Local Flaps in Facial Reconstruction

144
SECTION I  FUNDAMENTALS
FIGURE 8-13  ■  A, A 3.5 × 1.5-cm melanoma in situ outlined in blue. Adjacent transposition flap designed for repair of defect after
excision of melanoma. B, Melanoma excised and flap transposed. Standing cutaneous deformity excised along superior aspect of
lateral eyebrow. C, Postoperative view at 10 months. No revision surgery performed.
A
B
C
FIGURE 8-14  ■  A, A 1.4 × 1.1-cm skin defect of nasal dorsum. Transposition flap designed for wound repair. B, Flap transposed. Small
standing cutaneous deformity excised at superior border of defect. C, D, Postoperative views at 8 months. No revision surgery
performed.
A
B
D
C

8  TRANSPOSITION FLAPS
145
rhomboid configuration with two sets of equal or nearly
equal interior angles. Rhombic flaps and their many
modifications are discussed in detail in Chapter 11.
The planned inferior excision was rectangular in con­
figuration. Triangle-shaped transposition flaps are useful
for repair of rectangular skin defects because a portion of
the standing cutaneous deformity that forms at the base of
the flap as it pivots toward the recipient site assists with
covering a portion of the surface area of the primary defect.
Similar to Case 2, the linear axis of a triangular flap
was oriented parallel to the long axis of the anticipated
rhombus-shaped flap was used to repair the defect result­
ing from excision. The flap was designed by extending
superomedially a diagonal of the rhombus. The length of
the extension was the length of a side of the rhombus.
This created the first side of the flap. A second line was
drawn of equal length parallel to the superior border
of the planned excision to create the second side of the
flap. The flap design used the advantage of the relative
skin laxity of the temple for construction of the flap and
to minimize wound closure tension. Rhombus-shaped
flaps may be used for repair of skin defects that have a
FIGURE 8-15  ■  A, A 1.7 × 1.7-cm and a 2 × 1.3-cm melanoma in situ skin lesion outlined in blue. Adjacent transposition flaps designed
for repair of defects after excision of melanomas. B, Melanomas excised and flaps transposed. C, D, Postoperative views at 1 year.
No revision surgery performed.
A
B
D
C

146
SECTION I  FUNDAMENTALS
shown in Figure 8-16. This 68-year-old man presented
with a 3 × 2.5-cm skin defect of the malar eminence after
micrographic surgery for a basal cell carcinoma. This
defect could have easily been repaired with primary
wound closure but would have necessitated excision of
two large standing cutaneous deformities, one of which
would have extended into the lower eyelid skin. The use
of an advancement flap would also have been a reliable
option. In this case, an inferiorly based transposition flap
was designed with plans to excise the standing cutaneous
deformity at the inferior aspect of the defect. Designing
the base of the flap inferiorly allowed recruitment of skin
for construction of the flap from the lower temple, where
skin laxity is relatively greater than in the medial superior
cheek region. This design also ensured that the greatest
defect after excision of the melanoma in situ. This design
maximizes the use of the standing cutaneous deformity
for resurfacing of the adjacent primary defect and mini­
mizes the necessary excision of skin at the base of the flap.
The orientation of the triangular flap in this particular
patient allowed the recruitment of skin from the jowl for
construction of the flap. The jowl is the most redundant
skin of the face. Local flaps harvested from the area of
the jowl minimize donor site wound closure tension.
Case 4
Transposition flaps are almost always a reasonable recon­
structive option for repair of skin defects of the superior
medial cheek measuring 1 to 4 cm. An example of this is
FIGURE 8-16  ■  A, Basal cell carcinoma of malar eminence. B, A 3 × 2.5-cm cutaneous defect after micrographic surgical resection.
Transposition flap designed for repair. Standing cutaneous deformity (SCD) marked for excision. C, Flap transposed. SCD removed.
D, E, Postoperative views at 6 months. No revision surgery performed.
A
B
SCD removed here
D
E
C

8  TRANSPOSITION FLAPS
147
flap used for this case. The transposition flap was based
superolaterally, and the standing cutaneous deformity
was excised at the extreme superolateral aspect of the
defect. Designing the base of the flap superolaterally
enabled the construction of the flap from the lax skin of
the jowl and minimized the wound closure tension of the
flap donor site repair.
The patient shown in Figure 8-18 developed a mela­
noma in situ of the superior medial cheek. Tumor-free
margins were obtained by the square technique as
described for Case 3. The area requiring resection
wound closure tension, which is at the flap donor site,
was oriented horizontally. This prevented the exertion of
excessive wound closure tension on the lower eyelid.
Figure 8-17 also shows a skin defect of the superior
medial cheek that measured 3 × 4-cm. This defect could
have been reconstructed with an advancement or rotation
flap based inferiorly. A rotation flap would have required
a lengthy curvilinear incision extending laterally perhaps
as far as the auricle. If a rotation flap had been selected,
it would have been necessary to design the flap with a
surface area considerably larger than the transposition
FIGURE 8-17  ■  A, B, A 3 × 4-cm skin defect of superior medial cheek. Superolaterally based transposition flap designed for repair of
wound. Anticipated standing cutaneous deformity marked with vertical lines lateral to defect. C, Flap dissected in subcutaneous
tissue plane. D, Flap transposed. Standing cutaneous deformity developed superiorly at base of flap. E, Deformity excised and
wound repaired. F, Postoperative view at 10 months. No revision surgery performed.
A
B
D
E
F
C

148
SECTION I  FUNDAMENTALS
A
SCD removed here
B
C
D
FIGURE 8-18  ■  A, A 3 × 5-cm melanoma in situ of medial cheek outlined in blue. Superiorly based transposition flap designed for
repair of defect after excision of melanoma. Anticipated standing cutaneous deformity (SCD) marked for excision. B, Melanoma
excised. Flap transposed. Superior portion of primary defect closed by advancement of wound margins. C-F, Preoperative and 4-year
postoperative views. No revision surgery performed.

8  TRANSPOSITION FLAPS
149
defect. Keeping with the concept of not transposing a
local flap across a facial aesthetic boundary, the flap was
not used to resurface the defect of the alar base. This
small component of the facial defect was covered with a
full-thickness skin graft. This approach enabled the
leading border of the flap to be positioned in the alar-
facial sulcus for scar camouflage while at the same time
maintaining the concave contour of the sulcus. The skin
graft used to cover the alar defect was obtained from the
excised standing cutaneous deformity of the cheek flap.
The patient shown in Figure 8-20 has a skin defect
similar in size and location to that of the patient shown
in Figure 8-19. The defect is irregular in shape and has
a limited extension into the upper lip. Although the
patient was of similar age (74 years) to the patient in
Figure 8-19, she did not display facial skin laxity because
she previously had a rhytidectomy. Because of this, the
patient did not demonstrate a discernible melolabial
crease or fold. For this reason, the lip component of the
defect was not repaired with a separate flap but was
reconstructed together with the cheek portion of the
defect with a single large transposition flap. The flap was
based superolaterally to take advantage of the greater skin
laxity of the face located inferomedially. The flap was
designed with an irregular shape to accommodate the
limited extension of the defect into the upper lip. The
flap was dissected in the subcutaneous tissue plane. After
transposition of the flap, it was not possible to completely
measured 3 × 5-cm and had a rhomboid configuration.
After resection, the resulting skin defect was repaired
with a rhombus-shaped transposition flap, similar to the
previously discussed case. The long linear axis of the skin
defect enabled primary wound repair of the most superior
aspect of the defect. This approach ensured less wound
closure tension between the superior aspect of the flap
and the lower eyelid skin. Similar to the previously dis­
cussed case, the transposition flap was based superolater­
ally to facilitate recruitment of skin from the inferior
cheek for construction of the flap.
Case 5
Skin defects of up to 5 cm of the inferior medial cheek
are readily reconstructed with transposition flaps. An
example of this is shown in Figure 8-19. This 72-year-old
man presented with a 3.5 × 3-cm skin defect of the medial
cheek after micrographic excision of a basal cell carci­
noma. A portion of the defect extended into the base of
the ala. Although this defect could have been recon­
structed with a large rotation or V-Y subcutaneous tissue
pedicled advancement flap, a transposition flap was
selected for repair of the wound. The flap was based
superiorly and designed to recruit the redundant skin in
the region of the jowl. The flap was dissected in the
subcutaneous tissue plane, and the standing cutaneous
deformity was excised at the superolateral aspect of the
E
F
FIGURE 8-18, cont’d

