair16 (Fig. 6-24). Use of more
than one rotation flap is advantageous because it recruits
tissue for reconstruction from different locations on the
scalp. Within limits, the greater the number of flaps used,
the more diffuse is the tissue recruitment. Likewise, the
burden of the repair of the secondary defect is shared by
the number of donor sites of the flaps used. Two or three
rotation flaps work best for reconstruction of most scalp
defects. When three flaps are used, each flap is respon­
sible for repairing one-third of the surface area of the
defect. Wound closure is accomplished by pivoting all
three flaps in the same direction. Repair of the defect has
an appearance of a pinwheel, and wound closure configu­
ration resembles the closing of a camera lens.16 When a
single rotation flap is used, the parameter of the arc of
the flap should be at least four times the diameter of the
scalp defect. Sometimes one or two back cuts at the base
of the flap are necessary to reduce wound closure tension.
On rare occasions, the secondary defect must be skin
grafted or left to heal by secondary intention. Standing
cutaneous deformities at the base of scalp flaps are not
resected at the time of flap transfer because resection has
the effect of reducing the width of the base of the flap
and may impair vascularity. In addition, deformities tend
to flatten during a 4- to 6-week interval. Usually after 6
weeks, any remaining deformity may be removed safely
because recipient site vascularity is sufficient to maintain
flap viability.
Forehead
The most effective technique for reconstruction of the
forehead usually involves one or more advancement flaps.
In spite of the relative inelasticity of forehead skin, the
use of advancement flaps versus pivotal flaps is preferred
because they typically produce the best cosmetic results.
This is because incisions necessary for advancement flaps
may be placed in the horizontal creases of the forehead
or along the border of the eyebrow, depending on the
location of the defect. Transposition flaps do work well
in the region of the temple, but more medially on the
forehead. It becomes difficult to close the donor site
when such flaps are used. Dividing the forehead into
three zones (median, paramedian, lateral) assists in plan­
ning reconstruction. In spite of a wound closure scar that
TABLE 6-2  Options for Repair of Facial
Cutaneous Defects
Healing by granulation
Primary wound closure
Local flaps
Regional and distant flaps
Microvascular flaps
Composite grafts
Full-thickness skin grafts
Split-thickness skin grafts
Flaps plus skin grafts
or distant flap repair (Table 6-2). Optimally, each layer of
absent tissue should be replaced with like tissue. When
possible, the cutaneous defect should be closed with skin
of similar thickness, color, and texture as that of the
missing skin. Missing cartilage should be replaced by
appropriately positioned, contoured, and sculptured car­
tilage. Mucosa should generally be repaired with neigh­
boring mucosal tissue.
PREFERRED FLAPS
A number of different flap designs can typically be con­
sidered for any given facial cutaneous defect. However,
in the majority of cases, one or two flap designs are
usually preferred, and this is determined by a host of
factors. Location and size of the facial defect are the two
most important factors governing the selection of a spe­
cific local flap. The aesthetic region of the face where the
defect is located is important because the skin of each
region has certain intrinsic properties. The most impor­
tant of these properties are elasticity and redundancy,
each of which may influence the method of repair. The
facial region also determines the adjacent facial structures
that may be distorted or in other ways suffer impairment
of function after repair of a defect. The size of the defect
is the other important factor affecting the selection of the
preferred local flap. For instance, potential donor sites
for a flap must provide sufficient skin to close the defect
and still achieve closure of the donor site. Larger defects
of the face and neck may be difficult to resurface with
local flaps without considerable impairment in form or
function. In such circumstances, the surgeon must select
a regional flap or skin graft that may be aesthetically less
pleasing but will provide a more functional repair. In
other circumstances, a local flap may be combined with
the use of a skin graft. These decisions are determined
by clinical judgment. The defect size will also influence
the degree of secondary tissue movement that may result,
and this in turn may affect the margins of adjacent facial
structures.
Scalp
Large (6 cm or greater) partial-thickness scalp defects are
best repaired with a full-thickness skin graft. The galea
aponeurosis severely limits tissue movement, causing flap
repair of even small defects to be difficult. The preferred

6  FLAP CLASSIFICATION AND DESIGN
95
FIGURE 6-24  ■  O-Z plasty useful for repair of scalp defects. A, A 4 × 4-cm full-thickness vertex scalp defect. Rotation flaps designed
to pivot in same (clockwise) direction. B, Wound repair assumes Z-shaped closure. (From Baker SR: Reconstructive surgery for skin
cancer. In Friedman RJ, Dzubow LM, Rigel D, et al, editors: Cancer of the skin, Philadelphia, Elsevier-Saunders, 2005.)
A
B
the midline of the forehead, advancement flaps should be
elevated in the subcutaneous plane to preserve the supra­
orbital and supratrochlear nerves. Defects in the midline
are best closed without making horizontal incisions.
Rather, they are treated like a primary wound closure,
using advancement by dissecting in the subgaleal plane,
because all sensory nerves are superficial to this plane of
dissection. If the defect cannot be completely closed by
primary apposition of wound margins, the remaining
portion of the wound is left open to heal by second
intention.
Medial Cheek
The surgeon has a number of options when repairing skin
defects of the medial cheek. This is because of the elastic­
ity of skin in this area and the relative abundance of
redundant facial skin. The preferred method of flap
repair is usually by a transposition or advancement flap.
Advancement flaps may be designed with a cutaneous or
subcutaneous tissue pedicle. When it is designed solely
on a subcutaneous tissue pedicle, it is known as an island
pedicle flap. Transposition flaps used for repair of medial
is perpendicular to the horizontal creases of the forehead,
defects of the central third of the forehead may be
repaired with a vertical orientation with a predictably
good aesthetic result (Fig. 6-25). This is probably due to
the natural dehiscence or attenuation of the frontalis
muscle in this portion of the forehead. In contrast, defects
located solely within the paramedian and lateral zones of
the forehead are best repaired with wound closure ori­
ented in a horizontal axis when possible. Advancement
flaps should be designed with horizontal orientations
because this design facilitates scar camouflage and mini­
mizes the vertical component to the repair. Vertical scars
in the paramedian and lateral zones of the forehead are
perpendicular to forehead creases and their appearances
are accentuated by contraction of the frontalis muscle.
Because of the inelasticity of forehead skin, bilateral
advancement flaps are typically designed on opposite
sides of the defect. This arrangement reduces the degree
of tissue movement required compared with use of a
single flap. Two opposing advancement flaps recruit
tissue from two separate areas of the forehead, and this
has the effect of reducing wound closure tension com­
pared with the use of a single flap (Fig. 6-26). Except in

96
SECTION I  FUNDAMENTALS
FIGURE 6-26  ■  Bilateral advancement flaps preferred for repair of
small (2 cm or less) skin defects of paramedian and lateral fore­
head. Except in midline, advancement flaps are elevated in
subcutaneous tissue plane to preserve supraorbital and supra­
trochlear nerves. A, Margins of lentigo maligna outlined by
sutures. B, Bilateral advancement flaps (H-plasty) designed.
Shaded triangles represent Burow triangles, which were excised.
A
B
FIGURE 6-25  ■  Skin defects of central forehead repaired with ver­
tical orientation provide acceptable aesthetic results. A, A 3.5 ×
3.0-cm skin defect of central forehead repaired by primary
closure. Areas marked for excision (horizontal lines) represent
anticipated standing cutaneous deformities. B, Postoperative
view at 10 months. No revision surgery performed. (From Baker
SR: Reconstructive surgery for skin cancer. In Friedman RJ, Dzubow
LM, Rigel D, et al, editors: Cancer of the skin, Philadelphia, Elsevier-
Saunders, 2005.)
A
B
cheek defects are best designed so that the donor site is
in the vicinity of the jowl (Fig. 6-27). The jowl is the area
of greatest facial skin redundancy. In older patients, this
redundancy can provide a source for a large flap and still
enable primary closure of the donor site. Flaps are usually
superiorly based, and whenever possible, the closure of
the donor site should be designed to lie in the melolabial
and labial mandibular creases. The standing cutaneous
deformity is removed just lateral to the superior border
of the defect.
The V-Y subcutaneous tissue pedicle island advance­
ment flap is an option for repair of medial cheek skin
defects at or below the level of the nasal alae.17 The flap
is particularly well suited for skin defects located imme­
diately adjacent to the alae (Fig. 6-28). A triangle-shaped
skin island is designed with the base of the triangle
formed by the inferior margin of the defect. Optimally,
the vector of flap advancement is designed to parallel the
melolabial crease. The width of the skin island should
equal the width of the defect at its widest point. The
length of the skin island should generally be twice the
length of the defect. The trailing half of the skin island

6  FLAP CLASSIFICATION AND DESIGN
97
subsequently closed such that wound closure tension is
equally distributed over the entire length of the flap. The
donor site is closed in a V-Y fashion, with care taken to
compensate for any differences in the length of the oppos­
ing margins of the donor site.
Cutaneous pedicled advancement flaps are less useful
compared with island advancement flaps and transposi­
tion flaps in repair of medial cheek defects. When tissue
advancement is used for repair of the medial cheek, it
often takes the form of primary wound closure. Standing
cutaneous deformities are removed in aesthetic borders
when possible (see Fig. 6-19). If incisions are necessary
to create a flap, they are designed so that they are placed
in the natural lines of the face. Two parallel or slightly
divergent incisions are made adjacent to the defect, and
the flap is elevated in the subcutaneous plane and advanced
over the defect. If the flap does not stretch sufficiently, it
may be necessary to excise the Burow triangles on either
side of the flap’s base. These triangular excisions help
equalize the distance between the sides of the flap and
the margins of the primary and secondary defect.
Lateral Cheek
Lateral cheek skin has less subcutaneous fat and is more
adherent to the underlying fascia than is medial cheek
skin. For this reason, subcutaneous tissue pedicle island
advancement flaps work less well here because such flaps
depend on ample subcutaneous tissue for movement. The
preferred flap for smaller defects of the lateral cheek is
the transposition flap. Larger defects are best repaired
with rotation advancement flaps designed to recruit
upper cervical skin into the flap (Fig. 6-30). Transposition
flaps are usually superiorly based, and the skin immedi­
ately above the angle of the mandible serves as the donor
tissue for the flap. This is because skin of the lateral
inferior cheek is more redundant and mobile compared
with skin in the lateral superior cheek near the temple.
The increased mobility is attributed to the presence of
the platysmal muscle covering the mandible.
Large defects (greater than 3 or 4 cm) in the lateral
cheek are most easily reconstructed with rotation advance­
ment flaps. From the lateral inferior border of the defect,
a curvilinear incision extends downward and posteriorly
below the earlobe and then backward to the posterior
hairline. From there, the incision extends inferiorly along
the posterior border of the sternocleidomastoid muscle.
Flaps are based medially and inferiorly and can provide a
flexible means of transferring large areas of skin from the
remaining cheek and upper cervical regions.
Central Lip
Depending on the laxity of the lips, cutaneous defects
approaching half the width of the lip may be converted
to full-thickness excisions of the lip followed by primary
wound closure (see Fig. 6-29). The majority of skin
defects of the central upper and lower lips that cannot be
closed primarily can be repaired most favorably with
bilateral advancement flaps. For the upper lip, incisions
for opposing advancement flaps are made along the
vermilion-cutaneous border and immediately below the
tapers to a point to facilitate donor site closure in a V-Y
fashion after flap advancement. The skin island may
extend as far as the inferior border of the mandible if
necessary (Fig. 6-29). Positioning the inferior tip of the
skin island directly in the melolabial crease optimally
conceals the donor site scar. Insofar as possible, incisions
should be designed so their scars are parallel to or in
borders of aesthetic regions.
The perimeter of the skin island is incised to the level
of the superficial subcutaneous tissue. Undermining of
the adjacent facial skin for a distance of 2 cm is performed
at this level. Blunt and sharp dissection is then carried
through the subcutaneous tissue surrounding the skin
island, beveling slightly away from the skin island down
to the level of the fascia overlying the facial muscles. This
frees the elastic subcutaneous tissue pedicle from its
medial and lateral fibrous attachments to the surrounding
cheek fat while preserving its vascular supply, which is
derived from its deep attachments. The skin island is then
advanced toward the defect by placing a skin hook at its
leading border. At this point, the pedicle can be narrowed
to facilitate advancement of the flap. This is accomplished
by back cutting the peripheral borders of the flap in a
subcutaneous plane, leaving at least one-third of the total
flap surface area attached to the underlying subcutaneous
tissue. Further thinning of the subcutaneous tissue under­
lying the undermined portion of the flap may be per­
formed to create a match of appropriate thickness between
the leading border of the flap and the recipient site. A
central pedicle of one-third the total skin island surface
area will adequately perfuse the skin island. Further sub­
cutaneous undermining of the skin adjacent to the flap is
required if puckering of the peripheral facial skin occurs
with flap mobilization. Subcutaneous undermining is also
performed at the recipient site. In addition, the recipient
site’s depth and shape may be modified by removing skin
and subcutaneous tissue so that scars will be along aes­
thetic boundary lines and the defect will more appropri­
ately accommodate the thickness of the advancement flap.
The leading border of the skin island is fixed in place,
and the wound surrounding the remaining perimeter is
C
C, Postoperative view at 5 months. No revi­
sion surgery performed. (From Baker SR: Reconstructive surgery
for skin cancer. In Friedman RJ, Dzubow LM, Rigel D, et al, editors:
Cancer of the skin, Philadelphia, Elsevier-Saunders, 2005.)
FIGURE 6-26, cont’d  ■

98
SECTION I  FUNDAMENTALS
Lateral Lip
Cutaneous defects of the lateral aspect of the upper and
lower lips that cannot be repaired primarily are best
repaired with rotation flaps or subcutaneous tissue pedicle
island advancement flaps (Fig. 6-32). Skin is recruited
from the adjacent perioral area. In general, flaps from the
medial cheek should not be used because by necessity
they traverse the melolabial crease and obliterate this
nasal sill (Fig. 6-31). For the lower lip, incisions are
placed in the vermilion-cutaneous border and the mental
crease. Although the skin of the lips is elastic, it is tightly
adherent to the underlying muscle and must be dissected
sharply from the orbicularis oris as there is little subcu­
taneous fat present. It is usually necessary to remove a
Burow triangle from the vermilion to prevent excessive
bunching when the opposing borders of the two advance­
ment flaps are approximated.
FIGURE 6-27  ■  Transposition flaps used to repair medial cheek defects are best designed so donor site is in vicinity of jowl.
A, B, Preoperative views of melanoma in situ. Margins were cleared by assessing histology of strips of skin surrounding melanoma.
C, Incised transposition flap designed to recruit skin from region of jowl. D, Wound closure. Standing cutaneous deformity removed
from superolateral aspect of defect. E, F, Postoperative views at 6 months. No revision surgery performed. (From Baker SR: Recon­
structive surgery for skin cancer. In Friedman RJ, Dzubow LM, Rigel D, et al, editors: Cancer of the skin, Philadelphia, Elsevier-Saunders,
2005.)
A
B
C
D
E
F