150
SECTION I  FUNDAMENTALS
tumor-free margins of the skin lesion were confirmed,
the area marked by sutures was removed, resulting in a 4
× 3-cm skin defect. The primary defect was reconstructed
with a superolaterally based transposition cheek flap. A
single flap was used to cover the defect, which occupied
two aesthetic regions, the nasal sidewall and the cheek.
Because of her advanced age, her facial skin was suffi­
ciently thin to allow the flap to cross over the nasofacial
sulcus without blunting or distortion of the sulcus.
To repair the flap donor site on the inferior cheek, it
was necessary to design and transfer a second flap, which
was constructed from the jowl skin. The second flap is
shown in Figure 8-21B. It was designed as a transposition
flap, but considerable advancement of the flap was also
necessary. The distal tip of the flap marked with an X was
close the donor site deformity because of the tautness of
the patient’s facial skin. Therefore, a small full-thickness
skin graft was used to assist with the repair of the donor
site. The graft was obtained from the standing cutaneous
deformity excised from the superolateral aspect of the
defect. The graft is seen as a triangle of skin beneath the
inferior border of the flap in Figure 8-20B. The concept
of employing full-thickness skin grafts together with local
cutaneous flaps is discussed in detail in Chapter 16.
Case 6
A 91-year-old woman was treated for a melanoma in situ
of the right cheek and nasal sidewall by the square tech­
nique to obtain clear surgical margins (Fig. 8-21). Once
FIGURE 8-19  ■  A, A 3.5 × 3-cm skin defect of medial cheek. B, Superiorly based transposition flap designed for repair of wound.
Standing cutaneous deformity (SCD) excised superolaterally. C, Flap transposed. Small defect involving alar base repaired with
full-thickness skin graft harvested from SCD excised superolaterally to cheek defect. D, Postoperative view at 2 months. No revision
surgery performed. (From Baker SR: Reconstruction of facial defects. In Cummings CW, Fredrickson JM, Harker LA, et al, editors:
Otolaryngology—head and neck surgery, ed 3, Philadelphia, Mosby, 1998.)
A
SCD removed here
B
C
D

8  TRANSPOSITION FLAPS
151
FIGURE 8-20  ■  A, A 3.5 × 3-cm skin defect of medial cheek. Superiorly based transposition flap designed for repair of wound. B, Flap
transposed. Small portion of donor site closed with full-thickness skin graft (FTSG) to reduce wound closure tension. Graft obtained
from standing cutaneous deformity excised superolaterally to cheek defect. C, Postoperative view at 8 months. No revision surgery
performed.
A
FTSG
B
C
A
X
X
SCD removed here
X
B
C
FIGURE 8-21  ■  A, A 4 × 3-cm melanoma in situ marked in blue. Superolaterally based transposition flap designed for repair of defect
after excision of melanoma. Anticipated standing cutaneous deformity (SCD) marked for excision. B, Incision for second transposi­
tion flap marked by interrupted line. Flap designed to assist with closure of donor defect. Distal end of flap marked with X. After
transposition and advancement, distal end must meet upper lip at point marked with second X.
Continued
transposed and advanced to the upper lip at the junction
of the lip with the melolabial crease, also marked with an
X. Figure 8-21C shows the second flap in position. The
X marks the junction of the distal tip of the second flap
with the upper lip. As demonstrated in this case, it is
sometimes necessary to use a skin flap to assist with
closure of a secondary defect when an especially large
cutaneous flap has been used to repair the primary facial
defect. In this case, redundant skin in the area of the jowl
and superior neck was used to repair the secondary defect.
Case 7
A 47-year-old woman developed a squamous cell carci­
noma of the skin of the inferior cheek. The tumor was
resected by frozen-section margin control. This resulted
in a skin defect measuring 4 × 4.5-cm (Fig. 8-22). Recon­
struction of the defect with a local flap could have been
accomplished by a large cervicofacial rotation advance­
ment flap, recruiting skin from the posterosuperior neck,
or by a sizeable rotation flap based medially, recruiting
skin from the submental area of the neck. Another effec­
tive alternative was to use a transposition flap. Such a flap
was selected in this case. The flap was based posterosu­
periorly and recruited redundant skin from the superior
cervical region. The surface area of the flap was designed
smaller than the surface area of the defect because of
moderate skin laxity in the facial skin adjacent to the
defect. Thus, part of the wound closure was achieved by
advancing the borders of the defect. The transposition
flap was dissected in the subcutaneous tissue plane and
transposed, removing the standing cutaneous deformity

152
SECTION I  FUNDAMENTALS
D
E
F
G
C, Melanoma excised. Flaps transposed. X marks junction of distal end of second flap with upper lip. D-G,
Preoperative and 7-month postoperative views. No revision surgery performed.
FIGURE 8-21, cont’d  ■

8  TRANSPOSITION FLAPS
153
FIGURE 8-22  ■  A, Squamous cell carcinoma of cheek. B, A 4 × 4.5-cm skin defect after resection of tumor. Transposition flap designed
for repair of wound. C, Postoperative view at 1 week. Standing cutaneous deformity excised superior to cheek defect.
A
B
C
at the superior aspect of the defect. Although the use of
a transposition flap to repair this defect required shorter
incisions in the neck compared with a cervicofacial rota­
tion advancement flap, the incisions on the cheek were
longer because of the necessity of removing a large stand­
ing cutaneous deformity resulting from pivoting of the
transposition flap upward into the cheek.
Case 8
A 46-year-old woman had micrographic surgical excision
of a microcystic carcinoma of the chin and lower lip. Her
defect measured 5 × 4-cm and occupied nearly half of the
surface area of the chin and lip (Fig. 8-23). The defect
was large for reconstruction with a local flap. The
A
B
FIGURE 8-23  ■  A, A 5 × 4-cm skin defect of lower lip and chin. Long inferiorly based melolabial transposition flap designed with base
adjacent to defect. B, Flap transposed. Standing cutaneous deformity formed from transposition left in situ. Deformity subsequently
excised and scar revision, consisting of several Z-plasties, performed along superior border of flap.
Continued

154
SECTION I  FUNDAMENTALS
C
D
E
F
C, E, Preoperative views. D, F, Postoperative views at 3 years, 7 months.
FIGURE 8-23, cont’d  ■

8  TRANSPOSITION FLAPS
155
location and size of the defect prevented repair of the
wound with a single unipedicle advancement flap because
of the inelasticity of the chin skin. The defect could prob­
ably have been reconstructed with a transposition or rota­
tion flap harvested from the submental area of the neck.
Another alternative was to transfer a flap from the cheek
in the form of a transposition or advancement flap. An
inferiorly based melolabial transposition flap was selected
(Fig. 8-23A). The flap was designed to recruit skin from
the melolabial fold. It was slightly curved in its linear axis
to parallel the melolabial crease. This facilitated place­
ment of the flap donor site scar directly within the melo­
labial crease. Because the flap was long relative to the
width of the base, the standing cutaneous deformity that
formed on transposition of the flap was not excised for
fear of compromising the vascularity of the flap. The
standing cutaneous deformity was resected in a second
stage 4 months later. As seen in Figure 8-23B, the flap
was not constructed with sufficient width to prevent
downward displacement of the vermilion. The mild
retraction of the vermilion persisted after healing and was
corrected during the second stage when the standing
cutaneous deformity was excised. The correction of the
lip displacement was accomplished by performing four
Z-plasties along the scar delineating the superior border
of the flap from the adjacent remaining skin of the lip
between the vermilion and the flap. The patient’s 4-year
postoperative result is shown in Figure 8-23D, F. The
inferior retraction of the vermilion was completely cor­
rected, and there was no significant ablation of the melo­
labial fold, providing nearly perfect symmetry of the
cheeks. The flap’s donor site scar was camouflaged well
by its location within the melolabial crease.
REFERENCES
1. Gorney M. Tissue dynamics and surgical geometry. In: Kernakan
DA, Vistnes LM, editors. Biological aspects of reconstructive
surgery. Boston: Little, Brown; 1977.
2. Koranda FC, Webster RC. Trap-door effect in nasolabial flaps.
Arch Otolaryngol 1985;111:421.
3. Webster RC, Benjamin RJ, Smith RC. Treatment of “trap-door
deformity.” Laryngoscope 1978;88:707.
4. Park C, Lineaweaver WC, Buncke HJ. New perioral arterial flaps:
anatomic study and clinical applications. Plast Reconstr Surg
1994;94:268.
5. Walike JW, Larrabee WF Jr. The note flap. Arch Otolaryngol
1985;111:430.
6. Larrabee WF Jr. Design of local skin flaps. Otolaryngol Clin North
Am 1990;23:899.
7. Limberg AA, Wolf SA, trans. The planning of local plastic opera­
tions on the body surface: theory and practice. Lexington, Mass:
Collamore Press; 1984.
8. Bray DA. Rhombic flaps. In: Baker SR, Swanson NA, editors. Local
flaps in facial reconstruction. St. Louis: Mosby; 1995.
9. Webster RC, Davidson TM, Smith RC. The thirty degree trans­
position flap. Laryngoscope 1978;88:85.
10. Bernstein L. Transposed and interposed flaps in head and neck
surgery. Otolaryngol Clin North Am 1972;5:531.
11. Yabe T, Takemura H, Muraoka M. Circle-to-W flap. Plast Recon­
str Surg 1999;104:1430.
12. Anderson KW, Baker SR, Lowe L. Treatment of head and neck
melanoma, lentigo maligna subtype. Arch Facial Plast Surg
2001;3:202.
13. Anderson KW, Baker SR. Management of early lentigo and lentigo
maligna melanoma of the head and neck. Facial Plast Surg Clin
North Am 2003;11:93.

156
C H A P T E R 9 
ADVANCEMENT FLAPS
Shan R. Baker
INTRODUCTION
Most local cutaneous flaps used in the head and neck have
some component of advancement during movement of
the flap to the recipient site. An example is the paramedian
interpolated forehead flap. Although this flap is classified
as pivotal, it frequently is necessary to undermine the
pedicle in the brow area to gain additional mobility and
length to the flap. Thus the pedicle is advanced inferiorly
below the bony orbital rim, adding some advancement to
the main pivotal movement of the flap. The rhombic flap
is another example in which both pivotal and advance­
ment movements are important in transferring the flap to
the recipient site. Most rotation flaps are also facilitated
by advancement of their pivotal point. True advancement
flaps have a linear configuration and are moved by sliding
toward the defect. This involves stretching the skin of the
flap. Thus, advancement flaps work best in areas of greater
skin elasticity. The most basic advancement flap is the
simple linear layered closure, which involves undermin­
ing and direct advancement of tissue side to side to close
the defect primarily. This closure does not create a sec­
ondary defect, and additional incisions are made only for
the removal of standing cutaneous deformities. However,
the term advancement flap usually refers to a flap created
by incisions that allow a “sliding” movement of the tissue.
Tissue transfer is achieved by moving the flap and its
pedicle in a single vector. The greatest wound closure
tension is perpendicular to the distal border of the flap.
Advancement flaps may be categorized as unipedicle,
bipedicle, V-Y, Y-V, and subcutaneous tissue pedicled
island flap (Table 9-1). By necessity, all advancement flaps
must be designed so that the advancing border of the flap
also represents a margin of the cutaneous defect that the
flap is designed to repair. When an advancement flap is
transferred to a defect, the motion of the flap is considered
the primary tissue movement of the repair. Secondary
tissue movement is the displacement of skin surrounding
the defect toward the center of the primary defect (Fig.
9-1). Secondary movement always assists in wound closure
by reducing wound closure tension. However, at times,
secondary tissue movement may be detrimental if the
defect is located near a mobile margin of a facial structure.
Facial structures that are likely to be distorted if secondary
tissue movement is excessive include the vermilion, nostril
margin, lower and upper eyelids, and eyebrows. The
stronger the attachments of facial structures to the
underlying bone, the less propensity for distortion or
displacement of these structures from secondary tissue
movement. Complete undermining of advancement flaps
as well as of the skin and soft tissue around the flap is likely
to reduce wound closure tension and thus limit secondary
tissue movement. If secondary movement could be ben­
eficial in reducing wound closure tension and does not
cause excessive distortion of facial landmarks, then wide
undermining of the skin and mobilization of the tissue
surrounding the defect are also indicated. At times it is
preferable to allow movement only of the flap, in which
case there should be limited or no undermining of the
margins of the defect.
All local flaps have inherent advantages and disadvan­
tages, and these are often related to the flap design and
the location where the flap is used. Certain cutaneous
flaps work best in certain anatomic locations (see discus­
sion of preferred flaps in Chapter 6). Advancement flaps
are used for reconstruction of many surgical defects of the
face. In considering the use of an advancement flap, it is
important to consider the location of the vectors of wound
closure tension and the location of incision lines and
whether they respect relaxed skin tension lines (RSTLs)
and aesthetic boundaries. The location where standing
cutaneous deformities are likely to form and how they will
be managed should be considered.1 Table 9-2 lists common
locations on the face where advancement flaps are effec­
tive in repairing skin defects. As with all local flaps, it is
important to evaluate the adjacent skin for matching
qualities of texture, color, consistency, and hair growth.
UNIPEDICLE ADVANCEMENT FLAPS
As the name implies, unipedicle advancement flaps have
a single cutaneous pedicle. The flap is created by parallel
incisions that allow a sliding movement of tissue in a
single vector toward a defect. The movement is in one
direction and flap advancement is directly over the defect.
This form of wound repair is sometimes referred to as
U-plasty. Complete undermining of the advancement
flap as well as of the skin and soft tissue around the
pedicle is important to enhance tissue movement. In
contrast to pivotal flaps, which form a single standing
cutaneous deformity, two deformities are created with
all unipedicle advancement flaps. Unlike with pivotal
flaps, in which the standing cutaneous deformity must be
dealt with at the base of the flap, the deformities that
develop from advancement can be excised anywhere
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9  ADVANCEMENT FLAPS
157
along the length of the flap and not necessarily juxtaposed
to the base. This is because of the mechanism of tissue
movement.
Unipedicle advancement flaps and rotation flaps have
one characteristic that is inherent only in these two flap
designs. Owing to their specific design, the use of either
type of flap creates a situation in which there exists an
unequal length of the borders of the wound once the flaps
are transferred to their respective recipient sites. This is
because the peripheral border of the wound (flap incision
plus defect width) is longer than the length of the flap.
Triangular skin excisions along the periphery of the
wound (equalizing or Burow triangles) in essence have
the effect of shortening the peripheral border of the
wound so that its length matches the length of the flap
(see discussion in Chapter 7). In the case of rotation flaps,
a single Burow triangle excision is required, whereas uni­
pedicle advancement flaps require two excisions, one on
either side of the flap. Excision of standing cutaneous
deformities of advancement flaps is predicated on the
most optimal site for excision. Typical excisions are
placed in RSTLs or borders between aesthetic regions of
the face. Sometimes the discrepancies in the length of the
borders of the wound may be eliminated by a halving
suture technique. The technique involves dividing in half
the length of the wound repair with each consecutive
suture. This evenly distributes the redundant tissue of the
standing cutaneous deformities as small puckers along
the entire length of the wound. Thus the redundancy is
“sewn out” without the need for excision of skin.
Unipedicle advancement flaps are useful for repair of
defects on the forehead. The flap is designed so that
TABLE 9-1  Advancement Flaps
Unipedicle
Bipedicle
V-Y
Y-V
Subcutaneous tissue pedicle island
FIGURE 9-1  ■  Unipedicle advancement flap. Primary and secondary skin movement occurs with wound repair.
A
B
Primary movement Secondary movement
TABLE 9-2  Useful Applications of
Advancement Flaps
Unipedicle and Bilateral (U- and H-Plasty)
Forehead
Medial cheek
Eyebrow
Helical rim
O-T and A-T (T-Plasty)
Forehead
Lower eyelid
Lip
Chin
Posterior auricular sulcus
Subcutaneous Tissue Pedicle Island
Lateral upper lip
Medial cheek
Upper nasal dorsum
Alar groove
Wedge Resection and Advancement
Lip
Auricle
Bipedicle
Scalp
incisions are placed in or parallel to horizontal creases
and, when possible, along the border of the eyebrow or
anterior hairline. The unipedicle advancement flap
should be conceptualized as rectangular in shape. Most
cutaneous defects are round or oval, and a rectangular
flap does not always precisely conform to a round defect.
It may be necessary to modify the shape of the distal flap
or the defect itself to minimize tissue distortion. It is
usually preferable to “square off” the defect than to
“round off” the flap. This is because angular incisions
produce straight scars that have fewer propensities to
develop trap-door deformities compared with curvilinear
scars. Regardless of which option is selected, it is helpful
to delay this modification until the flap has been elevated