6  FLAP CLASSIFICATION AND DESIGN
99
the vermilion border to prevent the flap from distorting
the vermilion.
Subcutaneous tissue pedicle island advancement flaps
are ideally suited for repair of lateral skin defects of the
upper lip. They do not work as well for defects of the
lower lip. As discussed earlier, this flap design is also ideal
for medial cheek defects adjacent to the nasal alae. The
flap is dissected in a fashion similar to the method dis­
cussed for its use in repair of medial cheek defects, except
important aesthetic boundary. Rotation flaps should be
designed so that the incision for the flap lies in or parallel
to the melolabial crease. The skin flap is elevated from
the orbicularis oris and is based on the ample subcutane­
ous fat located immediately lateral to the commissure. In
the case of upper lip defects, a back cut below the level
of the commissure may be necessary to facilitate suffi­
cient tissue movement. A standing cutaneous deformity
develops as the flap pivots and should be excised along
FIGURE 6-28  ■  V-Y subcutaneous tissue pedicle island advancement flap useful for repair of cheek defects adjacent to ala. A, B, A 4
× 3.5-cm skin defect of lip and cheek. V-Y subcutaneous tissue pedicle island advancement flap designed for repair. Remaining skin
of lateral upper lip marked for excision. C, D, Flap in place. E, F, Postoperative views at 2 years, 8 months. Contouring of flap per­
formed 9 months after surgery. (From Baker SR: Reconstructive surgery for skin cancer. In Friedman RJ, Dzubow LM, Rigel D, et al,
editors: Cancer of the skin, Philadelphia, Elsevier-Saunders, 2005.)
A
B
C
D
E
F

100
SECTION I  FUNDAMENTALS
A
B
C
Subcutaneous tissue pedicle
D
FIGURE 6-29  ■  Multiple flap designs may be used for concurrent facial cutaneous defects. A, A 3 × 3-cm cutaneous defect of medial
cheek. V-Y subcutaneous tissue pedicle island advancement flap designed for repair. B, C, Flap elevated on fat pedicle attached to
central portion of flap. D, Flap in place.
that the flap is freed from its orbicularis muscle attach­
ments near the commissure and is based solely on the
abundant subcutaneous fat located just lateral to the
commissure.
Nose
The two most commonly used local flaps for repair of
cutaneous defects of the nose and in which the donor site
of the flaps is confined to the nose are the subcutaneous
tissue pedicle island advancement flap and the bilobe
flap.18 The island flap is used for repair of defects located
at the anterior aspect of the alar groove. The bilobe flap
is used to repair small cutaneous defects of the nasal tip,
caudal dorsum, or caudal sidewall.
Small defects (1.5 cm or less in size) in the region of
the anterior alar groove between the ala and tip can be
effectively repaired with a subcutaneous tissue pedicle
island advancement flap (Fig. 6-33). It is based on subcu­
taneous tissue and portions of the transverse nasalis
muscle. A triangle-shaped flap with its base making up
the cephalic border of the defect is designed with the apex
of the flap positioned laterally. The posterior border of
the flap rests in the alar groove. The anterior border
extends cephalically and slightly medially from the defect
and is designed to recruit skin of the nasal sidewall. The
anterior border then arcs laterally to meet the posterior
border in the alar facial sulcus. The flap is incised to the
level of the perichondrium of the nasal cartilages. The
adjacent nasal skin is undermined widely, and the proxi­
mal and distal thirds of the flap are undermined in the
subcutaneous plane. The central third of the flap remains
pedicled on the subcutaneous tissue. The flap is under­
mined only to the degree that there is sufficient mobility
to allow the flap to be advanced into the recipient site.
The flap is advanced and secured at the recipient site first,
and then the donor site is closed, creating a V-Y configu­
ration to the repair.
Bilobe nasal flaps are the preferred flap to repair 1- to
1.5-cm cutaneous defects of the central tip or caudal
dorsum (Fig. 6-34).18 They may also be used to repair
skin defects of the lateral nasal tip. However, when the
defect encroaches on the nostril margin, there is a greater
likelihood of elevation of the nostril as the wound heals.
A distance equal to the radius of the defect is measured
from the lateral border of the defect to the pivotal point
of the two lobes of the bilobe flap. Two arcs are drawn
with their centers at the pivotal point. One arc passes

6  FLAP CLASSIFICATION AND DESIGN
101
F
E
Converted to
full thickness
G
V-Y advancement flap
H
E-H, Preoperative and 5-month postoperative views. No revision surgery performed.
FIGURE 6-29, cont’d  ■
Continued

102
SECTION I  FUNDAMENTALS
through the center of and the other tangential to the
distal border of the defect. The base of both lobes of the
flap arises from the first arc. The height of the first lobe
extends to the second arc. The height of the second lobe
is twice the height of the first lobe and tapers to a point.
The width of the first lobe equals the width of the defect.
The width of the second lobe may be 25% less than the
first lobe. The axis of the defect and the two lobes of the
flap are approximately 45° apart for a total of 90° to 110°.
The donor site of the second lobe is closed first. The first
lobe is transposed and the standing cutaneous deformity
removed. The second lobe is then transposed and
trimmed to fit precisely without wound closure tension.
Eyelid
Requirements for eyelid repair are dependent on whether
the defect is partial or full thickness. Full-thickness
defects ideally require a mucous membrane for internal
FIGURE 6-30  ■  A, A 5 × 7-cm skin and soft tissue defect of temple. Temporal branch of facial nerve resected. Cervical-facial rotation
advancement flap designed to recruit upper cervical skin for purpose of repair. Direct brow lift marked to treat brow ptosis resulting
from paralysis. SCD, standing cutaneous deformity. B, Wound closed. C, Postoperative view at 6 months. No revision surgery
performed.
A
SCD
removed here
Direct brow lift
Skin recruited
from neck
B
C
I
I, Postoperative view at 5 months. Cutane­
ous lip defect converted to full-thickness lip wedge excision
closed primarily. No revision surgery performed.
FIGURE 6-29, cont’d  ■

6  FLAP CLASSIFICATION AND DESIGN
103
the eyelids. The external surface of the eyelids should be
surfaced with thin skin sufficiently supple to allow eyelid
excursion. Many small superficial eyelid defects can be
repaired by primary wound closure or by thin full-
thickness skin grafts. Larger cutaneous defects of the
lining and for lubrication of the ocular surface. Skeletal
support that provides adequate lid rigidity and contour
yet is sufficiently malleable to conform to the surface of
the globe is also required. A rigid eyelid margin is neces­
sary to keep eyelashes and skin away from the cornea.
Adequate muscle is necessary to provide for closure of
FIGURE 6-31  ■  Cutaneous defects of central upper and lower lips that cannot be closed primarily may be repaired most favorably
with bilateral advancement flaps. A, A 3 × 2.5-cm skin defect. B, Bilateral advancement flaps designed with incisions in vermilion-
cutaneous border and adjacent to nasal sill. Bilateral Burow triangles marked in alar facial sulcus. C, Wound closed. Single standing
cutaneous deformity removed from vermilion inferiorly and bilateral deformities removed from alar facial sulcus superiorly.
D, Postoperative view at 8 months. No revision surgery performed. (From Baker SR: Reconstructive surgery for skin cancer. In Friedman
RJ, Dzubow LM, Rigel D, et al, editors: Cancer of the skin, Philadelphia, Elsevier-Saunders, 2005.)
A
B
C
D
Text continued on p. 107

104
SECTION I  FUNDAMENTALS
FIGURE 6-32  ■  Cutaneous defects of lateral upper lip may be repaired with V-Y subcutaneous tissue pedicle island advancement flaps.
A, A 3 × 2.5-cm skin defect of lateral upper lip. V-Y subcutaneous tissue pedicle island advancement flap designed for repair. Skin
of lip marked for removal to place scar at vermilion-cutaneous border. B, Incised flap recruits skin from perioral area. Flap advanced
and wound closed. C, D, Postoperative views at 5 months. No revision surgery performed.
A
Skin removed here
Skin removed here
B
V-Y wound
closure
C
D
FIGURE 6-33  ■  Skin defects smaller than 1 cm and located at anterior alar groove between ala and tip may be repaired with subcu­
taneous tissue pedicle island advancement flap. A, Flap designed adjacent to skin defect. B, Flap advanced. C, Postoperative view
at 2 months. No revision surgery performed.
A
B
C

6  FLAP CLASSIFICATION AND DESIGN
105
A
45 degree
angle
SCD removed here
B
Sub-fascial dissection
C
FIGURE 6-34  ■  Bilobe nasal flaps work best for repair of skin defects of central nasal tip. A, A 1 × 1-cm skin defect of nasal tip. Bilobe
nasal flap designed for repair. Axes of lobes oriented 45° from each other. SCD, standing cutaneous deformity. B, Wide undermining
in subfascial tissue plane required. C, Flap in place.
Continued

106
SECTION I  FUNDAMENTALS
E
D
F
G
D-G, Preoperative and 4-month postoperative views. Flap dermabraded 2 months after surgery.
FIGURE 6-34, cont’d  ■

6  FLAP CLASSIFICATION AND DESIGN
107
5. Baker SR. Local cutaneous flaps in soft tissue augmentation and
reconstruction in the head and neck. Otolaryngol Clin North Am
1994;27:139.
6. Gorney M. Tissue dynamics and surgical geometry. In: Kernakan
DA, Vistnes LM, editors. Biological aspects of reconstructive
surgery. Boston: Little, Brown; 1977.
7. Bray DA. Rhombic flaps. In: Baker SR, Swanson NA, editors. Local
flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 151–63.
8. Zitelli JA. Bilobe flaps. In: Baker SR, Swanson NA, editors. Local
flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 165–80.
9. Baker SR, Alford EL. Mid-forehead flaps. Oper Tech Otolaryngol
Head Neck Surg 1993;4:24.
10. Menick FJ. Aesthetic refinements in use of the forehead flap for
nasal reconstruction: the paramedian forehead flap. Clin Plast Surg
1990;17:607.
11. Suzuki S, Matsuda K, Nishimura Y. Proposal for a new compre­
hensive classification of V-Y plasty and its analogues: the pros and
cons of inverted versus ordinary Burow’s triangle excision. Plast
Reconstr Surg 1996;98:1016.
12. Baker SR. Internal lining flaps. In: Baker SR, editor. Principles
of nasal reconstruction. 2nd ed. New York: Springer; 2011.
p. 29–46.
13. Johnson TM, Baker SR, Brown MD, et al. Utility of the subcutane­
ous hinge flap in nasal reconstruction. J Am Acad Dermatol
1994;30:459.
14. Burget GC, Menick FJ. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg 1989;84:189.
15. Thomas JR, Frost TW. Immediate versus delayed repair of skin
defects following resection of carcinoma. Otolaryngol Clin North
Am 1993;26:203.
16. Baker SR. Options for reconstruction in head and neck surgery. In:
Cummings CW, Fredrickson JM, editors. Otolaryngology—head
and neck surgery, Update 1. St. Louis: Mosby; 1989. p. 192–248.
17. Rustad TJ, Hartshorn DO, Cleven RA, et al. The subcutaneous
pedicle flap in melolabial reconstruction. Arch Otolaryngol Head
Neck Surg 1998;124:1163.
18. Baker SR. Nasal cutaneous flaps. In: Baker SR, editor. Principles
of nasal reconstruction. 2nd ed. New York: Springer; 2011. p.
163–209.
eyelid are usually repaired with rotation advancement
flaps recruiting skin from the adjacent upper cheek. It is
generally preferred to advance skin toward the eyelid
from the lateral cheek rather than from the medial cheek
because scar contracture from the use of medial cheek
flaps tends to pull downward on the eyelid, causing ectro­
pion. Another common flap design used for lower eyelid
defects is a transposition flap in which skin from the
opposing upper eyelid is transferred to the lower eyelid
defect. These transposition flaps are usually based near
the lateral canthus, and the upper eyelid donor site for
the flap is closed primarily.
Full-thickness eyelid defects that cannot be closed pri­
marily often are repaired by interpolated composite flaps
harvested from the opposing healthy eyelid. Composite
flaps are flaps that consist of more than one tissue type.
In the case of eyelid repair, composite flaps consisting of
conjunctiva, tarsus, muscle, and skin are transferred to
the opposing eyelid, bridging the palpebral fissure while
maintaining a temporary attachment to the donor eyelid.
Because these are interpolated flaps, their attachment to
the donor eyelid is severed after the flap has established
sufficient vascularity at the recipient site.
REFERENCES
1. Larrabee WF Jr. Design of local skin flaps. Otolaryngol Clin North
Am 1990;23:899.
2. Burget GC, Menick FJ. Subunit principle in nasal reconstruction.
Plast Reconstr Surg 1985;76:239.
3. Clevens RA, Baker SR. Defect analysis and options for reconstruc­
tion. Otolaryngol Clin North Am 1997;30:495.
4. Baker SR. Reconstruction of facial defects. In: Cummings CW,
Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head
and neck surgery. 3rd ed. Philadelphia: Mosby; 1998. p. 527–59.