158
SECTION I  FUNDAMENTALS
Similar to single advancement flaps, bilateral flaps will
create wounds of unequal length often requiring removal
of Burow triangles. These triangles may vary in size and
location, depending on the location of the flaps and the
elasticity of the tissues (Fig. 9-3).2 For instance, Figure
9-3 shows Burow triangles removed at different locations
above and below the two flaps. In theory, these locations
correspond to areas that result in the best scar camou­
flage. Figure 9-3B shows half-buried mattress sutures
placed at the site of the Burow triangle excisions. Inferi­
orly, a four-point corner stitch is used.
T-PLASTY
The A-T and O-T wound repair are so named because
these methods transform a triangular (A-shaped) or
round (O-shaped) defect into a T-shaped scar (Fig. 9-4).
The T-plasty involves two flaps that are advanced in
opposite directions toward each other. The standing
cutaneous deformity that occurs to some degree with all
advancement flaps is excised as the vertical limb of the T.
If the horizontal limbs of the T-plasty are curved, flap
movement is not solely advancement but a combination
of rotation (pivotal movement) and advancement.
T-plasty represents a modification of bilateral unipedicle
advancement flaps. Instead of making two parallel inci­
sions to create the flap, only one incision on opposing
sides of the defect is made. The two flaps are advanced
and slightly pivoted toward each other to repair the
defect. A standing cutaneous deformity develops at the
defect site opposite the position of the two incisions. This
deformity is excised and the wound repaired, giving the
final suture line a T configuration. The vertical limb of
the T represents the excision of the standing cutaneous
deformity. In addition, depending on the length of the
incisions necessary to create the advancement flaps,
standing cutaneous deformities may also form and require
excision somewhere along the incision lines. An advan­
tage of T-plasty repair is that the technique divides the
defect in half by using two flaps for closure. Thus two
smaller flaps can be used for repair instead of a single
larger flap, which may be more difficult to harvest
in areas where skin redundancy is limited. Another
and has demonstrated its ability to cover the defect com­
pletely. Unipedicle advancement flaps are usually designed
with parallel incisions extending from one border of the
defect. However, these incisions are sometimes designed
to diverge from each other when a greater width to the
pedicle is desired or divergence can allow placement of
incisions in facial aesthetic borders. Typically, unipedicle
advancement flaps are designed with a ratio of defect
width to flap length of 1 : 3.1,2 Therefore, large defects are
more easily repaired with bilateral opposing flaps.
BILATERAL UNIPEDICLE
ADVANCEMENT FLAPS
Bilateral unipedicle advancement flaps are commonly
combined to close various defects, resulting in H- or
T-shaped repairs, depending on the configuration of the
defect and the number of incisions used. Repair in this
manner is often referred to as H-plasty (Fig. 9-2) or
T-plasty. In both cases, advancement flaps are incised on
opposite sides of the defect and advance toward each
other. Each flap is responsible for covering a portion of
the defect. When standing cutaneous deformities require
excision, they are excised either in the area of the defect
or along the borders of the flaps. The two flaps do not
necessarily have to be of the same length. Flap length is
determined primarily by the elasticity and redundancy of
tissue at the donor site. The basic principles of tissue
movement and wound closure are identical to those for
single unipedicle advancement flaps. When designing
and dissecting the flaps, it is wise to first incise and elevate
only one flap. On occasion, sufficient skin movement is
achieved with a single flap so that the second flap is not
necessary or can be designed with less length. Like single
unipedicle advancement flaps, bilateral flaps are useful for
repairing skin defects of the forehead, eyebrow, and ear.
Bilateral advancement flaps are particularly helpful for
repair of defects of the central lips and chin. The advan­
tage of bilateral flaps over a single flap for repair of these
midline structures is that equal “pull” from the two
opposing flaps lessens tissue distortion and the propensity
toward deviation of midline structures toward one side.
FIGURE 9-2  ■  Bilateral unipedicle advancement flaps (H-plasty).
A
B

9  ADVANCEMENT FLAPS
159
FIGURE 9-4  ■  A, O-T (T-plasty) repair of circular (O-shaped) wound. T-plasty requires two flaps advanced in opposite directions toward
each other. The standing cutaneous deformity forming superiorly from advancement is excised at vertical limb of T. B, A-T (T-plasty)
repair of triangular (A-shaped) wound. Wound closure suture line has T-shaped configuration. Opposing arrows indicate point of
greatest wound closure tension.
A
B
FIGURE 9-3  ■  A, H-plasty incised. B, Half-buried horizontal tip suture used to close the Burow triangular defects. Note that standing
cutaneous deformity is removed at different locations superior and inferior to advancement flaps. C, Epidermal closure with simple
running or interrupted sutures.
A
C
B

160
SECTION I  FUNDAMENTALS
works well. First, it is helpful to mentally superimpose a
triangle over the circular defect. In reality, the circle is
converted to a triangle by removal of wedges of tissue at
the perimeter of the circle at three points equally sepa­
rated from each other. In Figure 9-6A, note that the
superior wedge is in the form of an M-plasty, which helps
to minimize the length of the vertical limb of the scar.
Two horizontal incisions are made perpendicular to the
vertical limb to create advancement flaps. These incisions
may be varied in length and may curve, allowing proper
placement in RSTLs, such as the horizontal crease lines
of the forehead. The flaps are then elevated and advanced
into the primary defect, with the key suture being placed
at the central advancing borders of the two flaps. Under­
mining should be sufficient to allow minimal wound
closure tension. It is preferred not to excise the Burow
triangles until complete undermining is accomplished
and the flaps are advanced into the primary defect. Burow
triangles are usually removed near the base of the flaps
but, in actuality, can be removed from any area along the
incision line if it hides well in RSTLs. A four-point suture
is used to approximate the opposing distal tips of the two
flaps and adjacent skin (Fig. 9-6B). The tip of the M-plasty
is closed with a similar half-buried horizontal mattress tip
suture. Repair is completed by suturing the flaps together
by layered closure (Fig. 9-6C).
MODIFIED T-PLASTY
The greatest problem with T-plasty repair of large (2 cm
or greater) circular cutaneous defects of the lip is ectro­
pion of the vermilion as the wound heals. This is due to
the contracture of the vertical portion of the T-shaped
scar. In addition, T-plasty flaps are not pure advancement
flaps. Some pivotal movement occurs, and this causes a
small reduction in effective flap length. This in turn
causes shortening of the vertical wound closure line. To
avoid vermilion ectropion, a modified T-plasty can be
performed. Instead of excision of the standing cutaneous
deformity that develops opposite the incision lines for the
two opposing flaps, the tissue of the deformity is pre­
served and used to lengthen the vertical component of
the T-plasty scar (Fig. 9-7). The two opposing borders
of the flaps are first approximated at the vermilion line.
advantage of T-plasty is that only one incision is required
to create each flap; thus fewer scars are created by not
making parallel incisions to create the flaps as required
for standard bilateral unipedicle advancement flaps. The
horizontal limbs of the T-plasty can usually be positioned
in natural creases or at junctions of aesthetic regions.
T-plasty works very well for defects of the central fore­
head, where the vertical limb can be placed in the midline.
The technique may also be used just above the eyebrow
or on the temple adjacent to the hairline. In such cases,
the horizontal component of the T is positioned along
the lateral eyebrow or the anterior hairline. T-plasty is
also an effective method of repairing cutaneous defects
of the lateral lip adjacent to the vermilion (Fig. 9-5), the
chin, and the preauricular and postauricular areas.3 When
T-plasty is used to repair skin defects of the lips, excision
of standing cutaneous deformities of the vermilion are
not always necessary or can be made very small. In con­
trast, if primary repair is attempted, an excision of a large
standing cutaneous deformity of redundant vermilion is
required. T-plasty repair often eliminates this require­
ment and maintains the majority of incision lines on the
cutaneous portion of the lip. Bilateral incisions are made
along the vermilion margin at the base of the defect, thus
creating two horizontal limbs of the T-plasty. The border
of the defect opposite the vermilion is excised in a fusi­
form manner to remove a triangle of tissue. This triangle
represents the standing cutaneous deformity that will
form from advancement of the two flaps. The excision
converts a round defect into a triangular defect (Fig.
9-5A). Wide undermining of adjacent skin is important
to lessen wound closure tension, which in turn minimizes
the risk of distortion of the philtrum. A four-point suture
is placed in the midline of the base of the defect to pre­
cisely align the wound margins (Fig. 9-5B). When neces­
sary, Burow triangles are removed along the border of the
two flaps only after they have been advanced and secured.
Schematically, small Burow triangles are removed at the
most medial and lateral aspects of the horizontal limbs of
the flaps (Fig. 9-5A). At times, because of the elasticity
of lip skin, such triangles do not require excision. Instead,
the triangles are sewn out by the principle of using
halving sutures.3
Figure 9-6A shows a typical round surgical defect
above the left eyebrow, an area where the T-plasty repair
FIGURE 9-5  ■  A, O-T (T-plasty) repair of circular defect of upper lip near vermilion-cutaneous border. B, T-shaped wound closure
avoiding incisions into vermilion.
A
B

9  ADVANCEMENT FLAPS
161
FIGURE 9-6  ■  A, O-T (T-plasty) repair of circular skin defect near eyebrow. Wedges of skin removed from perimeter of circle. Supe­
riorly, M-plasty limits vertical scar length. The Burow triangles are removed at end of horizontal limb of flaps. B, Half-buried horizontal
mattress tip sutures. C, Wound closure with M-plasty avoids distortion of eyebrow.
A
B
C
The resulting standing cutaneous deformity that forms
opposite the flap incisions is marked. Only half of the
typical incision to excise the deformity is made. This
creates a flap of skin that is pivoted and advanced into a
second horizontally oriented incision made in the oppos­
ing lip segment. The orientation and length of the second
incision are designed after the first incision creating the
flap of skin has been performed. The flap is positioned
over the adjacent lip segment, and the distal end of the
overlapping flap is marked on the lip segment. A line is
drawn from this point to the lip segment wound border.
The line is angled so it is centered beneath the linear axis
of the overlapping flap. An incision is then made along
this line. The borders of the incision are undermined.
The flap is then sutured into the recipient site created
by the second incision. On occasion, a small portion
of the flap must be trimmed to allow it to fit perfectly
within the opposing lip segment. This technique in
essence is a modified Z-plasty, which has the effect of
lengthening the otherwise straight vertical component of
the T-plasty scar. The vertical scar resulting from the
modified T-plasty has an irregular Z-shaped configura­
tion (Fig. 9-8).
V-Y AND Y-V ADVANCEMENT FLAPS
Like the T-plasty, V-Y and Y-V advancement flaps do not
require two parallel incisions to create the flap (see dis­
cussion of these flaps in Chapter 6). The V-Y advance­
ment flap is unique in that the V-shaped flap is not
stretched or pulled toward the recipient site but rather
achieves its advancement by recoil or by being pushed
forward. Thus the flap is allowed to move into the recipi­
ent site in a nearly tension-free fashion. The secondary
triangular donor defect is then repaired with wound
closure tension by advancing the two borders of the
remaining wound toward each other. In so doing, the
wound closure suture line assumes a Y configuration,
with the common limb of the Y representing the suture
line resulting from closure of the secondary defect. The
flap is optimally designed so that the common limb of the
Y falls in the boundary of neighboring aesthetic regions
or within a natural crease, fold, or wrinkle.
V-Y advancement is useful in situations in which a
structure or region requires lengthening or release from
a contracted state. The technique is particularly effective
in lengthening the columella during the repair of cleft lip

162
SECTION I  FUNDAMENTALS
nasal deformities in which a portion or all of the colu­
mella is underdeveloped. A V-Y advancement flap is
elevated recruiting skin from the midportion of the lip
between the philtral ridges. The length of the columella
is augmented by advancement of the flap upward into the
base of the columella (Fig. 9-9). The secondary donor
defect is approximated by advancement of the remaining
lip skin together in the midline. V-Y advancement is
helpful in releasing contracted scars that are distorting
adjacent structures, such as the eyelid or vermilion. An
example is the correction of an ectropion of the vermilion
caused by scarring. The segment of distorted vermilion
is incorporated into the V-shaped flap and the flap is
advanced toward the lip to restore the natural topography
of the vermilion-cutaneous junction. The secondary
defect is closed by advancement. The suture line result­
ing from closure of the secondary defect becomes the
vertical component of the Y configuration (Fig. 9-10).
The Y-V advancement flap has a similar principle to
the V-Y flap except that the V-shaped flap is stretched or
pulled toward a linear incision made at the apex of the
triangular flap. The borders of this incision are allowed
to spread apart, creating a tissue void. The flap is advanced
into the void and sutured in place. The wound closure
suture line assumes a V configuration. The maximal
wound closure tension is at the apex of the flap. The Y-V
advancement flap has fewer applications than the V-Y flap
but may be used on some occasions to relocate, in a more
natural position, a distorted facial structure. An example
would be in correcting the position of an oral commissure
that has been displaced medially by scar. The commissure
is incorporated into the triangular flap, and a horizontal
incision is made lateral to the commissure. The flap con­
sisting of the commissure is then advanced laterally into
the tissue void created by the horizontal incision, restor­
ing a more natural position to the commissure.
SUBCUTANEOUS TISSUE PEDICLE ISLAND
ADVANCEMENT FLAP
The subcutaneous tissue pedicle island advancement flap
is a unipedicle advancement flap without a cutaneous
component to the pedicle. The pedicle of the flap consists
only of subcutaneous tissue, which is usually fat but on
occasion may also incorporate muscle underlying the
skin. The flap has no skin attachment and depends on the
sliding motion of its subcutaneous pedicle for advance­
ment. Thus the flap can be most easily advanced in areas
where there is an abundance of subcutaneous fat. The
region of the face with the most abundant fat is the
medial cheek. Thus island advancement flaps are effective
methods of repairing skin and soft tissue defects of the
lower medial cheek and lateral upper lip. The flap is
particularly well suited for skin defects located immedi­
ately adjacent to the alae.
BIPEDICLE ADVANCEMENT FLAPS
Bipedicle advancement flaps are used primarily for repair
of large defects of the scalp. The flap is designed adjacent
FIGURE 9-7  ■  A, Modified O-T (T-plasty) repair of circular cutane­
ous defect of upper lip. Inferior broken lines indicate incisions
to create advancement flaps as part of classic T-plasty repair.
Superior broken lines indicate incisions to create transposition
flaps for modified Z-plasty, which eliminates need to excise
standing cutaneous deformity superiorly. B, Flaps incised and
dissected, small standing cutaneous deformities excised from
vermilion border if necessary. C, Wound repaired. Vertical com­
ponent of scar has Z configuration.
A
Y
X
B
C
X
Y

9  ADVANCEMENT FLAPS
163
FIGURE 9-8  ■  A, A 1.5 × 1.2-cm circular cutaneous defect. Modified T-plasty designed for wound repair. Broken line indicates planned
incision along border of anticipated standing cutaneous deformity (SCD). B, Flap created by incision marked by broken line in
A overlaps medial lip segment to mark incision for recipient site. C, Incision marked to create recipient site for flap. Distal tip of flap
marked with circle. D, Flap transposed to create modified Z-plasty vertical wound repair. Circle marks distal end of flap. E, Postop­
erative view at 2 months.
A
SCD forms here
Incision to create flap
Incisions for T-Plasty
Flap overlaps apposing lip
segments to mark incision
B
Incision to create
flap recipient site
SCD removed
here
Apposed T-Plasty
advancement flaps
C
D
E
FIGURE 9-9  ■  A, B, V-Y advancement flap dissected from philtrum by recruiting skin from midportion of lip between philtral ridges.
Length of columella augmented by advancement of flap superiorly into base of columella.
A
B

164
SECTION I  FUNDAMENTALS
spite of a wound closure scar that is perpendicular to the
horizontal creases of the forehead, defects of the central
third of the forehead are best repaired with a vertical
orientation, with a predictably good aesthetic result. 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 oriented in a horizontal axis when possi­
ble. Advancement flaps should be designed with horizon­
tal orientations because this design facilitates scar
camouflage and minimizes the vertical component to the
repair. Vertical scars in the paramedian and lateral zones
of the forehead are perpendicular to the forehead creases,
and their appearances are accentuated by contraction of
the frontalis muscle.
Because of the inelasticity of forehead skin, bilateral
unipedicle 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 skin from two separate areas of the forehead, and
this has the effect of reducing wound closure tension
compared with the use of a single flap. Except in the
midline of the forehead, advancement flaps should be
elevated in the subcutaneous plane to preserve the supra­
orbital and supratrochlear nerves. Defects in or near the
midline (within 3 cm) are best closed without making
horizontal incisions. Rather, they are treated like a
primary wound closure, with advancement by dissection
in the subgaleal plane, because all sensory nerves are
superficial to this plane of dissection. If the entire defect
cannot be closed by primary apposition of wound margins,
the remaining portion of the wound is left open to heal
by granulation.
Cheek
Cheek defects are commonly repaired with advancement
flaps and take to their advantage the relative mobility and
elasticity of the skin and soft tissue of the cheek.4,5 A
common site for the development of skin cancers is the
junction between the nose and cheek along the nasofacial
sulcus. Defects resulting from removal of cancers in this
to the defect and is advanced into the defect at a right
angle to the linear axis of the flap. This leaves a secondary
defect that usually must be repaired with a split-thickness
skin graft. As a consequence, bipedicle flaps are rarely
used for reconstruction of the face and neck. The excep­
tion to this is bipedicle nasal vestibular skin advancement
flaps used for lining full-thickness nasal defects of the
hemi-tip or ala that have a vertical height of no more than
1.0 cm (see discussion of this flap in Chapter 18). The
flap consists of vestibular skin and mucosa based medially
on the septum and laterally on the floor of the nasal
vestibule. An extended intercartilaginous incision is made
and the flap is elevated off the undersurface of the alar
cartilage and mobilized inferiorly to line the ala or hemi-
tip. The donor site on the ventral aspect of the cartilage
is covered with a thin full-thickness skin graft. The
bipedicle flap is thin and provides natural physiologic
material for the interior of the nasal passage with suffi­
cient vascularity to support the concomitant use of free
cartilage grafts placed over the lining flap for structural
support of the construction.
APPLICATIONS
Forehead
A general discussion of surgical techniques and preopera­
tive and postoperative surgical care of patients undergo­
ing local flap reconstruction is provided in detail in
Chapters 4 and 5. The most effective technique for
reconstruction of forehead cutaneous defects usually
involves one or more advancement flaps. In spite of the
relative inelasticity of forehead skin, the use of advance­
ment flaps versus pivotal flaps is preferred because they
typically produce the best aesthetic 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 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, para­
median, and lateral, assists in planning reconstruction. In
FIGURE 9-10  ■  A, B, V-Y advancement flap used to correct ectropion of vermilion. Segment of distorted vermilion incorporated into
V-shaped flap and flap advanced toward lip to restore natural topography of vermilion-cutaneous border.
A
B