108
C H A P T E R 7 
ROTATION FLAPS
Shan R. Baker
INTRODUCTION
Rotation flaps are pivotal flaps with a curvilinear configu­
ration. By necessity they must be designed immediately
adjacent to the defect. Thus, a border of the defect
becomes the advancing border of the skin flap. Although
rotation flaps are useful in many clinical situations, the
configuration creates curved incisions that frequently do
not lie completely in relaxed skin tension lines (RSTLs).
Like all pivotal flaps, rotation flaps develop standing cuta­
neous deformities at the base of the flap that cannot be
easily removed without compromising the vascularity of
the flap. Most rotation flaps have a random pattern blood
supply; however, depending on the position of the base
of the flap, they may on occasion be axial by incorporat­
ing the underlying fascia or musculature into the pedicle
of the flap. Regardless of whether their blood supply is
random or axial, rotation flaps are broad based with a
favorable length-to-width ratio, and their vascularity
tends to be reliable.
Although rotation flaps are pivotal flaps in their move­
ment, most are also advanced by stretching of the flap.
Depending on the degree of stretching, the vector of
greatest wound closure tension may be along a line
extending from the base to the apex of the distal flap.
When no advancement is used in movement of rotation
flaps, the greatest wound closure tension is perpendicular
across the distal border of the flap, not across the long
length of the flap.1,2
Studies by Larrabee and Galt have demonstrated
minimal benefit at the defect site of extending the arc of
rotation flaps beyond 90° from the axis of the defect.2
This is to say, wound closure tension is not reduced at
the defect site by increasing the pivotal movement of the
flap by more than 90° from the axis of the defect. However,
there is often some benefit in extending the incision to
accommodate redraping of skin.
The secondary defect created by rotation flaps
re­presents a transformation and a translocation of the
primary defect.3 The surface area encompassed by the
primary defect is equivalent to the surface area of
the secondary defect.3 The geometry of the secondary
defect is determined by the size of the flap. The larger
the flap, the longer and narrower is the secondary defect.
The narrower the width of the secondary defect, the less
is the tension required to close the wound and the less is
the secondary movement of tissue adjacent to the donor
site. Another way of stating this is that the greater the
length of the arc and thus the larger the flap, the less is
the wound closure tension across the repair of the sec­
ondary defect.
Rotation flaps are best suited for repair of defects that
are triangular. Design of the classic rotation flap is seen
in Figure 7-1. A standing cutaneous deformity will
develop at the base of the flap. A Burow triangle can be
removed to facilitate repair of the donor site wound. A
back cut4 at the base of the flap shifts the position of the
pivotal point and changes the location of the standing
cutaneous deformity.5-7 When a rotation flap is converted
to a two-dimensional form, it appears as in Figure 7-2.
As can be seen in the illustration, a problem encountered
with rotation flaps is the unequal length of the flap’s
border, labeled B in the drawing, compared with the
width of the primary and secondary defects, labeled A in
the drawing. A common method to equalize this discrep­
ancy is to excise an equalizing Burow triangle at some
point along the periphery of the curvilinear incision. The
triangle’s base is equal in width to the width of the base
of the defect, labeled C in Figure 7-2. Excision of the
triangle of skin results in equalizing of the length of the
two sides of the incision. An alternative solution to the
management of the discrepancy in length of wound
margins is to modify the movement of the flap from one
that is purely pivotal to one that is both pivotal and
advancement. By advancing the flap while at the same
time rotating it around its pivotal point, the flap is
stretched to equalize the discrepancy (Fig. 7-3). In so
doing, the surgeon takes advantage of the distensibility
(Fig. 7-4, side B) and the compressibility (Fig. 7-4, side
A) of the skin along the wound margins. Repair is then
accomplished by use of the principle of halving by sutur­
ing on the bias (Fig. 7-4C, D). This is accomplished by
placing a suture to appose the two borders of the wound
at the halfway point along the length of the flap. Succeed­
ing sutures are placed in a manner that continues to
equally divide the remaining distances along the flap’s
border. An experienced surgeon will learn to suture on
the bias from one end of the flap to the other without
resorting to planned halving sutures.
As a general rule, in designing rotation flaps on the
face, the length of the flap (Fig. 7-2, side B) should be
four times the width of the base of the triangular defect
(Fig. 7-2, side C). When this ratio is used, excision of an
equalizing Burow triangle is usually not required. Under­
mining of the base of the flap along with its pivotal point
enables advancement of the flap toward the defect during
wound closure. Advancement reduces wound closure
tension and often necessitates a smaller flap with less

7  ROTATION FLAPS
109
FIGURE 7-1  ■  A, Rotation flap with excision of an equalizing Burow triangle. B, Opposing arrows indicate point of greatest wound
closure tension. Large arrow indicates closure site of the equalizing Burow triangle excision.
A
B
FIGURE 7-2  ■  Rotation flap converted to two-dimensional form. Discrepancy between border of rotation flap (side B) and width of
primary and secondary defects (side A) is equalized by excision of a triangle of skin (Burow triangle) at some point along curvilinear
periphery of incision (side A) with base equal in width to maximum width of defect (side C).
A
B
C
FIGURE 7-3  ■  A, B, Need for excision of a Burow triangle is often avoided by advancement of distal tip of rotation flap and repair of
wound by suturing on bias.
A
B

110
SECTION I  FUNDAMENTALS
proportion of 2 : 1 (Fig. 7-5). In addition, if the arc of
rotation of the flap is to be a completely symmetric curve,
the height of the triangular defect should be 0.5 to 1
times the radius of the curve of the flap (Fig. 7-6). To
create the ideal condition for use of a rotation flap, the
defect can be enlarged by removing normal tissue and
converting the defect into a triangle with a height-to-
width ratio of 2 : 1 (Fig. 7-7).9
There are several advantages of using rotation flaps.
The flap has only two sides; as a result, the surgeon can
sometimes position the arced incision in an aesthetic
border. The flap is broad based, and therefore its vascu­
larity tends to be reliable. There is great flexibility in
design and positioning of the flap.10-12 Design of inferi­
orly based rotation flaps promotes lymphatic drainage
and reduces flap congestion and edema. Similarly, arterial
and venous disruptions may be minimized and sensory
innervation may be maximized by appropriately position­
ing the base of the flap.
Rotation flaps should not be selected as a first option
in situations in which design of the flap will necessitate
placement of incisions that cross RSTLs or aesthetic
movement about its pivotal point than when the flap’s
pedicle is not widely undermined and advanced. In addi­
tion to reducing the overall size of the flap, undermining
limits the development of a standing cutaneous deformity
by advancing a portion of the deformity peripherally
away from the flap’s base.
Increasing the degree of undermining of the flap
without lengthening the border of the flap does not sig­
nificantly decrease wound closure tension. Likewise,
enlarging the flap beyond the length of four times the
width of the defect does not significantly decrease wound
closure tension.8 When a single flap is used for wound
repair, the arc of the flap may be adjusted for a number
of considerations. For instance, the arc of the flap may
be shortened to maintain the incision along or inside
hair-bearing tissue. The arc may be extended more than
four times the width of the defect when the defect is
located in areas of limited skin mobility.
To avoid a standing cutaneous deformity at the
base of a rotation flap used to repair a defect, the defect
should ideally assume the configuration of an inverted
triangle. The triangle should have the height-to-width
FIGURE 7-4  ■  A, B, Surgeons take advantage of distensibility of side B and compressibility of side A to achieve wound closure without
excision of an equalizing Burow triangle by advancing and stretching side B to reach most distal border of defect. C, D, Wound is
repaired by principle of halving sutures.
A
A
B
B
A
B
C
D

7  ROTATION FLAPS
111
FIGURE 7-5  ■  To minimize standing
cutaneous deformity that develops
at base of rotation flap, most ideal
configuration of triangular defect
has height-to-width ratio of 2 : 1.
h
w
1
2
FIGURE 7-6  ■  For symmetric rota­
tion flap, height of triangular defect
should be 0.5 to 1 times the radius
of curvature of flap’s border.
r
0.5r

112
SECTION I  FUNDAMENTALS
APPLICATIONS
Scalp
Rotation flaps are the preferred method to repair most
scalp defects with use of local tissue. Because of its spheri­
cal topography, the scalp accommodates curvilinear inci­
sions well and the flaps can be constructed sufficiently
large without the need to regard RSTLs or aesthetic
borders. Rotation flaps are transferred by a pivotal motion
rather than depending on stretching of tissue for move­
ment as required by advancement flaps. Because of the
inelasticity of scalp tissue, any movement of tissue by
advancement is limited. Whenever possible, multiple
rotation flaps are preferred to the use of a single flap for
scalp reconstruction. Each flap is designed to pivot on an
independent pivotal point. When two rotation flaps are
used, the flaps may be designed to pivot in opposite direc­
tions, creating a T configuration of the wound repair.
Most defects left after micrographic surgery are round or
oval. When this configuration is present, it is best to use
two flaps that pivot in the same direction, either clock­
wise or counterclockwise. Each flap is designed with an
opposite orientation on either side of the defect. The two
borders at right angles. This will likely result in an
inadequately camouflaged scar along a portion of the
donor site. Rotation flaps are not a good choice to
repair central upper cheek skin defects in men because
hair-bearing skin of the sideburn is moved medially into
the non–hair-bearing area of the cheek covering the
malar eminence. Except for the dorsal nasal flap, rota­
tion flaps are not often used in repair of nasal defects
because donor site scars do not follow the boundaries
separating the nasal aesthetic units. The skin of the
nasal tip is inelastic, making the use of rotation flaps
difficult. Small defects over the dorsum of the nose are
best repaired with transposition flaps, such as a bilobe
or rhombic flap. Furthermore, rotation flaps transferred
from the cheek to the sidewall of the nose usually have
an unacceptable result because of the necessary bridging
of the flap across the nasofacial sulcus. This partially
obliterates this important landmark. Similarly, rotation
flaps from the cheek are inappropriate for reconstruc­
tion of lateral lip defects because the arc of the flap
must extend across the melolabial fold and crease at
right angles. The melolabial crease is a prominent aes­
thetic border, and incisions crossing it perpendicularly
often create unsightly scars.
FIGURE 7-7  ■  To create ideal condition for use of rotation flap, defect enlarged by removing normal tissue and converting defect into
triangle with height-to-width ratio of 2 : 1.
1
2

7  ROTATION FLAPS
113
flaps are apposed with a Z-shaped repair. This type of
repair is known as an O-Z repair. In designing a double
rotation flap in an O-Z pattern, the optimum design for
wound closure is an acute-angled flap with a length equal
to four times the radius of the defect being closed. Use
of more than one rotation flap is advantageous because it
recruits scalp tissue for reconstruction from different
locations and the burden of closing the secondary defect
is shared by the number of flaps used. Two or three rota­
tion flaps work best for reconstruction of scalp defects.
When three flaps are used, each is responsible for repair
of one-third of the surface area of the defect. Wound
closure is accomplished by pivoting all three flaps in the
same direction. Repair of the defect has the appearance
of a pinwheel, and wound closure configuration resem­
bles the closing of a camera lens.13
To use two or more rotation flaps for repair of scalp
defects, the defect must be located in the central aspect
of the scalp. For peripherally located defects, it is often
difficult or impossible to design two effective rotation
flaps. In such instances, a single flap is designed larger
than would be required if two flaps could be used. When
a single rotation flap is used, the perimeter of the arc of
the flap should be at least four times the diameter of the
scalp defect. Sometimes one or two back cuts at the base
of the flap are necessary to reduce wound closure tension.
On rare occasions, the secondary defect must in part be
skin grafted or left to heal by secondary intention. Stand­
ing cutaneous deformities are not resected at the base of
scalp flaps at the time of transfer because resection has
the effect of decreasing the width of the base of the flap
and may impair vascularity. In addition, deformities tend
to be resorbed during a 4- to 6-week interval. Usually
after 6 weeks, any remaining deformity may be removed
safely without jeopardizing the vascularity of the flap.
Face
Rotation flaps work extremely well in repair of cheek
defects larger than 3 or 4 cm in the lower preauricular
area, where recruitment of the upper posterior cervical
skin is required for wound closure. The curvilinear inci­
sion is positioned juxtaposed to the earlobe and along the
hairline of the postauricular scalp. If necessary, the inci­
sion extends along the border of the trapezius muscle. An
incision in this area of the neck produces a favorable scar
even though it does not follow RSTLs. A Z-plasty at the
base of the flap often facilitates closure of the secondary
defect without the need for excision of an equalizing
(Burow) triangle. In cases in which patients use tobacco
or have been irradiated in the region of the defect, cervi­
cal rotation flaps may be elevated beneath the superficial
fascia and the platysmal muscle. This will enhance the
vascularity of the flap.14
Rotation flaps are useful for repair of small (less than
2 cm) skin defects of the lateral forehead and temple.
Usually a single rotation flap is used, and whenever pos­
sible the arc of the flap is designed along the anterior
hairline. In other instances, the incision for the flap is
designed parallel and adjacent to the eyebrow. Flaps
should be laterally based because of greater skin
mobility.
Cutaneous defects of the lateral aspect of the upper
and lower lips that cannot be repaired primarily can often
be reconstructed with a single rotation flap. Skin is
recruited from the adjacent perioral area. The flap is
designed so that incision lines are in or parallel to the
melolabial crease. The skin flap is elevated from the orbi­
cularis oris and is based on the ample subcutaneous fat
located immediately lateral to the commissure. In the
case of an upper lip defect, a back cut below the level of
the commissure may be helpful in facilitating pivot of the
flap. A standing cutaneous deformity develops as the flap
pivots and should be excised along the vermilion border.
The excision of the deformity must extend laterally all
the way to the commissure.
In many circumstances, rotation flaps are an excellent
choice for repair of cutaneous defects of the chin. Two
opposing flaps are typically designed, one on either side
of the defect. Each flap is responsible for closing half of
the surface area of the defect, and each flap pivots toward
the midline. Incisions, in part, are designed to follow the
natural curvature of the mental crease.
I do not use many rotation flaps for reconstruction of
head and neck defects other than for the scalp and pre­
auricular region. This is because skin defects after micro­
graphic surgery are of the size or location that would
frequently necessitate curvilinear incisions that cross at
right angles to aesthetic borders or to RSTLs. This
results in a portion of the donor site scar that is difficult
to camouflage. In my practice, use of rotation flaps on
the face is usually limited to repair of large medial and
lateral cheek defects in which the incision can be placed
along the inferior bony orbital rim or in the preauricular
crease, both of which are aesthetic borders. In the case
of medial cheek defects, the standing cutaneous defor­
mity resulting from flap transfer can frequently be excised
in or parallel to the melolabial crease. In men, a disad­
vantage of using large rotation flaps designed to extend
laterally from the infraorbital rim or subciliary line into
a preauricular crease is that transfer of the flap may cause
hair-bearing skin of the sideburn to be displaced medially
into the non–hair-bearing area of the inferior temple
region or malar eminence.
Nose: Dorsal Nasal Flap
The dorsal nasal flap is a modified rotation flap that
recruits redundant skin from the glabella. The flap can
be used to repair skin defects of the nasal tip, dorsum,
and sidewall. Elliott15 detailed the banner and bilobe
flaps for nasal repair, designing them as interpolated
flaps that require inset. Rieger16 described the basic
design of the dorsal nasal flap used currently. The flap
uses the entire dorsal nasal skin to facilitate repair.
Further refinements of the flap were offered by Rigg,17
who introduced the concept of limiting the area of nasal
skin used for construction of the flap. He advocated a
back cut of the flap toward the medial canthus. Marchac
and Toth18 designed the flap with an axial vascular
pattern by incorporating a constant branch of the
angular artery in the pedicle. This enabled a longer
descent of the glabellar back cut to the level of the
medial canthus. The greater back cut facilitates flap

114
SECTION I  FUNDAMENTALS
tip. Skin laxity in the glabella and dorsal nasal regions is
best determined by the “pinch test.” This test consists of
grasping the skin between the surgeon’s thumb and index
finger and determining the degree of redundancy.19 For
success, sufficient skin laxity is present when the surgeon
can gather 1 or 2 cm of skin on the nasal bridge and
glabella. Greater laxity is necessary as the size of the
defect increases.
Commonly, the dorsal nasal flap is designed as a later­
ally based rotation flap with a back cut (Fig. 7-8). The
pedicle is centered in the region of the medial canthus.
A curvilinear line is drawn laterally from the defect to the
junction of the cheek and the nose. From this point, the
line is directed superiorly, passing 0.5 cm medial to
the medial canthus and extending to the superior aspect
of the glabella within a glabellar crease. Because the flap
transfer, reducing wound closure tension and distortion
of the nostril margin.
The dorsal nasal flap enables the surgeon to repair
caudal and midnasal defects measuring 2.5 cm in diam­
eter or less with matching adjacent tissue. There is insuf­
ficient nasal skin to repair larger defects in this manner.
The flap is ideally suited for elderly patients with skin
defects located centrally on the tip. By necessity, the flap
is designed with a large surface area to maximize tissue
movement and to decrease wound closure tension at the
donor site. Excessive cephalic rotation of the nasal tip and
alae is prevented by the large size of the flap, which
incorporates the majority of the remaining nasal skin. It
is imperative to assess nasal skin laxity when use of the
flap is being considered and to plan for some degree of
secondary movement at the margins of the nasal alae and
FIGURE 7-8  ■  A, Dorsal nasal flap is a modified rotation flap based on branches of angular artery. Glabellar portion (shaded) dissected
in subcutaneous tissue plane. B, Nasal portion dissected beneath nasal musculature. Standing cutaneous deformity excised in or
parallel to alar groove. C, Glabellar donor site wound closed in V-Y configuration. (From Baker SR: Nasal cutaneous flaps. In Baker SR,
editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
Subcutaneous
Submuscular
A
B
C

7  ROTATION FLAPS
115
thickness between flap and native medial canthal skin is
often a problem. This is the greatest disadvantage of
using this flap, which precludes its common use by the
author.
I occasionally use a modified design of the dorsal nasal
flap for midline skin defects of the upper dorsum (Fig.
7-9). The design is such that the lateral border of the flap
remains anterior to the thin skin of the medial canthal
region to avoid mismatch in skin thickness. I call this
design a dorsal heminasal flap. The design limits the arc
of tissue movement; the modified flap can be used only
for smaller (less than 2 cm) skin defects of the nasal
bridge that are at least 1 cm cephalic to the nostril margin
and not inferior to the tip-defining points.19 The dorsal
heminasal flap does not necessarily require a glabellar
incision. The lateral incision is along the junction of the
nasal sidewall and dorsum and therefore recruits skin
only from the nasal bridge.
Reduction rhinoplasty may occasionally facilitate
repair of a nasal skin defect by creating a relatively
greater amount of skin redundancy. The patient in
Figure 7-10 presented with a 3 × 2-cm skin defect of
the upper dorsum and a marked convexity and overpro­
jection of the upper and middle nasal vaults.20 She
desired a reduction of the nasal bridge. An aesthetic rhi­
noplasty was performed concomitant with a modified
dorsal nasal flap. Reducing the volume of the bony and
cartilaginous nasal skeleton created greater skin redun­
dancy, which enabled partial wound closure by advance­
ment of nasal skin medially. This in turn reduced the
size requirement of a modified dorsal nasal flap used to
repair the remaining portion of the defect. The stand­
ing cutaneous deformity resulting from bilateral medial
advancement of the nasal sidewall skin was excised in
the midline immediately inferior to the caudal border of
the skin defect.
is transferred primarily by pivoting, the effective length
of the flap diminishes progressively as the flap rotates
about its pivotal point (medial canthus). The height of
the flap and thus the arc of pivotal movement must be
sufficient to compensate for this shortening. Supplemen­
tal flap height is gained from the glabellar extension. The
higher the extension, the greater the height of the flap,
and the easier it will be to close the primary defect. From
the nasofrontal angle, the glabellar extension is approxi­
mately 112 to 2 times the vertical height of the nasal
defect. From the superior point of the glabellar exten­
sion, a line angles inferiorly toward the contralateral
medial canthus, creating a 30° to 45° angle back cut. The
back cut remains just superior to the level of the medial
canthal tendon to protect the axial vessels from the
angular artery located inferior to the tendon. In design­
ing the flap, it is helpful to triangulate the defect by
excising the standing cutaneous deformity in such a
manner that the excision lays within the alar groove or
above and parallel to it. Incisions for the flap should not
extend below the alar groove or obliteration of the
concave topography will occur between the ala and the
nasal sidewall.
After the nose is injected with a local anesthetic con­
taining epinephrine, the flap is elevated in a fashion
similar to that of other nasal cutaneous flaps. The portion
of the flap arising from the glabella is elevated in the
subcutaneous plane, and the remaining portion of the flap
is dissected beneath the nasal musculature. Nasal skin
surrounding the flap is widely undermined, which may
include a limited dissection of the medial cheek skin,
releasing the fibrous attachment between cheek skin and
periosteum along the junction of the cheek with nasal
sidewall. Complete mobilization of the pedicle beneath
the nasal muscles is necessary for proper tissue move­
ment. The flap is secured with a temporary suture to
allow the surgeon to check for discrepancy of skin thick­
ness or distortion of alae or nasal tip. The undersurface
of the distal flap may be trimmed to improve the thick­
ness match between flap and recipient site. Only three or
four deep sutures are necessary to position the flap. Skin
incisions are repaired with 5-0 polypropylene vertical
mattress cutaneous sutures to evert wound edges.
The donor site in the glabella may be closed by V-Y
advancement, Z-plasty, or, more commonly, primary
repair. When primary wound closure is used, the trian­
gular segment of glabellar skin that moves with the flap
is trimmed for a perfect fit, creating a single glabellar
incision line. Thinning of the flap in the area of the
medial canthus is critical to improve the mismatch of
thickness between the thin skin of the medial canthus and
the thicker glabellar skin of the flap.
A disadvantage of the dorsal nasal flap is common
cephalic displacement of the nostril margin and nasal tip.
In older patients with tip ptosis and a central tip defect,
slight elevation of the nasal tip is beneficial. In younger
patients, however, elevation of the tip may result in an
unacceptable appearance. Repair of lateral nasal defects
may result in permanent mild to extreme elevation of the
ala in patients with insufficient laxity of the nasal and
glabellar skin. In spite of aggressive thinning of the flap
in the area of the medial canthus, marked discrepancy in
FIGURE 7-9  ■  Dorsal nasal and heminasal flaps. The heminasal
flap is used to repair more cephalic skin defects. Its borders
remain anterior to thin skin of medial canthal region. (From
Baker SR: Nasal cutaneous flaps. In Baker SR, editor: Principles of
nasal reconstruction, ed 2, New York, Springer, 2011.)
Dorsal
nasal flap
Dorsal
heminasal flap

116
SECTION I  FUNDAMENTALS
lidocaine containing epinephrine in a concentration of
1 : 100,000. For very large cervicofacial flaps, a mixture
of equal parts of 0.5% lidocaine (Xylocaine) and 0.25%
bupivacaine (Marcaine) (both solutions containing a
concentration of 1 : 200,000 epinephrine) is used. This
mixture provides rapid onset and long duration of anes­
thesia, allowing the surgeon to use a volume greater than
30 mL if required.
The entire face is then prepared and draped. A skin
marking pen is used to design the flap and to mark areas
adjacent to the defect that will require excision. When
micrographic excision has been used to remove a skin
tumor, the entire margin of the defect is excised with
incisions perpendicular to the skin margin. Additional
skin in the vicinity of the defect is usually excised to
create a triangular defect that will allow movement of the
flap into position. Depending on the size and location of
SURGICAL TECHNIQUE
Preparation of the patient for surgery and preoperative
and postoperative care are discussed in detail in Chapter
5. All facial reconstruction using rotation flaps is per­
formed as an ambulatory surgical procedure. In the
majority of cases, monitored anesthesia consisting of
intravenous administration of midazolam and fentanyl is
used. Rotation flaps of the face are usually designed so
that they are inferiorly and medially based. The border
of the flap is positioned in an aesthetic border when pos­
sible and in RSTLs when an aesthetic border is not in
the immediate vicinity of the defect. On occasion, addi­
tional skin is removed adjacent to the defect so that the
margin of the flap can be positioned along such borders.
After induction of intravenous analgesia, regional and
local infiltration of anesthetic is accomplished with 1%
FIGURE 7-10  ■  A, A 3 × 2-cm skin defect of nasal dorsum. B, Reduction of nasal bridge projection created relatively greater amount
of skin redundancy. Defect partially closed by medial advancement of nasal skin. Modified dorsal nasal flap designed to repair
remaining portion of defect. C, Flap in position. Standing cutaneous deformity resulting from medial advancement of nasal sidewall
skin excised in midline, immediately inferior to caudal border of transferred flap. D-G, Preoperative views before removal of skin
cancer and postoperative views 10 months after surgery. No revision surgery performed. (From Johnson TM, Swanson NA, Baker SR,
et al: The Reiger flap for nasal reconstruction. Arch Otolaryngol Head Neck Surg 121:634-637, 1995.)
A
B
C
D
E
F
G

7  ROTATION FLAPS
117
as required. This enables the surgeon to develop the flap
while preventing unnecessary incisions. A Z-plasty at the
base of the flap can facilitate closure of the secondary
defect, often eliminating the need for a Burow triangle
excision. The configuration of rotation flaps creates a
right angle at the distal tip, and care must be taken in
positioning the tip so that it is not subjected to excessive
wound
closure
tension
and
subsequent
vascular
compromise.
The greater the arc of rotation, the greater is the
standing cutaneous deformity of rotation flaps unless the
defect has the correct triangular proportions as discussed.
Except for scalp defects, standing cutaneous deformities
can be excised by enlarging the skin defect and in essence
converting the defect into a triangular configuration with
a height-to-width ratio of 2 : 1. When this is not possible,
secondary staged excision of the standing cutaneous
deformity is recommended. Much of the deformity flat­
tens (resorbs) during a 6-week interval. Any residual
deformity after this time usually requires excision to
restore a natural contour of the reconstructed area.
Wound closure consists of placement of subcuticular
sutures along the entire length of the wound. The first
suture is placed at the advancing border of the flap, which
is the point of greatest wound closure tension. The
second subcuticular suture is used to secure the distal tip
of the flap. Subcuticular sutures are then placed along the
entire periphery of the flap, every 8 to 10 mm. For sub­
cuticular sutures supporting the points of greatest wound
closure tension, 4-0 polydioxanone sutures are used; the
remaining subcuticular sutures are 5-0. In the case of
large cervicofacial rotation flaps for medial cheek defects,
a deep suture is placed between the dermis of the flap and
the periosteum of the inferior bony orbital rim. This
suspension suture may be beneficial in countering scar
contracture, which can cause a downward pull on the
eyelid skin. Skin closure is accomplished with 5-0 absorb­
able or nonabsorbable cutaneous sutures placed in an
interrupted or running fashion.
A compression dressing is applied to the reconstructed
area and flap donor site for 24 hours. An antibiotic oint­
ment is applied to the suture line and then a nonadhesive
(Telfa) bandage covers the wound. Cotton balls are
layered external to the nonadherent bandage. A topical
adhesive is applied to the surrounding skin, and an
expandable nylon tape is applied firmly over the cotton
balls. By stretching the tape slightly during application,
effective local compression of the wound is achieved.
Patients having large rotation flaps should be checked
within 24 hours after surgery to ensure that no hematoma
has formed beneath the flap or at the donor site. Patients
are instructed to avoid strenuous exercise for 2 weeks
after surgery and are asked to avoid sun and extreme
temperature exposures for at least 1 month postopera­
tively. Suture removal should be accomplished in 5 to 7
days after facial flaps and 10 to 14 days after cervical and
scalp flaps. Facial scars resulting from repair with rota­
tion flaps can often be improved in appearance with
dermabrasion. Dermabrasion is usually accomplished 6
weeks after the initial surgery. Because of the curvilinear
configuration of rotation flaps, trap-door deformity may
occur. Injection of the affected area with triamcinolone
the defect, skin may also be excised to enable the flap to
extend to adjacent aesthetic borders or RSTLs. All of
these excisions are made before the flap is dissected. All
incisions are vertical to the surface of the skin with no
beveling. The borders of the flap are incised, and the flap
is then sharply undermined in the subcutaneous plane.
In addition, all sides of the donor defect are undermined
for a distance of at least 2 cm. An exception to this rule
is when borders of the donor site are relatively fixed, such
as the melolabial fold, alar-facial sulcus, or eyelid. These
areas are undermined 4 or 5 mm so that wound edge
eversion can occur, but without distortion of adjacent
facial structures. All undermining is accomplished with
sharp dissection in the subdermal plane. Hemostasis is
established with monopolar electrocautery.
For most rotation flaps used to repair cheek, lip,
temple, and forehead defects, the flap is elevated in the
subcutaneous plane. This is particularly true in repair of
forehead defects to preserve the supratrochlear and the
supraorbital cutaneous nerves. Scalp flaps should be dis­
sected in the subgaleal plane. Cervicofacial flaps used to
repair defects over the parotid gland may be elevated in
the subcutaneous or subplatysmal plane. When subpla­
tysmal dissection is used, care must be taken not to injure
the mandibular branch of the facial nerve when dissecting
in the upper posterior neck region. Flaps used to repair
large lateral cheek defects in patients who use tobacco
products may be elevated beneath the superficial muscu­
loaponeurotic system (SMAS) plane to enhance the
vascularity of the flap. In such instances, the plane of
dissection shifts from subcutaneous to beneath the SMAS
approximately 2 cm anterior to the tragus. The dissection
over the parotid gland is relatively free of risk to the facial
nerve because the nerve is protected by the substance of
the gland. However, anterior to the gland, care must be
taken to avoid injury to the branches of the facial nerve,
which are no longer protected by intervening parotid
tissue. Dissection in this area is accomplished by bluntly
separating the SMAS from the underlying masseteric
fascia that lies superficial to the branches of the facial
nerve. This is an avascular plane that can be easily dis­
sected. If it is necessary, dissection is extended inferiorly
below the angle of the mandible deep to the platysma to
recruit upper cervical skin. In such instances, the pla­
tysma must be detached from its insertion along the ante­
rior border of the sternocleidomastoid muscle. Dissection
continues inferiorly and anteriorly below the mandible
on the immediate ventral aspect of the platysmal muscle
to protect the mandibular branch of the facial nerve.
Bipolar electrocautery for hemostasis is recommended to
minimize the risk of nerve injury in this area of dissection.
Once the composite flap consisting of skin, underlying
SMAS, and platysmal muscle is adequately mobilized, it
is pivoted into the defect and secured with deep sutures
attaching the platysmal muscle to the fascia surrounding
the skin defect. Muscle attachment to the periparotid
fascia reduces the wound closure tension on the skin of
the suture line.
In harvesting of large rotation flaps, such as the cervi­
cofacial flap, a graduated approach should be practiced.
A portion of the flap is incised, followed by dissection of
the flap, followed by further flap incision and dissection