9  ADVANCEMENT FLAPS
165
border of the flap and are sutured deeply to the perios­
teum of the underlying bone. This technique helps relieve
wound closure tension on the suture line along the distal
border of the flap and concomitantly helps maintain the
nasofacial sulcus by minimizing dead space beneath the
flap. Standing cutaneous deformities form at the base of
the flap’s pedicle and can be easily removed by extension
of the incisions along the same aesthetic borders as shown
in Figure 9-11B. The excised skin, of sufficient size, pro­
vides an excellent source for grafting of any defect of the
sidewall of the nose.
The V-Y subcutaneous tissue pedicle advancement
flap is ideally suited for repair of medial cheek defects
located at or below the level of the ala. A triangular skin
island is designed with its base formed by the inferolateral
margin of the defect. Optimally, the vector of flap
advancement is designed to parallel the linear axis of 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
height of the defect. The trailing half of the skin island
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. 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 that resulting scars are parallel to RSTLs.
The perimeter of the skin island is incised to the level
of the subcutaneous tissue. Undermining of the adjacent
facial skin peripheral to the flap 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
area that cannot be closed primarily are usually best
repaired by moving cheek skin medially to the aesthetic
border between the nasal sidewall and the cheek. This
usually is accomplished by using a laterally based uni­
pedicle advancement flap (Fig. 9-11). Medium to large
defects (2-4 cm) in this area can be closed by medial
advancement of cheek skin. Standing cutaneous deformi­
ties are excised superiorly at the junction line between
the cheek and the nasal sidewall and inferiorly in the
melolabial crease (Fig. 9-11B). For smaller defects of the
medial cheek (2 cm or less) near the nasal sidewall, inci­
sions to create an advancement flap may not be necessary.
The defect can frequently be closed primarily through
advancement of the wound margins with excisions of
standing cutaneous deformities along the nasofacial and
alar-facial sulcus.
For defects of the medial cheek, it is important to
maintain the integrity and contour of the nasofacial
sulcus, which is the valley between the nasal sidewall and
cheek. If cheek advancement flaps are advanced into the
nasal sidewall, they often blunt the concavity of the naso­
facial sulcus. Other times such techniques may tent up
tissue in the sulcus, causing the appearance of a bridge or
web of tissue across the concavity of the sulcus. There­
fore, defects of the medial cheek that also involve the
nasal sidewall should be repaired with separate flaps or
grafts, one for the sidewall and one for the cheek com­
ponent of the defect. Even when defects located in the
nasofacial sulcus do not extend to the nasal sidewall,
cheek advancement flaps used to repair the defect may
cause some blunting of the sulcus. This undesirable effect
can be minimized by the use of a periosteal tacking suture
made of absorbable polyglactin or polydioxanone (Fig.
9-11B).6 Such sutures are placed in the dermis of the
advancing flap several millimeters behind the advancing
FIGURE 9-11  ■  A, Advancement flap used to repair skin defect of medial cheek. Superior incision made at infraorbital crease between
eyelid and cheek skin. Inferior incision made in nasofacial sulcus extending, if necessary, into melolabial crease. Broken line repre­
sents extent of skin undermining. B, Suspension suture used to attach dermis of flap to periosteum of maxilla. Excision of Burow
triangles performed at base of flap. C, Wound closure suture line within aesthetic borders between cheek, lip, nose, and eyelid.
A
B
C

166
SECTION I  FUNDAMENTALS
leaving at least one-third of the total flap surface area
attached to the underlying subcutaneous tissue. Further
thinning of the subcutaneous tissue underlying the
undermined portion of the flap may be performed to
create an appropriate thickness match between the
leading border of the flap and the recipient site. A central
pedicle of one-third of the total skin island surface area
will adequately perfuse the skin island. Further subcuta­
neous undermining of the skin adjacent to the flap is
musculature. This frees the elastic subcutaneous tissue
pedicle from its medial and lateral fatty attachments to
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 (Fig. 9-12). At this point,
the pedicle can be narrowed to facilitate the advancement
of the flap. This is accomplished by back cutting the
peripheral borders of the flap in a subcutaneous plane,
FIGURE 9-12  ■  A, Circular skin defect of medial cheek converted
to angular defect by removal of small triangles of tissue at
perimeter of defect. Triangular island flap marked by broken
line. B, Flap advanced on subcutaneous tissue pedicle. C, Sec­
ondary defect closed in V-Y configuration.
A
B
C

9  ADVANCEMENT FLAPS
167
underlying fascia. For this reason, V-Y subcutaneous
tissue pedicle island advancement flaps work less well
here because such flaps depend on ample subcutaneous
tissue for movement. Although smaller defects of the
lateral cheek are best repaired with transposition flaps,
large defects (greater than 3-4 cm) are most easily recon­
structed with rotation advancement 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 trans­
ferring large areas of skin from the remaining cheek and
upper cervical regions. Patients who use tobacco prod­
ucts or have been irradiated in the area of the defect may
benefit from inclusion of the platysmal muscle in the
advancement flap used to repair large lateral cheek defects
(see discussion in Chapters 6 and 7). The deeper plane
of dissection ensures a greater blood supply to the flap
than if dissection is in the subcutaneous plane.
Eyelid
When a defect of the anterior lamella of the lower eyelid
is encountered, a horizontal subcilial incision is made
along the length of the eyelid approximately 2 mm
beneath the lash line.8 An advancement flap consisting of
the entire lateral lower eyelid skin and muscle is devel­
oped. To avoid any distortion of the eyelid or fat pads, it
is important that the musculocutaneous flap be dissected
completely free of any adherence to the underlying
orbital septum. It may be necessary to carry this incision
past the lateral canthus to recruit adjacent skin from the
temple and lateral cheek. If necessary, an inferior incision
along the nasofacial sulcus can also be used to free up
additional tissue for the superior movement of cheek
skin.
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. The majority of skin defects of the central
upper and lower lips that cannot be closed primarily can
be repaired most favorably with bilateral unipedicle
advancement flaps. For the upper lip, incisions for oppos­
ing advancement flaps are made along the vermilion-
cutaneous border and immediately below the nasal sill.
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 subcutaneous fat
present. It is usually necessary to remove a Burow tri­
angle from the vermilion to prevent excessive bunching
when the opposing borders of the two advancement flaps
are approximated.
V-Y 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
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 perim­
eter is 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 opposing margins of the donor site.
For sizeable (2-3 cm) skin defects located adjacent to
the inferior border of the ala, it may be beneficial to
excise the small peninsula of skin between the ala and
melolabial fold in the process of enlarging the defect so
that it extends to an aesthetic boundary (see Fig. 9-12).7
This peninsula is then reconstructed by appropriately
designing the island flap so that the superior portion of
the flap replaces the peninsula. This technique provides
the best scar camouflage because the superior border
of the flap is positioned within the aesthetic boundary of
the alar-facial sulcus. When this peninsula is not replaced,
the flap must cross the base of the peninsula and may mar
an otherwise excellent result.
The major advantage of subcutaneous tissue pedicle
advancement flaps used to repair cutaneous defects is that
there is no need to resect standing cutaneous deformities
because these do not develop. For this reason, they are
particularly advantageous compared with transposition
and cutaneous pedicled advancement flaps, which often
have sizeable deformities that must be resected and dis­
carded. There is no wasted skin with the island flap.
Another important advantage of using the island flap for
reconstruction of cutaneous defects is that there is con­
siderably less dead space beneath the flap as well as
beneath skin surrounding the defect compared with use
of cutaneous pedicled flaps. Less dead space means less
space available for collection of blood and serum. There­
fore, there is less risk of development of a hematoma
compared with use of other types of flaps. The major
disadvantage of the island flap is a tendency for develop­
ment of trap-door deformity, especially for a smaller flap
(less than 2 cm in size).
For a cutaneous cheek defect located near the medial
lower eyelid or medial canthus, a unipedicle advancement
flap is usually the preferred flap for repair. Advancement
of tissue should be based laterally rather than inferiorly
to help prevent the development of lower lid ectropion.
In these instances, it is often unnecessary to make a hori­
zontal incision at the orbital rim because the skin can
frequently be advanced by stretching without the neces­
sity of the incision. Advancement does cause a standing
cutaneous deformity to develop in the area of the medial
canthus and sidewall of the nose that should be excised
along this aesthetic border. Avoiding the horizontal inci­
sion below the eyelid whenever possible reduces postop­
erative edema of the lower eyelid.
Lateral cheek skin has less subcutaneous cheek fat
and is more adherent than medial cheek skin to the