118
SECTION I  FUNDAMENTALS
to perform a serial excision of the affected area. Because
of the lateral location of the alopecia, only a single large
rotation flap could be effectively transferred to cover the
proposed resection of the scarred scalp. Therefore, the
majority of the remaining hair-bearing scalp was included
in a large rotation flap designed so that it was based pos­
teriorly and laterally on the occipital and postauricular
arteries. The perimeter of the arc of the flap was five
times the width of the portion of scalp planned for resec­
tion. A single back cut at the base of the flap was incor­
porated into the design to reduce wound closure tension.
The flap was elevated in the subgaleal tissue plane, and
the remaining scalp and all of the forehead skin were
undermined in a similar plane to reduce wound closure
tension (Fig. 7-12). The area of scalp involved with alo­
pecia and planned for resection was not removed until
the rotation flap was pivoted and the donor site for the
10 mg/mL in the deep subcutaneous tissue will often
accelerate resolution of the deformity. Physical massage
of the flap beginning 4 weeks postoperatively will assist
in reducing postoperative edema. Surgical revision of the
flap or scars should not be entertained for 9 to 12 months
after the initial flap transfer.
CASE REPORTS
Case 1
A 3-year-old girl suffered a third-degree burn injury to
the left parietal scalp, resulting in permanent alopecia
measuring 10 × 4-cm (Fig. 7-11). The options for cor­
rection of the alopecia included hair transplantation and
excision with reconstruction by a scalp flap. It was elected
FIGURE 7-11  ■  A, A 10 × 4-cm area of alopecia from burn injury of scalp. B, Large rotation scalp flap with back cut designed to repair
anticipated defect after excision of scarred scalp.
A
B
FIGURE 7-12  ■  Same patient shown in Figure 7-11. A, Flap elevated in subgaleal tissue plane. B, Area of alopecia excised and flap
transferred. C, Postoperative view at 2 months.
A
B
C

7  ROTATION FLAPS
119
Use of more than one rotation flap for reconstruction
of the scalp is advantageous because it recruits scalp tissue
for reconstruction from different locations and the
burden of closing the secondary defect is shared by
the number of flaps used. This concept was applied to the
repair of the patient shown in Figure 7-14. This patient
presented with a circular defect 9 cm in diameter in the
same location as that of the patient shown in Figure 7-13.
Because the defect was considerably larger, three rotation
scalp flaps were designed to repair the defect rather than
using an O-Z repair. Each flap was responsible for repair
of one-third of the surface area of the defect. Wound
closure was accomplished by pivoting all three flaps
in the same direction and resembled the closing of a
camera lens; the final suture line had the appearance of a
pinwheel.
To use two or more rotation flaps for repair of a scalp
defect, the defect must be located in the central aspect of
the scalp. The two defects presented in this case study
were ideally suited for repair with multiple rotation flaps.
In contrast, for peripherally located defects as in Case 1,
it is often difficult or impossible to design multiple effec­
tive rotation flaps for repair. In such instances, a single
flap is designed larger than would be required if two or
more flaps can be created.
Case 3
A 48-year-old woman developed a recurrent basal cell
carcinoma of the right temple. It had been treated twice
in the past but had recurred. The tumor was resected by
micrographic surgery, and she presented with a 4 × 3-cm
skin defect of the right lateral eyebrow and forehead (Fig.
7-15). The two preferred options for repair of this large
defect were a full-thickness skin graft and a local flap
harvested from the adjacent temple skin. Because of the
flap closed. The portion of scarred scalp that was covered
by the rotation flap was then resected and the wound
repaired after placement of a Penrose drain beneath the
scalp flap. Approximately 90% of the area of alopecia
was excised in a one-stage procedure by this approach
(see Fig. 7-12).
The scalp is inelastic, and therefore any movement of
tissue by advancement is limited. Thus, pivotal move­
ment is the alternative for transfer of scalp flaps. Rotation
flaps are the preferred method to repair most scalp defects
with use of local tissue. The spherical topography of the
scalp accommodates curvilinear incisions necessary for
creation of rotation flaps. Scalp flaps are elevated in the
subgaleal plane for ease of dissection and to maintain
scalp vascularity. In this case, the design of a very large
flap enabled the surgeon to close the secondary defect
without the need for skin grafting or leaving a portion of
the wound to heal by secondary intention.
Case 2
Figure 7-13 shows a circular defect 5 cm in diameter
resulting from micrographic excision of a basal cell car­
cinoma involving the anterior parietal and frontal scalp.
The defect included loss of the periosteum of the skull
in the depths of the wound. This defect could have been
repaired with a single rotation scalp flap. However,
whenever possible, multiple rotation flaps are preferred
to a single flap for scalp reconstruction. Each flap is
designed to pivot on an independent pivotal point. An
O-Z repair was elected for reconstruction of the defect.
The two flaps were laterally based and designed with an
opposite orientation so that they wound pivot in a
clockwise direction. Each flap was designed with an
acute angle and with a length equal to four times the
radius of the defect.
FIGURE 7-13  ■  A, A 5-cm circular full-thickness scalp defect. Dotted lines indicate incision line for rotation flaps. B, Each flap pivoted
in clockwise direction for O-Z wound closure. C, Postoperative view at 6 months.
A
B
C

120
SECTION I  FUNDAMENTALS
FIGURE 7-15  ■  A, A 4 × 3-cm skin defect of forehead including eyebrow. Rotation flap designed for repair. B, Flap incised. Standing
cutaneous deformity excised laterally along bony orbital rim. C, Flap in place.
A
B
C
FIGURE 7-14  ■  A, A 9-cm circular full-thickness scalp defect. Three rotation flaps designed to repair defect. B, All three flaps pivot in
same direction to close defect. C, Postoperative view at 2 months. (From Baker SR: Local cutaneous flaps. Otolaryngol Clin North Am
27:139, 1994.)
A
B
C
large size of the defect, the donor site of any local flap
using skin from the central forehead would be difficult to
close primarily. That option would also create a scar
located more centrally on the face. A large rotation skin
flap from the temple was selected for repair. This flap was
selected because of the circular configuration of the
defect and the possibility of incorporating both pivot and
advancement in the tissue movement of the flap. By
undermining laterally as far as the skin overlying the
malar eminence, considerable advancement of the skin
could be added to the pivotal movement of the flap, thus
reducing wound closure tension. The majority of the
donor site scar could also be aligned within the horizontal
creases of the forehead.
The flap was elevated in the subcutaneous tissue plane
to avoid injury to the temporal branch of the facial nerve.
The standing cutaneous deformity was excised parallel to
the superior bony orbital rim just lateral to the defect,

7  ROTATION FLAPS
121
portion of the donor site scar. It was necessary to extend
the incision for the flap along the border of the sterno­
cleidomastoid muscle.
Figure 7-18 shows a smaller skin defect (3 × 2-cm) in
a location similar to that of the previous case; however, a
portion of the lower eyelid skin was involved with the
defect. A rotation skin flap was designed to repair the
defect. The arc of the border of the flap was designed to
extend well above the level of the eyelid defect to accom­
modate the reduction in effective length of the flap as it
pivoted around its base. This ensured that the flap would
have sufficient height to reach the superior and medial
borders of the eyelid defect without placing excessive
wound closure tension along the suture line of the eyelid
repair. A deep suture of 4-0 polypropylene was used to
anchor the border of the flap to the periosteum of the
lateral bony orbital rim superior to the lateral canthus to
fix the flap in position and to reduce wound closure
tension along the inferior eyelid. The standing cutaneous
deformity was excised lateral to the defect parallel to
RSTLs.
Rotation flaps can be used anywhere on the face;
however, they look best when they are designed so that
the resulting scar is in or approximates the location of
RSTLs of the face or lie along borders of facial aesthetic
regions. Defects larger than 3 cm located on the medial
cheek or over the malar eminence may require sizeable
rotation flaps. This necessitates extensive dissection and
a potentially greater raw surface area for bleeding to
occur than when comparable defects are repaired with
transposition flaps (Fig. 7-19). More important, rotation
flaps used to repair superior medial cheek defects require
incisions perpendicular to RSTLs of the upper cheek.
This often results in unsightly scars. For this reason, I
curving slightly toward the lateral canthus. Figure 7-16
shows the appearance of the forehead 1 year later. The
medial portion of the scar resulting from the repair is
slightly depressed and is diagonal to the horizontal creases
of the forehead. The lateral portion of the scar is barely
visible because it is located in RSTLs.
Case 4
A 65-year-old woman underwent resection of a superfi­
cial melanoma of the right cheek resulting in an irregu­
larly shaped 6 × 5-cm skin defect of the malar eminence
(Fig. 7-17). Reconstruction options for repair of the
defect included a full-thickness skin graft, unipedicle
advancement flap, transposition or bilobe flap, and rota­
tion cheek flap. Although a large superiorly and laterally
based transposition flap could have effectively recon­
structed this defect, a rotation flap with a small back cut
was selected for repair. The flap was designed to recruit
skin from the lateral cheek and upper cervical region.
The anticipated standing cutaneous deformity was
marked with horizontal lines (Fig. 7-17A). The flap was
dissected in the subcutaneous tissue plane to protect the
facial nerve branches to the orbicularis oculi and frontalis
muscle. The defect was lateral to the lower eyelid, so it
was not necessary to arch the border of the flap above the
level of the lateral canthus. When the skin defect is more
medial adjacent to the lower eyelid, it is advisable to
extend the arc of the rotation flap above the level of the
lateral canthus when designing the flap. This will give
added height to the flap, which in turn will reduce wound
closure tension in the area of the eyelid skin. The incision
for the flap extended to the auricle in RSTLs and tucked
beneath the earlobe, a structure that assisted in hiding a
FIGURE 7-16  ■  A, B, Same patient shown in Figure 7-15. Postoperative view at 1 year. No revision surgery performed.
A
B

122
SECTION I  FUNDAMENTALS
FIGURE 7-17  ■  A, A 6 × 5-cm skin defect of cheek in area of malar eminence. Rotation flap designed for repair. Anticipated standing
cutaneous deformity marked by horizontal lines. B, Flap in place. C, D, Postoperative views at 2 years. No revision surgery
performed.
A
B
C
D

7  ROTATION FLAPS
123
was used to repair the defect. The flap was dissected in
the subcutaneous tissue plane, and the standing cutane­
ous deformity was excised at the medial border of the
defect with a horizontal orientation so the resulting scar
would remain parallel to the body of the mandible. A
Z-plasty was designed at the base of the flap to reduce
the need for excision of a Burow triangle along the
peripheral border of the wound. However, it was not
necessary to implement the Z-plasty as the discrepancy
of border lengths between the flap and the remaining
cervical skin was sewn out by use of the principle of
suture halving. This technique is discussed in an earlier
portion of the chapter. In contrast, Figure 7-23 shows a
defect of the chin and submental skin repaired with a
much smaller rotation flap. In spite of a Z-plasty at the
base of the flap, it was necessary to excise a sizeable equal­
izing Burow triangle along the border of the flap. The
wound closure of this excision is represented by the
extension of the suture line medially from the flap.
Because the rotation flap had a shorter border length
compared with the flap design in Figure 7-22, there was
less wound margin available to equalize the discrepancy
in lengths of the wounds by the principle of suture
halving.
Figure 7-24 shows a superior neck skin defect repaired
with a rotation flap. As in the previous two flaps dis­
cussed, a Z-plasty was designed at the base of the flap.
Because this flap had a longer arc to its border than the
flap shown in Figure 7-23, it was not necessary to excise
an equalizing triangle of skin along the border of the flap.
However, in contrast to the larger flap shown in Figure
7-21, the Z-plasty designed at the base of the flap was
necessary to avoid excision of such a triangle of skin. The
three skin defects of the superior neck discussed in this
favor transposition flaps over rotation flaps for medially
located cheek defects. However, rotation flaps work
extremely well for repair of skin defects in the range of
3 to 6 cm located in the preauricular region, where supe­
rior and posterior cervical skin can be recruited into the
flap (Fig. 7-20). The patient shown in Figure 7-21 had a
squamous cell carcinoma of the skin that was removed,
creating a 6 × 6-cm skin defect. A large cervicofacial rota­
tion flap was designed so that the upper posterior neck
skin could be pivoted and advanced toward the defect.
The curvilinear incision was placed juxtaposed to the
earlobe and along the anterior border of the trapezius
muscle near the hairline. An incision in this area of the
neck often produces a favorable scar even though it does
not follow RSTLs. A Z-plasty at the base of the flap
facilitated closure of the secondary defect without the
need for excision of a Burow triangle.
Case 5
Rotation flaps are a useful method of repairing defects
involving neck skin because of the redundancy of cervical
skin relative to the face. In addition, the importance of
placing incisions in RSTLs is less in the neck compared
with the face. This is because cervical incisions perpen­
dicular to RSTLs can be partially hidden by clothing and
tend not to form hypertrophic or depressed scars com­
pared with similar incisions on the face. Figure 7-22
shows a 10 × 7-cm skin defect of the inferior cheek and
upper neck after removal of a basal cell carcinoma in a
65-year-old woman. Lax skin of the neck provides an
excellent source for creating skin flaps with advancement,
transposition, rotation, or a combination of these flap
designs. In this case, a large rotation flap based medially
FIGURE 7-18  ■  A, A 3 × 2-cm skin defect of malar eminence and lateral lower eyelid. Rotation flap designed with arc of flap extending
above level of lateral canthus to accommodate reduction in effective height of flap as flap pivots and to minimize wound closure
tension along eyelid suture line. B, Flap in place. Buried suspension suture placed in periosteum of lateral orbital bony rim. C,
Postoperative view at 6 months. No revision surgery performed.
A
B
C

124
SECTION I  FUNDAMENTALS
FIGURE 7-19  ■  A, Melanoma in situ marked by horizontal lines for excision. Rotation flap designed for repair. Anticipated standing
cutaneous deformity (SCD) marked by vertical lines. B, Skin lesion excised. Rotation flap reflected downward to expose large raw
surface area. C, Flap pivoted toward recipient site. D, E, Standing cutaneous deformity forms at base of flap and requires excision.
F, G, Postoperative views at 2 years. Scar is perpendicular to RSTLs, causing an unsightly appearance.
A
SCD develops here
SCD excised here
Subcutaneous
tissue plane
Secondary
defect
B
C
D
E
F
G

7  ROTATION FLAPS
125
FIGURE 7-20  ■  A, A 3.5 × 2-cm preauricular skin defect. Rotation flap with Z-plasty designed for repair. Anticipated standing cutane­
ous deformity (SCD) marked for excision. B, Flap in place. C, D, Preoperative and 2-month postoperative views. No revision surgery
performed.
A
SCD removed
here
B
C
D
FIGURE 7-21  ■  A, A 6 × 6-cm skin defect of posterior cheek. Large cervical rotation flap designed. Z-plasty at base of flap eliminates
need to excise an equalizing Burow triangle. Standing cutaneous deformity (SCD) excised from inferior medial aspect of defect.
B, Flap in place. SCD removed. C, Postoperative view at 1 year. (From Baker SR: Local cutaneous flaps. Otolaryngol Clin North Am
27:139, 1994.)
A
SCD removed
here
B
C

126
SECTION I  FUNDAMENTALS
FIGURE 7-22  ■  A, A 10 × 7-cm skin defect of cheek and neck. Rotation flap designed for repair. Vertical lines represent anticipated
standing cutaneous deformity as flap pivots. B, Flap in place. Z-plasty at base of flap not necessary to correct discrepancy of wound
border lengths.
A
B
FIGURE 7-23  ■  A, A 3 × 2.8-cm skin defect of chin and neck. Rotation flap with Z-plasty at base of flap designed for repair. Dotted
line represents location of an equalizing Burow triangle excision. B, Flap in place.
A
B
FIGURE 7-24  ■  A, B, A 6 × 5-cm skin defect of neck repaired by rotation flap with Z-plasty at base of flap.
A
B