168
SECTION I  FUNDAMENTALS
in the melolabial crease, an important aesthetic border.
All scars are confined to the aesthetic regions of the lips.
In men, the flap contains hair-bearing skin with the same
downward orientation of hair growth as in the remaining
upper lip.9
As in the upper lip, lower lip cutaneous defects can
frequently be reconstructed with advancement flaps.
Repair may take the form of a unilateral or bilateral uni­
pedicle advancement flap. The flaps are dissected free
from their skin attachments to the underlying orbicularis
oris. Incisions are typically placed along the vermilion-
cutaneous border and in the mental crease to provide the
best scar camouflage. In other instances, T-plasty may be
used for such repairs.
CASE REPORTS
Case 1
A 57-year-old woman was evaluated for excision of a 4
× 3-cm central forehead skin graft that was used to
repair a cutaneous defect after micrographic excision of
a basal cell carcinoma (Fig. 9-13). The options for local
flap reconstruction of the defect resulting from skin
graft excision included bilateral advancement flaps in
the form of a large H-plasty and excision of the graft
and underlying frontalis muscle with repair by primary
wound closure. H-plasty would have required lengthy
horizontal forehead incisions and dissection of advance­
ment flaps in the subcutaneous tissue plane. Because
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
the flap is freed from its orbicularis muscle attachments
near the commissure and is based solely on the abundant
subcutaneous fat located just lateral to the commissure.
The flap is designed as an isosceles triangle, the base of
which abuts the defect to be repaired.9 The two approxi­
mately equal sides of the triangle are designed to meet in
the melolabial crease inferiorly and laterally. The base of
the triangle is the height of the defect, and the height of
the triangle is two times the width of the defect. The
incisions to create the flap are made to the level of the
orbicularis oris. If the width of the flap does not extend
to the cheek fat lateral to the orbicularis oris, the muscle
is left attached to the majority of the underside of the
flap. Only peripheral margins of the flap are undermined
to allow eversion of the wound edges. It may be necessary
to incise through some of the muscle to increase mobility.
When the flap is sufficiently wide to incorporate the
abundant fat lateral to the orbicularis oris, the flap may
be partially or completely released from the orbicularis
oris for greater mobility. After the flap is advanced into
the recipient site, the secondary defect is closed by
advancement in a horizontal vector. A vertical vector of
closure should be avoided to prevent upward distortion
of the vermilion.9 When it is properly designed, the flap
provides the best skin color and texture match with lip
skin because the flap is composed solely or predominantly
of skin of the lip. The flap donor site scar parallels or lies
FIGURE 9-13  ■  A, A 4 × 3-cm skin graft of central forehead. Excision and primary wound closure planned. Anticipated standing cuta­
neous deformities (SCD) resulting from advancement of wound margins after excision of skin graft are marked with horizontal lines
using M-plasty inferiorly. B, Skin graft excised and wound repaired. C, D, Preoperative and 2-month postoperative views. No revi­
sion surgery performed.
A
M-Plasty
SCD removed
here
B
C
D

9  ADVANCEMENT FLAPS
169
If complete wound closure is not possible, portions of the
wound can be left to heal by secondary intention. This
provides a predictably good aesthetic result.
The patient shown in Figure 9-14 presented with a
similar unsightly appearance of the forehead. The patient
suffered a full-thickness avulsion of the soft tissue of the
lateral forehead. The tissue defect was reconstructed with
a microvascular radial forearm flap. Although the flap
provided adequate cover for the exposed frontal bone, it
was unsightly because of skin color and texture mismatch
with adjacent native forehead skin. The flap measured 6.0
× 5.5-cm and was too large to be excised in one surgical
stage and for complete wound closure to be expected. For
this reason, serial excision of the flap concomitant with
forehead skin advancement was planned.
Serial excision required four surgical procedures to
completely excise the flap. An interval of 6 to 7 months
elapsed between partial excisions of the flap. Figure
9-14A-H shows the patient’s forehead before and imme­
diately after each surgical stage. The standing cutaneous
deformity forming at the superior border of the eyebrow
as a result of advancement of the forehead and temple
skin during wound closure after partial flap excisions
were partially excised by an M-plasty excision as described
long flaps would have been necessary, flap vascularity
may have been compromised. For this reason, primary
wound repair of large forehead skin defects is usually
preferred. Primary wound closure requires advancement
of the remaining forehead skin, which creates large
standing cutaneous deformities superior and inferior to
the skin defect. In this case, the skin graft and underly­
ing muscle were excised and the forehead skin on either
side of the defect resulting from excision was under­
mined in the subgaleal plane. This dissection plane pre­
served the supraorbital sensory nerves supplying the
skin of the forehead and anterior scalp. An M-shaped
excision (M-plasty) was used to remove the standing
cutaneous deformity inferior to the defect resulting
from the advancement of forehead skin. This method of
excising the deformity eliminated the need for extension
of incisions into the eyebrow and upper eyelid. The
standing cutaneous deformity forming superior to the
defect was excised in an ellipse. Complete closure of the
wound was possible.
In spite of a wound closure scar that is perpendicular
to the horizontal creases of the forehead, defects of the
forehead skin larger than 3 cm are best repaired by
primary wound approximation in a vertical orientation.
FIGURE 9-14  ■  A, A 6 × 5.5-cm radial forearm flap used to cover large full-thickness soft tissue defect. Vertical line indicates planned
incision for serial excision (first stage) of flap. B, After first surgical stage. C, Planned second surgical stage serial excision. D, After
second surgical stage. E, Planned third surgical stage serial excision. F, After third surgical stage. G, Planned fourth surgical stage
serial excision and scar revision with direct eyebrow lift. H, After fourth surgical stage.
A
B
C
D
E
F
G
H

170
SECTION I  FUNDAMENTALS
FIGURE 9-15  ■  A-D, Same patient shown in Figure 9-14. Preoperative and 6-month postoperative views after the fourth surgical stage.
A
B
C
D
the lesion had been established by members of the Uni­
versity of Michigan dermatology department by use of a
system known as the square technique.10,11 The square
technique is discussed in detail in the Case Reports
section of Chapter 8. The patient in Figure 9-16 shows
a melanoma in situ with the margins outlined by a
running suture creating a square of the central forehead
skin measuring 1.5 × 1.5-cm. The square of skin was
excised and the wound repaired with bilateral unipedicle
advancement flaps. The area of skin excised was small
relative to the examples discussed in case 1. Therefore,
it was elected to excise the lesion and to repair it with
bilateral unipedicle advancement flaps. Each flap was
dissected in the subcutaneous plane to preserve the
cutaneous innervation of the forehead skin. The stand­
ing cutaneous deformities that formed along the supe­
rior borders of the flaps were excised together in a
vertical line immediately above where the two flaps
were opposed. Because of the elasticity of the lower
portion of the forehead skin, the standing cutaneous
deformities forming at the inferior borders of the flaps
were eliminated by a halving suture technique. The
H-plasty used in this patient places the majority of the
incisions in RSTLs. This ensures that scars are camou­
flaged by lying in or parallel to the horizontal creases of
the forehead.
in the preceding case. Not all of the standing cutaneous
deformities developing near the eyebrow could be excised
without resection of a portion of the eyebrow. As a result,
the eyebrow was displaced inferiorly. This was corrected
at the time of the last surgical stage by including a direct
brow lift with the vertical scar revision that was per­
formed. Figure 9-15 shows the preoperative and final
appearance of the forehead after a total of four partial
excisions of the flap.
This case clearly demonstrates the value of serial exci­
sions followed by primary wound closure in removal
of large congenital nevi, vascular malformations, or
skin deformities of the forehead by use of this surgical
approach. The case presented could have also been
treated with controlled tissue expansion of the native
forehead skin followed by excision of the flap and advance­
ment of the expanded forehead skin laterally to repair the
defect resulting from excision. This option was discussed
with the patient. The patient declined in favor of serial
excisions. Controlled tissue expansion is discussed in
detail in Chapter 25.
Case 2
A 56-year-old woman was referred for treatment of a
melanoma in situ of the forehead. Clear margins around