7  ROTATION FLAPS
127
section support the axiom that the larger the rotation
flap, the less likely is the need to excise an equalizing
Burow triangle along the border of the flap.
Case 6
As discussed in Case 5, rotation flaps are an effective way
of reconstructing skin defects located in the superior
aspect of the neck because redundant skin in the submen­
tal area can be used to create sizeable flaps. Rotation flaps
can also be very useful to repair skin defects of the lower
neck. An example of this is shown in Figure 7-25. A
53-year-old woman had micrographic surgery to remove
a basal cell carcinoma from the right shoulder. The defect
measured 7.5 × 6.3-cm and involved the skin of the lower
neck and supraclavicular region. This defect could have
been repaired with an advancement, transposition, or
rotation skin flap. A rotation flap was designed to recruit
redundant skin from the supraclavicular fossa. A Z-plasty
incision was designed at the base of the flap to facilitate
closure of the secondary defect and to avoid the need to
excise a Burow triangle. The flap was elevated in the
subcutaneous tissue plane, and the donor site was closed
under moderate wound closure tension. Excision of the
standing cutaneous deformity was performed at the
lateral border of the defect parallel to the clavicle. Because
of excessive wound closure tension, a limited hypertro­
phic scar formed along the advancing border of the flap.
The scar hypertrophy regressed in response to triamcino­
lone injections.
Case 7
The patient shown in Figure 7-26 presented with a 1.2 ×
1.2-cm circular skin defect of the upper lip after
FIGURE 7-25  ■  A, A 7.5 × 6.3-cm skin defect of inferior neck. Rotation flap designed for repair. Anticipated standing cutaneous defor­
mity marked with vertical lines. B, Flap in place. Z-plasty eliminated need to excise an equalizing Burow triangle. C, Postoperative
view at 8 months. No revision surgery performed.
A
B
C
micrographic surgery for basal cell carcinoma. The
options for repair of this defect included bilateral advance­
ment flaps, a transposition flap from the cheek, a subcu­
taneous tissue pedicle island advancement flap, and a
rotation flap from the lateral tissues of the lip. A rotation
flap was selected for repair and was designed so that the
border of the flap was positioned in the melolabial crease
with a back cut at the level of the oral commissure. The
standing cutaneous deformity resulting from pivoting of
the flap was excised inferior to the defect. The flap was
elevated superficial to the orbicularis oris and was based
on the subcutaneous tissue of the oral commissure and
on the skin of the lower lip. After the flap was dissected,
a Z-plasty at the base of the flap was used to eliminate
the need to excise an equalizing Burow triangle. The flap
design enabled strategic placement of the wound closure
suture line in the melolabial crease (Fig. 7-26C).
A skin defect of the upper lip in a location similar to
that of the previously discussed defect measured 1.5 ×
2.0-cm and was also repaired with a rotation flap (Fig.
7-27). The arc of the border of the flap was positioned
in the melolabial crease, and the standing cutaneous
deformity resulting from the pivotal movement of the
flap was excised inferior to the defect. Similar to the
previously discussed case, a Z-plasty designed at the base
of the flap was used to facilitate flap transfer without the
need for excising an equalizing Burow triangle of skin.
Postoperatively, the patient developed a hypertrophic
scar of the vertical portion of the repair extending from
the vermilion to the nose. This was corrected with a
Z-plasty 5 months later. The result of the revision surgery
is shown in Figure 7-27C, D.
Although rare relative to the upper lip, skin cancers of
the lower lateral lip do occur and can be repaired with
cutaneous rotation lip flaps similar in design to those

128
SECTION I  FUNDAMENTALS
FIGURE 7-26  ■  A, A 1.2 × 1.2-cm skin defect of lateral upper lip. Rotation flap designed for repair. Horizontal lines represent anticipated
standing cutaneous deformity (SCD). Back cut designed to facilitate pivotal movement. B, Flap in place. Z-plasty designed to elimi­
nate need to excise an equalizing Burow triangle. C, Majority of wound closure suture line positioned in melolabial crease for
maximum scar camouflage. D-G, Preoperative and 3-year postoperative views. Hypopigmentation causes noticeable scar. No revi­
sion surgery performed.
A
SCD removed
here
Back cut
Z-plasty incision
B
C
D
E
F
G

7  ROTATION FLAPS
129
FIGURE 7-27  ■  A, A 1.5 × 2.0-cm skin defect of upper lip. Rotation flap designed with Z-plasty at base. B, Flap in place. C, D, Postop­
erative views at 1 year. Z-plasty performed on vertical portion of scar.
A
B
C
D
FIGURE 7-28  ■  A, A 5 × 3-cm skin defect of lower lip. Rotation flap designed for repair. Arc of flap positioned parallel to melolabial
crease. Anticipated standing cutaneous deformity (SCD) marked for excision along border of upper vermilion. B, Flap in place.
C, Postoperative view at 1.5 years. No revision surgery performed.
A
SCD removed here
Defect squared
B
C
already discussed. In such circumstances, flaps are
designed to be based superiorly, recruiting the remaining
skin of the lateral lower lip and the commissure area into
the flap. Like inferiorly based flaps, superiorly based flaps
are designed so that their borders lie within or parallel to
the melolabial crease. An example of this type of flap is
seen in Figure 7-28. The defect resulted from excision of
a morpheaform basal cell carcinoma and was repaired
with a cutaneous rotation flap from the skin of the upper
lip and medial cheek. As in the upper lip defects previ­
ously discussed, the standing cutaneous deformity was
excised along the vermilion-cutaneous border, and the
majority of the flap border remains parallel to the melo­
labial crease to provide maximum scar camouflage.

130
SECTION I  FUNDAMENTALS
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1969;44:147.
16. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr
Surg 1967;40:147.
17. Rigg BM. The dorsal nasal flap. Plast Reconstr Surg 1973;52:361.
18. Marchac D, Toth B. The axial frontonasal flap revisited. Plast
Reconstr Surg 1985;76:686.
19. Rohrich RJ, Muzaffar AR, Adams WP Jr, et al. The aesthetic unit
dorsal nasal flap: rationale for avoiding a glabellar incision. Plast
Reconstr Surg 1999;104:1289.
20. Johnson TM, Swanson NA, Baker SR, et al. The Reiger flap for
nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;
121:634.

131
C H A P T E R 8 
TRANSPOSITION FLAPS
Shan R. Baker
INTRODUCTION
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 manner that one border of the flap is
also a border of the defect for which it is intended to repair.
Like rotation flaps, transposition flaps may be designed so
that one border of the flap is also a border of the defect;
however, the transposition flap may also be designed with
borders that are removed from the defect. In this circum­
stance, 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. Depending 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 peripheral border of the flap. Transposition flaps
are the most common flap design used to repair skin
defects of the head and neck. They are designed in a mul­
titude of sizes, shapes, and orientations. A transposition
flap as a reconstructive option is applicable to almost any
conceivable situation in which a local flap is required to
repair small to medium-sized cutaneous defects of the
face. This fact makes transposition flaps the most useful
of local flaps in head and neck reconstruction.
Transposition flaps are usually designed as random
cutaneous flaps but may occasionally be axial or com­
pound. Although the majority of flaps on the face have a
random blood supply, the abundant vascularity of the skin
of the face and scalp often enables the successful transfer
of flaps that exceed the 3 : 1 ratio of length to width. More
important than such a ratio are the location and orienta­
tion of transposition flaps. For example, a superiorly or
inferiorly based melolabial transposition flap can be suc­
cessfully transferred with a length considerably longer
than three times the width of the base. This is due to
orienting the linear axis of the flap directly above and
parallel to the linear axis of the angular artery. Although
the flap is rarely elevated as a true axial flap incorporating
the angular artery, many small peripheral branches of the
artery are probably included in the base of the melolabial
flap. This accounts for its dependable vascularity when it
is designed even as a lengthy flap.
Transposition flaps can be designed in a number of
different configurations; however, their linear dimension
is always longer than their width. Common configura­
tions of transposition flaps are listed in Table 8-1. The
majority of facial cutaneous defects are repaired with
transposition flaps designed as a rectangle, parabola, or
rhombus. A rhombic flap and its modifications are trans­
ferred to the recipient site by advancement as well as by
pivoting. However, I discuss them here because their
major method of movement is pivotal, and like pure
pivotal flaps, they develop a single standing cutaneous
deformity at their base. Z-plasty and bilobe flaps repre­
sent the use of two transposition flaps concomitantly. In
the case of Z-plasty, diagonally opposing triangle-shaped
flaps trade locations after transposition. A bilobe flap
represents two transposition flaps designed on a common
base. However, each lobe has an independent pivotal
point, and each lobe develops an independent standing
cutaneous deformity.
There are a number of advantages of using transposi­
tion flaps. The greatest advantage is the ability to harvest
a flap at some distance from the location of the defect.
This advantage offers the surgeon the ability to use donor
sites on the face with greater skin elasticity and redun­
dancy. It also often allows placement of donor site scars
in the most advantageous locations, providing the best
possible donor scar. Transposition flaps can be designed
in a number of configurations to adapt to irregularly
shaped defects. Ample quantities of subcutaneous fat may
be left attached to the undersurface of the flap and can
be transferred with the cutaneous portion of the flap to
assist with filling of deep facial defects. Another advan­
tage of transposition flaps is that a lengthy flap relative
to the width of the base can be developed, and this facili­
tates closure of the donor defect without excessive wound
closure tension. Specifically, the secondary defect for
rectangular and parabola-shaped flaps is elliptical, allow­
ing them to be easily closed. In addition, closure of donor
sites for parabola-shaped flaps usually does not require
excision of a standing cutaneous deformity.
Because transposition flaps are pivotal flaps, the greater
the arc of pivotal movement, the greater will be the size
of the standing cutaneous deformity and the less will be
the effective length of the flap. Pivoting a transposition
flap 45° from its in situ position reduces the effective
length 5%. A 90° and 180° pivot reduces length by 15%
and 40%, respectively (see discussion in Chapter 6).1 The
reduction in effective length must be accounted for when
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132
SECTION I  FUNDAMENTALS
of flap movement and effective length, there is a direct
and positive association between the degree of pivoting
and the size of the standing cutaneous deformity. The
greater the pivot of the flap, the larger is the deformity
that develops from the pivotal movement. Thus, increas­
ing the flap’s pivot will shorten the effective length,
increase wound closure tension (if it is not designed suf­
ficiently long), and change the flap’s shape as a result of
forming a standing cutaneous deformity. To limit these
restricting factors, whenever possible, transposition flaps
should be designed not to pivot more than 90°.
In the majority of cases, standing cutaneous deformi­
ties resulting from transposing flaps can be resected at the
time of the initial flap transfer to the recipient site. Exci­
sion should always be in a vector that diverges from the
base of the flap so vascularity is not unduly impaired (Fig.
8-1). For scalp and large transposition flaps of the face, it
may be prudent to delay excision of the deformity for 4
to 6 weeks to allow revascularization of the distal flap.
FIGURE 8-1  ■  Transposition flaps are pivotal flaps that form single standing cutaneous deformities (SCD) at base of flap. Only base
of flap must be contiguous with defect. Excision of SCD should always be in vector that diverges from base of flap to minimize
impairment of blood supply. Opposing arrows indicate area of greatest wound closure tension.
SCD forms here
CORRECT
INCORRECT
SCD forms here
CORRECT
INCORRECT
TABLE 8-1 Common Configurations of
Transposition Flaps
1. Classic
Rectangular
Parabola
2. Triangular
Note
30° Webster
3. Bilobe
4. Rhombic
60°-120° Limberg
Dufourmentel
5. Z-plasty
6. Island
May assume any shape
transposition flaps are designed, so that greater pivoting
requires a longer design of the flap. The most common
error in using transposition flaps of any kind is to design
the flap too short because of a poor understanding of this
concept. As transposition flaps turn in an arc around their
relatively fixed pivotal point, a standing cutaneous defor­
mity forms. Similar to the relationship between the arc

8  TRANSPOSITION FLAPS
133
frequently can avoid these problems. Small flaps of this
design can also be used to repair defects of the dorsum
and sidewall of the nose, chin, and upper and lower lips.
Transfer of skin or of skin and muscle from the upper to
the lower eyelid to repair anterior lamellar defects may
readily be accomplished by using either medially or later­
ally based cutaneous or musculocutaneous (containing
orbicularis muscle) transposition flaps.
When transposition flaps are used to repair small
(2 cm or less) cutaneous defects of the cheek, they may
be based superiorly or inferiorly. However, transposition
flaps used to repair defects larger than 3 cm should be
superiorly based because there is more redundancy of
facial skin in the inferior regions of the cheek. Transposi­
tion flaps used for repair of medial cheek defects are best
designed so that the donor site is in the vicinity of the
jowl. The jowl is the area of greatest facial skin redun­
dancy. In older patients, this redundancy can provide a
source for a large flap and still enable primary closure of
the donor site. Superiorly based flaps maximize the use
of skin in the area of the jowl. In such instances, flaps
should be designed so that whenever possible, closure of
the donor site is in the melolabial and labiomandibular
creases. The standing cutaneous deformity is removed
just lateral to the superior border of the defect.
In the lateral cheek, transposition flaps are the pre­
ferred method of reconstructing small defects (less than
3 cm). Larger defects are best repaired with rotation
advancement flaps designed to recruit upper cervical skin.
As in the medial cheek, transposition flaps used for repair
of defects in the lateral cheek should be based superiorly.
Skin immediately above the angle of the mandible serves
as the donor tissue for the flap. This is the preferred
donor site because the inferior cheek skin has greater
redundancy and mobility compared with skin in the
lateral superior cheek near the temple. The increased
mobility is attributed to the presence of the platysmal
muscle covering the mandible.
Island Transposition Flaps
Most transposition flaps used on the face have a cutane­
ous pedicle and a random blood supply. However, island
transposition flaps based on an axial blood supply can be
harvested from the region of the forehead and medial
cheek. In the forehead, the flap is transferred with the
supratrochlear artery and vein. Such flaps have limited
use for facial reconstruction but can be used to repair
defects located on the upper nasal dorsum or medial
canthus. Park and colleagues have shown that the supe­
rior labial artery gives rise to an artery to the nasal septum
that divides into a superficial and deep branch and a
second independent artery to the nasal ala.4 The deep
division of the septal artery can be used to nourish a size­
able mucosal island axial transposition flap harvested
from the inner aspect of the upper lip. This flap can be
used to reconstruct large defects of the vermilion. Simi­
larly, a sizeable island transposition flap harvested with
the skin and subcutaneous tissue of the upper melolabial
fold can be transferred as an axial flap based on the alar
artery, which arises from the facial artery just before the
vessel gives rise to the superior labial artery. Common
A disadvantage of transposition flaps is the potential
for development of a trap-door deformity.2,3 The defor­
mity is present when the flap appears bulky, protruding
above the surface of the surrounding skin and giving the
appearance of a pincushion. This complication tends to
occur a few weeks after transfer. Trap-door deformity
occurs most often when curvilinear incisions are made at
the distal border of flaps. Concentric contraction of the
resulting scar presumably causes the curvilinear arc of the
scar to contract toward its center, which in turn forces
the skin to protrude outward above the surface of the
surrounding skin. Creating straight rather than curved
incisions and designing the distal border of the flap with
an angle instead of an arc prevents curvilinear scars.
Trap-door deformity may also develop because adjacent
tissue surrounding the recipient site is not sufficiently
undermined at the time of transposition. The sheet of
scar that forms between the undersurface of the flap and
the depth of the defect contracts in a concentric fashion.
Contraction of the scar beneath the flap causes the flap
to bulge outward. Fortunately, trap-door deformity
usually resolves with time. Trap-door deformities can be
minimized or prevented by wide subdermal undermining
of the margins of the primary defect and using a flap with
the same thickness as the depth of the recipient site. For
defects located in skin with sebaceous gland hypertrophy,
it is helpful to maintain the bevel of the defect resulting
from micrographic surgery or to create one and counter­
bevel the edge of the flap. This creates a diagonally
sloping scar beneath the epidermis that may reduce con­
centric scar contraction. As noted, concentric scars are a
common cause of trap-door deformity.
When trap-door deformity does develop, it always
occurs within the first 3 months postoperatively. The
deformity can usually be treated medically by injecting
0.1 to 1 mL (depending on the size of the flap) of triam­
cinolone acetonide (10 mg/mL) into the area of the
deformity and at the base of the flap. Injection should
begin 4 weeks postoperatively and should be repeated
two or three times at 6-week intervals. Injections should
be placed deeply in the subcutaneous fat, not immediately
beneath the dermis. Superficial injection may cause
atrophy or telangiectasias of the flap’s skin.
If the deformity has not resolved after 8 months, a
frequently successful solution is scar revision. This is
achieved by making an incision through a portion of the
scar surrounding the flap, dissecting beneath the flap, and
removing excessive subcutaneous fat and scar followed by
wound closure. It is also beneficial to perform a Z-plasty
in the area of the incision.
APPLICATIONS
Classic Design
The rectangle- or parabola-shaped transposition flap is
commonly used for repair of cutaneous defects of the
medial and lateral cheek, temple, and glabellar area (Fig.
8-2). A linear closure of cutaneous defects of the temple
often results in elevation of the lateral brow or webbing
of the lateral canthus. The use of transposition flaps

134
SECTION I  FUNDAMENTALS
FIGURE 8-2  ■  A-D, Rectangle-shaped transposition flaps most frequently used for repair of cutaneous defects of medial and lateral
cheek.
A
B
C
D

8  TRANSPOSITION FLAPS
135
Rhombic Flap
The rhombic flap is a common flap used by plastic sur­
geons. The flap is discussed in great detail in Chapter 11.
Transfer of the flap involves advancement and pivotal
tissue movement. A rhombus can be considered a square
usually tilted toward one side. The greater the tilt of the
rhombus, the greater is the discrepancy in length between
the short and long diagonals of the rhombus. A rhombus
may have right angles, in which case it is also a square;
however, in addressing rhombic flaps, the rhombus-
shaped defect is usually not square in configuration, so
opposing interior angles are obtuse or acute. The classic
rhombic flap described by Limberg is used to repair a
defect that has a configuration of a rhombus with two
opposing 60° and two opposing 120° interior angles (Fig.
8-4).7 The 60° to 120° rhombus can be thought of as two
equilateral triangles placed base to base. This means the
short diagonal of the rhombus is equal in length to the
sides of the rhombus. The Limberg flap is designed to
repair a defect of this configuration. The flap is designed
by extending the line of the short diagonal a length equal
to the diagonal, which is also the length of the side of the
defect. This creates the first side of the flap. A second
line is then drawn of equal length parallel to either adja­
cent side of the defect. Because there are two sides adja­
cent to the extended diagonal, two flaps can be designed.
In addition, because the short diagonal can be extended
in two directions from the rhombic defect, a total of four
flaps can be designed around a rhombus-shaped defect.
The majority of wound closure tension is at the donor
site and has been calculated to be 20° to the short diago­
nal of the rhombus defect (see Fig. 8-4).8 Skin mobility
and extensibility are important to consider in designing
a rhombic flap, and an understanding of the resultant
wound closure tension vector is critical to avoid distor­
tion of surrounding facial structures.
There are a number of variations in the design of
rhombic flaps. A useful variation is a 30° rhombic flap.
An M-plasty may be combined with transposition of the
examples of island transposition flaps used in the head
and scalp are flaps from the forehead transferred to the
upper nose, temporal hair-bearing scalp flaps transferred
to the anterior scalp to treat male pattern baldness, and
palatal mucoperiosteal flaps transferred to the nasal
surface of the velum.
Note Flap
The note flap described by Walike and Larrabee is an
angular transposition flap that, when designed, looks like
a musical eighth note.5 This flap allows one to close a
circular defect with a triangular transposition flap that
maximizes the use of surrounding tissue (Fig. 8-3).6 The
flap is designed by first drawing a tangent on either side
of the circle parallel to relaxed skin tension lines (RSTLs).
The tangent should have the length of 1.5 times the
diameter of the circular defect. At the end of the tangent
line, a 50° to 60° angled flap is designed, with the second
side of the flap having a length approximately equal to
the diameter of the circle.6 The flap is transposed into
the defect, and the distal tip of the flap is trimmed so that
there is no wound closure tension. As with rectangular
and parabolic transposition flaps, the greatest wound
closure tension is at the closure of the donor site. In the
case of the note flap, the greatest wound closure tension
is approximately perpendicular to the tangent line created
when the flap is designed. The surface area of the note
flap is designed so that it is 25% less than the area of the
defect; thus clinical judgment is required when this flap
is used. The flap is recommended primarily for small
(2 cm or less) skin defects. Because the pivotal arc of the
note flap is approximately 45°, a minimal standing cuta­
neous deformity develops that may not require excision.
Standing cutaneous deformities of larger flaps will require
subsequent surgical revision unless the deformities are
removed at the time of flap transfer. I use the note flap
primarily for defects on the cheek, temple, and lateral
nasal sidewall. However, it may be used everywhere on
the head and neck, including the lip.
FIGURE 8-3  ■  Note flap has configuration of musical eighth note. The note flap is used for repair of circular skin defects 2 cm or less
in size. One side of flap drawn parallel to relaxed skin tension lines and tangent to defect has length of 1.5 times diameter (D) of
defect. Second side of triangle-shaped flap forms 50° to 60° angle with first side and is length of diameter of defect. Point of greatest
wound closure tension is indicated by opposing arrows.
1.5 D
60°
D
D

136
SECTION I  FUNDAMENTALS
flap.9 The 30° rhombic flap has the advantage of mini­
mizing the standing cutaneous deformity because there
is less pivotal movement than with the classic Limberg
flap. When it is used, the M-plasty reduces the length of
excision necessary to remove the standing cutaneous
deformity. The 30° rhombic flap can be designed by
approximately halving an equilateral triangle.6 The length
of the side of the triangle should be the length of a side
of the defect (Fig. 8-5). The angle of the apex of the
transposition flap is 30°. The width of the base of the flap
is half the greatest width of the defect (see Fig. 8-5).6
The Dufourmentel modification of the rhombic flap
can be used for rhombus-shaped defects that have any
combination of interior angles, not just those of 60° to
120°. It is particularly useful for repair of rhombic defects
FIGURE 8-5  ■  A 30° rhombic transposition flap designed by approximately halving an equilateral triangle. Length of triangle side is
length of side of defect (A). Angle formed at apex of triangle-shaped flap is 30°. Width of flap is half widest width of defect (B). Point
of greatest wound closure tension is indicated by opposing arrows. Standing cutaneous deformity (SCD) forms at base of flap.
A
SCD
A
30°
1/2 B
Pivotal
point
B
•
FIGURE 8-4  ■  Limberg flap used for repair of skin defects that have configurations of a rhombus with two opposing 60° and two
opposing 120° interior angles. Flap designed by extending line of short diagonal equal to diagonal length. Second line drawn of
equal length parallel to either adjacent side of defect. Point of greatest wound closure tension is indicated by opposing arrows.
Standing cutaneous deformity (SCD) forms at base of flap.
Pivotal
Advancement
120°
60°
Pivotal point
•
SCD
with acute angles of 60° to 90° when the surgeon does
not wish to excise additional tissue to create a 60° to 120°
rhombus.6 The flap is designed first by bisecting the angle
between the extension of the short diagonal and one of
the sides of the defect (Fig. 8-6). The bisecting line is
extended a length equal to the length of a side of the
defect. This creates the first side of the flap. A second
line of the same length is drawn parallel to the long
diagonal of the rhombus defect. This creates the second
side of the flap that is not parallel to the side of the defect,
as with the Limberg flap. Like in other transposition flaps
designed to close rhombus-shaped defects, the greatest
wound closure tension is at the closure site of the donor
defect. Therefore, whenever possible, the donor site
closure should be planned so that it is parallel to the lines

8  TRANSPOSITION FLAPS
137
of maximum extensibility (LME) and perpendicular to
RSTLs.
Rhombus-shaped transposition flaps are useful for
repair of defects anywhere on the face and neck but are
particularly helpful for defects on the cheek and temple.
When designing a rhombic flap, the surgeon must select
the optimum flap for a given defect. The surgeon first
draws two lines parallel to the LME and creates rhom­
boids. The four possible rhombic flaps are then concep­
tualized. Of the four flaps, two will have a short diagonal
parallel to the LME, and one of these should be selected.6
If one flap is near a mobile facial structure, the other
should be used. Design of a rhombic flap is more complex
than that of most other facial skin flaps because of the
exact geometry and option of placing the flap in four
separate locations about the defect. I do not frequently
use the rhombic flap in my practice because most micro­
graphic defects are not rhombus shaped, and to convert
the defect to a rhombus requires discarding normal tissue
unnecessarily. In addition, the scar is usually more visible
than when other flaps are used because approximately
half of the entire length of the resulting scar does not
parallel or does not fall within the RSTLs of the face.
This disadvantage is more important in the area of the
forehead and lips, where skin creases are more promi­
nent, and less important in the cheek and temple, where
creases are not as prominent, the skin is thinner, and the
resulting scar tends to blend better with the adjacent skin.
Z-Plasty
Z-plasty is discussed in detail in Chapter 14. Z-plasty can
be considered a double transposition of triangular flaps,
FIGURE 8-6  ■  Dufourmentel flap designed by bisecting angle between extension of short diagonal and one side of defect. Length of
bisecting line extended length of side of defect (A). Line of same length creating second side of flap drawn parallel to long diagonal
of rhombic defect. Point of greatest wound closure tension is indicated by opposing arrows. Standing cutaneous deformity (SCD)
forms at base of flap.
SCD
A
Pivotal point
•
A
A
Advancement
each with independent points of pivot. When the flaps
are rounded at their ends, the process is sometimes
referred to as S-plasty. In Z-plasty, one flap is transposed
about its pivotal point in a clockwise direction, the other
in a counterclockwise direction. In addition to pivoting,
the flaps are advanced into their triangular recipient sites.
Thus, to achieve proper flap movement, it is necessary to
undermine widely at the base of each flap. When Z-plasty
is used for scar revision, it is designed so the scar is posi­
tioned in and oriented along the central limb of the Z.
With this design, Z-plasty changes the direction of the
old scar and relieves scar contracture at the expense of
increasing the final length of the scar that results from
revision. Z-plasty can be used to “lengthen” or to release
a segment of skin distorted by scar contraction. Advance­
ment, not the pivotal movement of the flaps, accounts for
the lengthening in the axis of scar contracture. This is
because, in essence, skin adjacent to the scar is recruited
through the mechanism of advancement to augment the
contracted area. The larger the triangular flaps used in
Z-plasty, in terms of both the angles of the tips of the
flaps and the length of the sides of the flaps, the greater
the amount of skin advanced toward the contracted site
and the greater the lengthening of the contracted
segment. However, the greater the angles of the triangu­
lar flaps, the greater are the standing cutaneous deformi­
ties that result from the pivotal movement of the flaps.
Likewise, the longer the limbs of the Z-plasty, the greater
will be the length of the final revised scar. Used appro­
priately, Z-plasty is a highly effective method of improv­
ing the appearance of scars, relieving tension during
wound closure, and correcting scar contraction causing
distortion of facial structures.

138
SECTION I  FUNDAMENTALS
always have to be equal; however, the three limbs of the
Z must be of similar length owing to the requirement
that the flaps outlined by the limbs are interchanged and
their common borders sutured together.
Z-plasty is most often used to lengthen the axis of a
scar that is causing deformity of adjacent facial skin or
facial structures. It may also be employed to prevent
contracture of a scar by using the technique at the time
of suturing a linear incision or laceration. This is particu­
larly useful in repair of lacerations that do not parallel
RSTLs.
Z-plasty is commonly used to change the orientation
of a scar that does not parallel RSTLs. The degree of
realignment of a given scar depends on the angle of the
Z-plasty and the orientation of the scar. The greater the
angle of the Z, the greater is the change in scar orienta­
tion. Z-plasty may also be used to correct trap-door
deformity. This often occurs when a flap has a curvilinear
border that does not follow RSTLs. The curvilinear scar
is divided into segments and several Z-plasties are created.
Z-plasties help realign the scar so that portions of it are
parallel to RSTLs. They also convert a circular scar into
an irregular one that has fewer propensities for concen­
tric contraction, a major contributor to trap-door
deformity.
Z-plasty may be an effective method of effacing a skin
web. By transposing the short diagonal, which is posi­
tioned on the crest of the web, with the long diagonal
position at an angle to the web, the transposition of the
Z-plasty flaps creates an elongation of tissue in the place
of the previous web. Some underlying hypertrophic scar
must also usually be removed for this procedure to be
successful. Z-plasty is particularly useful in correcting
scars that cause webs in the area of the medial canthus.
Multiple Z-plasties are often required to correct the web
(Fig. 8-8).
Standing cutaneous deformities, rather than being
excised, may sometimes be treated by Z-plasty. This
method is most useful with unipedicle advancement flaps
(Fig. 8-9). Z-plasties on either side of the base of the
advancement flap are designed so that their limbs extend
outward away from the base of the flap. This design
prevents the Z-plasties from compromising the vascular­
ity of the flap. The Z-plasties in effect redistribute
the tissue of the standing cutaneous deformities by
moving the deformities in the same vector as the flap
movement.
A Z-plasty may be helpful in repair of an oval skin
defect whose long axis is not parallel to RSTLs. Trian­
gular flaps are designed adjacent to the long axis of the
oval so that when the flaps are transposed, the central
limb of the Z (long axis of the oval) is realigned with the
RSTLs (Fig. 8-10). Similarly, a circular skin defect may
also be repaired by modified Z-plasties, which cause the
suture line of the wound closure to assume a zigzag shape.
This is accomplished by designing two modified
Z-plasties, one on either side of the circle and with oppo­
site orientation.11 With use of a compass, two circles of
the same size as the skin defect are drawn opposite each
other on each side of the defect. The centers of the circles
are shifted the length of one radius toward the defect so
that two new circles can be constructed in which points
The standard Z-plasty design is a Z-shaped figure with
a central limb and two peripheral limbs, all of equal
length. The peripheral limbs are extensions from each
end of the central limb and are on opposite sides and
parallel to each other so that the two angles thus formed
are equal. The central limb represents the area of desired
lengthening or alterations in orientation. The principle
of Z-plasty can be better understood if the figure is com­
pleted by drawing lines across the bases of the two trian­
gular flaps outlined by the Z-plasty, thus forming a
parallelogram (Fig. 8-7).10 The central limb of the Z
becomes the short diagonal of the parallelogram, and an
imaginary line joining the outer ends of the two periph­
eral limbs becomes the long diagonal. Transposing the
two triangles formed by the flaps will result in replace­
ment of the short diagonal of the parallelogram (central
limb of the Z) with the long diagonal.10 Thus a Z-plasty
has the effect of interchanging the existing short diagonal
for the long diagonal of the parallelogram. The differ­
ence between the lengths of the two diagonals is the
amount of lengthening in the direction of the central
limb of the Z that may be obtained after the flaps are
transposed.10 This difference in length of the two diago­
nals becomes greater by lengthening the limbs of the Z.
Similarly, the wider the angle of the triangular flaps, the
greater is the difference between the short and long diag­
onals. The wider the angle, the greater the gain but also
the greater the pivotal arc of the two flaps, resulting in
larger standing cutaneous deformities. Larger deformi­
ties make it more difficult to achieve transposition without
the need for excision of the deformities. Likewise, flaps
with smaller angles are easy to transpose with no signifi­
cant standing cutaneous deformities but afford minimal
change in length and risk vascular compromise of their
tips. The approximate percentages of elongation in the
direction of the central limb that can be expected from
Z-plasties of 30°, 45°, and 60° are 25%, 50%, and 75%,
respectively. Most often, Z-plasty flaps with 60° angles
provide an adequate margin of safety from the standpoint
of flap vascularity and also provide for significant length­
ening of scar contracture. The angle of the Z-plasty is
also influenced by the anatomic location of the Z-plasty
and the clinical situation.
Because creating a Z-plasty with longer limbs will
provide greater release of scar contracture, it is tempting
to design Z-plasties with long limbs. However, the longer
the limbs of the Z, the greater will be the length and
visibility of the overall scar. This is because the length of
a Z-plasty scar consists of the central limb plus the two
peripheral limbs, which are new scars created by the flaps;
thus overall length of the scar compared with the original
one is significantly increased. This is calculated to be
approximately 200% of the length of the central limb of
the Z.10 Although relatively large Z-plasties may be effec­
tively used in the neck, Z-plasties on the face are best
designed so that the limbs are no greater than 0.5 cm. If
greater release of scar contracture is required than what
a 0.5-cm Z-plasty can provide or the scar being revised
with Z-plasty is longer than 0.5 cm, multiple Z-plasties
should be used. In such circumstances, the number of
flaps designed depends on the length of the scar being
revised. The angles of the flaps of a Z-plasty do not

FIGURE 8-7  ■  Principle of Z-plasty may be understood if parallelogram is formed containing two opposing triangular flaps of Z-plasty.
Central limb of Z-plasty is short diagonal of parallelogram. Transposing triangular flaps result in replacement of short diagonal with
long diagonal of parallelogram. Difference in length between diagonals is amount of lengthening in direction of central limb of Z
that may be obtained after transposing flaps. Difference in length of two diagonals becomes greater by increasing angle of flaps.
x
x
a
b
x
x
y
Original scar
y
x
y
y
b
a
A
B
C
D
FIGURE 8-8  ■  Z-plasties may be an effective method of correcting skin webs in region of medial canthus. Central limb of Z placed
along crest of web.
1
2
4
3
1
2
3
4

140
SECTION I  FUNDAMENTALS
first and second lobes of the flap are the location of the
defect and the availability of donor skin for construction
of the two lobes. In such instances, the first and second
lobes are designed in areas of greatest skin laxity or in
areas where scar camouflage will be maximized. This may
on occasion necessitate design of the second lobe along
an axis that is 180° to the axis of the defect. The major
advantage of bilobe flaps is the ability to recruit redun­
dant skin for construction of the flap from areas that are
not adjacent to the defect. This skin redundancy may be
located at some distance from the defect and may be dif­
ficult to transfer to the recipient site by other surgical
approaches. In general, bilobe flaps are designed in such
a way that the first lobe is immediately adjacent to the
defect and has a surface area that is less than the surface
area of the defect. Thus, part of the closure of the defect
is achieved by secondary movement of surrounding skin
through direct advancement. The relationship of the
surface area of the first lobe compared with the surface
area of the defect depends on the location of the defect
on the face and the elasticity of skin surrounding the
defect. On the lower nose, for instance, the first lobe
must nearly approximate the size of the defect because
of the inelasticity of nasal tip skin. However, on the
cheek, the first lobe may be designed considerably smaller
than the size of the defect (up to 25% less in surface area)
because of the elasticity of the skin of the cheek. The
on their circumferences touch in the center of the defect.
The four circles provide a template for designing two
modified Z-plasties with flaps that have curved borders
(Fig. 8-11). These borders can be designed more angu­
lated if desired. The flaps are transposed without the
need to excise standing cutaneous deformities, and the
resulting scar has a zigzag configuration.
Bilobe Flaps
Bilobe flaps are discussed in detail in Chapter 12. Bilobe
flaps are double transposition flaps that share a single
base. Similar to single transposition flaps, bilobe flaps
move around pivotal points located at their base and
develop standing cutaneous deformities as they pivot.
Because each flap or lobe moves around an independent
pivotal point, each lobe develops an individual standing
cutaneous deformity. The greater the arcs of rotation
about their pivotal points, the larger are the standing
cutaneous deformities. To minimize these deformities, it
is wise to limit the degree of movement through the arc
by orienting the linear axis of each lobe approximately
45° from the other, with the axis of the first lobe oriented
45° from the axis of the defect for a total arc of movement
of 90° to 110°. This is more important on the nose than
on the cheek. When bilobe flaps are used on the cheek,
the primary factors in determining the position of the
FIGURE 8-9  ■  Z-plasties on either side of base of advancement flap redistribute tissue of standing cutaneous deformities by moving
deformities in same vector of advancement as flap movement.
x
y
x
y
y
x
y
x
FIGURE 8-10  ■  Z-plasty may be helpful in repairing oval skin defect when long axis is not parallel to relaxed skin tension lines (RSTLs).
Triangular flaps are designed adjacent to long axis of oval so that when flaps are transposed, central limb of Z (long axis of oval)
is realigned with RSTLs.
RSTL
x
y
y
RSTL
x

8  TRANSPOSITION FLAPS
141
second lobe of a bilobe flap is usually designed so that its
surface area is less than the surface area of the defect left
by harvesting of the first lobe. Again, advancement of
adjacent skin assists the second lobe in repair of the donor
site of the first lobe. The defect left by the second lobe
is closed primarily by direct advancement of surrounding
skin. Thus, for the bilobe flap to work, there must be
considerable skin laxity in the vicinity of the first and
second lobes to achieve wound repair without excessive
wound closure tension.
The bilobe flap is best suited for reconstruction of
circular cutaneous defects on the caudal third of the nose.
In this location, reconstruction with other types of nasal
cutaneous flaps is difficult. The bilobe nasal flap enables
the surgeon to repair defects using adjacent skin without
causing nasal distortion. The aesthetic result is excellent
and often surpasses the result with use of full-thickness
skin grafts. This is especially true for deep nasal cutane­
ous defects. As a consequence, the bilobe flap is a pre­
ferred flap for reconstruction of the caudal nose in the
area of the tip and lower dorsum.
FIGURE 8-11  ■  Circular skin defects may be repaired by modified Z-plasties, which cause suture line of wound closure to assume
zigzag configuration. Two circles of size of defect are drawn opposite each other on each side of defect. Centers of circles are shifted
the length of one radius toward defect, and two new circles are drawn. Four circles provide template for designing two modified
Z-plasties with flaps that have curved borders. RSTL, relaxed skin tension line.
w
z
x
y
r
r
RSTL
RSTL
z
w
y
x
z
w
A
B
C
x
y
Variations of the bilobe flap are useful. On the nose,
the flap may be based medially, although it works best
and is most often designed with a lateral base. The lobes
of the flap may be designed in rhombic shapes for smaller
defects. The bilobe flap may be used for large defects
located on the cheek in lieu of a larger cervicofacial rota­
tion advancement flap. It also may be useful for transfer
of skin from the postauricular area to cover helical rim
defects that might otherwise require skin grafting.
The primary disadvantage of the bilobe flap is that
most of the incisions necessary to create the flap produce
scars that do not parallel RSTLs. The resulting scar is
also lengthy due to the need to elevate two lobes. Because
bilobe flaps have curvilinear incisions, they are prone
to develop a trap-door deformity. This is especially
true when they are used on the nose in patients with thick
skin or with sebaceous gland hyperplasia. Trap-door
deformity may be minimized by extensive peripheral
undermining of the nasal skin as far laterally as the
cheek. Adjusting the thickness of the first lobe so that it
matches the depth of the recipient site is accomplished

142
SECTION I  FUNDAMENTALS
standing cutaneous deformity to assist with closure of the
wound means that less of the deformity will require exci­
sion, preserving more of the nasal skin.
Case 3
A 76-year-old woman was treated for two independent
melanoma in situ skin lesions of the upper and lower
cheek. The margins of the skin lesions were cleared by
the square technique, which consists of the following
(Fig. 8-15).12,13 A Wood’s lamp (UVA black light) is used
to visualize the skin lesion. This may help distinguish any
subclinical extension. With use of the lamp, a margin is
outlined at 0.5 to 1 cm beyond the clinically apparent
borders of the lesion with the intent to establish margins
that are free of atypical junctional melanocytic hyperpla­
sia (AJMH), which is thought to represent a precursor of
melanoma. The margins around the lesion are marked
such that the borders of the margins are straight with
geometric sharp-angled corners. Thus, a shape with a
square, rectangle, or diamond configuration is created
around the lesion. The geometric configuration with
angled corners facilitates tissue processing and precise
orientation for total peripheral margin histologic exami­
nation. After the area is injected with local anesthetic, a
double bladed scalpel is used to remove a 2-mm-wide
strip of skin along each of the marked linear margins. A
“square” of tissue is removed in block from the patient.
The tissue square, which contains 100% of the peripheral
skin margin of the lesion, is tagged with a suture for
orientation. The resulting geometric-shaped wound strip
is sutured closed with a running nonabsorbable suture.
The central island of skin that contains the melanoma or
AJMH is left intact while the skin margins are assessed.
The tissue specimen is embedded in paraffin, and routine
vertical histologic sections that contain 100% of the
peripheral margins are processed. The specimen is inked,
and a map is drawn and included with the specimen for
precise anatomic orientation of the peripheral margins.
The dermatopathologist examines the permanent vertical
histologic sections and notes any areas that are positive
for melanoma or AJMH. By use of the tissue map, any
remaining positive areas are outlined in a fashion similar
to the creation of the first geometric shape, and margins
around this second shape are sent for permanent vertical
histologic sectioning as described before. This process is
repeated until all of the margins are free of disease. When
the entire peripheral margin is interpreted as being tumor
free, the central island of skin along with any other islands
necessitated by additional margin control is excised
within the defined clear peripheral margins. These islands
of skin are sent to the laboratory for serial sectioning and
histopathologic examination for any invasive component.
The reconstruction is performed with the confidence that
100% of the peripheral margins of a skin lesion have been
evaluated and interpreted as being free of melanoma.
In the case shown in Figure 8-15, the square technique
used for margin control created two areas on the left
cheek for planned excision. Both lesions are outlined by
blue sutures. The superior lesion measured 1.7 × 1.7-cm,
and the inferior lesion measured 2 × 1.3-cm. The planned
superior excision had nearly a square configuration. A
by thinning the flap if necessary, and it may also be
helpful in preventing the deformity.
CASE REPORTS
Case 1
A 43-year-old woman developed a basal cell carcinoma
of the right temple. It was removed with micrographic
surgery, leaving a 2.2 × 2-cm skin defect (Fig. 8-12).
Reconstruction of the defect with a skin flap could be
readily accomplished by tissue transposition, rotation, or
advancement. An appealing option would have been to
use bilateral unipedicle advancement flaps in the form of
an H-plasty (see discussion in Chapter 9). A transposition
flap was selected and was designed in the form of a note
flap.5 This flap enables the closure of circular skin defects
with a triangular transposition flap that maximizes the use
of skin surrounding the defect (see discussion in earlier
section of chapter). A tangent to the circular defect was
drawn. The length of the tangent was 1.5 times the diam­
eter of the defect. The second side of the flap equal to
the diameter of the defect was drawn in RSTLs. The
angle of the tip of the flap was 45°. The flap was dissected
in the subcutaneous tissue plane and transposed without
trimming of the distal tip of the flap.
The note flap is recommended primarily for circular
skin defects 2.0 cm or less in diameter. The pivotal arc
of the flap is approximately 45°, so the standing cutane­
ous deformity is small and may not require excision. In
the case shown in Figure 8-12, a small standing cutaneous
deformity was excised at the superolateral aspect of the
skin defect.
In Figure 8-13, a melanoma in situ is outlined in blue
and measures 3.5 × 1.5-cm. It is located immediately
superior to the medial eyebrow. Although the skin lesion
has a rectangular configuration, a triangular flap was
designed to repair the defect after surgical resection of
the melanoma. Similar to circular defects, rectangular
defects may be repaired with triangular transposition
flaps. In the case presented, selection of such a flap design
enabled a greater length of the final scar to lie parallel to
RSTLs compared with the use of a rectangular transposi­
tion flap.
Case 2
Figure 8-14 shows a 58-year-old woman with a 1.4 ×
1.1-cm skin defect of the nasal dorsum after micrographic
surgery for a basal cell carcinoma. The wound could have
been reconstructed with primary wound closure or with
a local flap using advancement. Primary wound closure
would have necessitated excision of two standing cutane­
ous deformities. A triangular transposition flap was
selected for repair of the wound. The vertical axis of the
defect was longer (1.4 cm) than the horizontal axis. For
this reason, the axis of the transposition flap was designed
parallel to the long axis of the defect. The advantage of
this design is that as the flap pivots toward the recipient
site, a portion of the standing cutaneous deformity will
cover the superior aspect of the defect. Use of the