9  ADVANCEMENT FLAPS
171
FIGURE 9-16  ■  A, A 1.5 × 1.5-cm square of forehead skin outlined
by sutures. Bilateral unipedicle advancement flaps (H-plasty)
designed for repair of wound resulting from excision of square.
B, Square excised and wound closed. Standing cutaneous defor­
mity formed by tissue advancement removed superior to H-plasty.
It was not necessary to remove standing cutaneous deformity
inferior to H-plasty. C, Postoperative view at 4 months. No revi­
sion surgery performed.
A
B
C
Bilateral unipedicle advancement flaps work well for
repair of small (2 cm or less) skin defects located any­
where on the forehead, like the one shown in Figure
9-16. H-plasty is particularly useful in repairing skin
defects in or adjacent to the eyebrow. This is because the
skin adjacent to the eyebrow is more elastic than skin
elsewhere on the forehead and is more easily transferred
as an advancement flap. In addition, the skin of the temple
can frequently be recruited into a laterally based advance­
ment flap to facilitate wound closure. An example of this
is shown in Figure 9-17. This 54-year-old woman pre­
sented with a 3.5 × 2.5-cm skin defect of the eyebrow and
forehead skin after micrographic excision of a basal cell
carcinoma. Although the defect encompassed a large
section of the eyebrow, a small portion of the eyebrow
persisted laterally. This portion was incorporated into an
H-plasty so that it could be advanced medially to estab­
lish eyebrow continuity. A Z-plasty was designed at the
superior border of the lateral flap, and Burow triangle
excisions were planned along the inferior borders at the
bases of the two advancement flaps.
The lateral-based flap was incised first and dissected
in the subcutaneous plane. Because of the mobility of the
flap, wound closure was possible without making planned
incisions along the full length of the medially based flap.
The lateral flap was advanced sufficiently to create a
standing cutaneous deformity that could not have been
eliminated with a Z-plasty. Therefore, Burow triangles
were excised above and below the base of the flap. The
degree of advancement of the lateral flap enabled a medial
flap of diminutive length. As a result, it was not necessary
to excise standing cutaneous deformities along the
borders of this flap. The H-plasty shown in Figure 9-17
places most of the suture lines in RSTLs and along the
border of the eyebrow, which is an important boundary
between aesthetic facial regions. This case demonstrates
the wisdom of first incising the flap that is designed in
the area of greatest skin elasticity. On occasion, signifi­
cant skin movement is achieved with a single flap so that
the second flap is not necessary or, as in this case, can be
created with less length than is anticipated.
For cutaneous defects of the temple, H-plasty is not
usually necessary. Transposition flaps or single unipedicle
advancement flaps work well because of the elasticity of
temple skin. However, when skin defects approach 3 cm
or greater and are located adjacent to the anterior hair­
line, repair with a T-plasty technique may be advanta­
geous. The modified bilateral unipedicle advancement
flaps of a T-plasty recruit skin from opposite borders of
the defect, and a portion of the wound closure line can
be designed in or at the hairline.
T-plasty is often effective in repairing small (2 cm or
less) skin defects located above the eyebrow. The rela­
tively lax skin immediately superior to the eyebrow can
be used to develop bilateral unipedicle advancement
flaps. An example of this is shown in Figure 9-18. The
patient is an 81-year-old woman who had micrographic
surgery for a basal cell carcinoma of the left central

172
SECTION I  FUNDAMENTALS
C
FIGURE 9-17  ■  A, B, A 3.5 × 2.5-cm skin defect of forehead and eyebrow. Bilateral unipedicle advancement flaps (H-plasty) designed
for repair of wound. Lateral portion of eyebrow incorporated into lateral advancement flap. Burow triangles marked in crow’s-feet
laterally and glabellar rhytid medially. Z-plasty marked at superior border of lateral flap. C, Flaps advanced. Marked advancement
of lateral flap eliminated need to make entire planned incisions of medial flap. Planned Z-plasty not performed. D, Flaps approxi­
mated. Standing cutaneous deformities removed inferiorly from crow’s-feet and superiorly at base of lateral flap. E, Postoperative
view at 4 months. No revision surgery performed.
A
B
D
E
aspect of the forehead. The resulting skin defect mea­
sured 1.7 × 1.4-cm and was adjacent to the medial aspect
of the eyebrow. The limb of the lateral flap of the
T-plasty is drawn along the border of the eyebrow and
the anticipated standing cutaneous deformities are
marked with horizontal lines. The flaps of the T-plasty
were dissected in the subcutaneous tissue plane. Wound
closure was achieved with only minimal wound closure
tension.
Case 3
A 55-year-old woman developed a superficial spreading
melanoma of the cheek. A 4 × 4-cm skin defect resulted
from resection of the lesion (Fig. 9-19). The three most
likely successful methods of repair for such a large defect
are full-thickness skin graft, a skin flap of the cheek
transferred as a transposition, and an advancement flap.
For cutaneous defects located near the lower eyelid, a
unipedicle advancement flap is usually preferred for
repair. Such a flap was designed in this case with bilateral
Z-plasties at the base of the flap to facilitate tissue move­
ment and to reduce the standing cutaneous deformities
resulting from advancement. The flap was elevated in the
subcutaneous plane and advanced superiorly and medi­
ally. The lengthy advancement of the flap necessitated
the excision of a small standing cutaneous deformity
anteriorly along the inferior mandibular margin.
Repair of skin defects of the superomedial cheek that
are smaller than the one seen in Figure 9-19 do not
always require making parallel incisions to create an
advancement flap. For example, the defect shown in
Figure 9-20 was repaired by a unipedicle advancement
flap. Although the majority of the flap movement was in

9  ADVANCEMENT FLAPS
173
lesion were established by the square technique described
in the Case Reports section of Chapter 8. The area out­
lined by sutures shown in Figure 9-22A measured 4 ×
4-cm and was resected in the subcutaneous tissue plane.
The resulting skin defect was reconstructed with an infe­
riorly based unipedicle advancement flap. The posterior
border of the flap was made longer than the anterior
border and a Z-plasty was used at the base of the flap.
Because of the marked redundancy of the upper cervical
and lower facial skin, the flap was advanced with ease,
resulting in repair without excessive wound closure
tension.
Case 4
A 52-year-old woman was referred for excision of a mela­
noma in situ of her right cheek. The square technique
had been used to establish clear margins around the skin
lesion (Fig. 9-23). The area marked with sutures and to
be resected was rectangular and measured 3.5 × 4.0 cm.
The alternative methods of repairing the cheek defect
with a local cutaneous flap after excising the lesion
included a flap transferred by advancement, transposi­
tion, or rotation. The advancement flap could have been
in the form of a cutaneous pedicled or a subcutaneous
tissue pedicled island flap. The latter design was selected
for repair. Island advancement flaps are most effective in
the area of the medial cheek. The abundant fat of the
the form of advancement, some pivotal movement was
also used to transfer the flap. The pivotal movement,
although limited, eliminated the need to make two paral­
lel incisions to create the flap. A single long incision was
designed in the melolabial crease in addition to a Z-plasty
to eliminate the standing cutaneous deformity forming at
the anterior border of the flap. A sizeable standing cuta­
neous deformity was excised lateral to the skin defect as
marked on the patient’s face. Wound closure resulted in
lower eyelid retraction, so the wound was open between
the border of the flap and the eyelid skin to release wound
closure tension. The exposed area was repaired with a
full-thickness skin graft that was obtained from the
excised and discarded standing cutaneous deformity.
Figure 9-21 shows the preoperative and postoperative
views of the patient. The prudent use of a small full-
thickness skin graft in combination with the advancement
flap prevented postoperative lower eyelid retraction or
ectropion. Chapter 16 discusses in detail the combined
use of full-thickness skin grafts and local cutaneous flaps
for repair of large facial defects.
Unipedicle advancement flaps work well for repair of
skin defects of the medial cheek because of the elasticity
of skin in this region of the face. However, unipedicle
advancement flaps may also be used for repair of defects
of the lateral cheek. An example of this is shown in Figure
9-22. The patient is a 70-year-old man with lentigo
maligna of the left cheek. Clear margins around the
FIGURE 9-18  ■  A, A 1.7 × 1.4-cm skin defect of left forehead. T-plasty designed with limb of laterally based flap positioned along
border of eyebrow. Anticipated standing cutaneous deformities (SCD) marked by horizontal lines for excision. B, Wound closed.
Standing cutaneous deformity removed. C, D, Preoperative and 6-month postoperative views. No revision surgery performed.
A
SCD removed
here
B
C
D

174
SECTION I  FUNDAMENTALS
this chapter. Medial cheek defects of 3 to 4 cm in size
can readily be reconstructed with subcutaneous tissue
pedicle advancement flaps. Such flaps are particularly
useful for repair of skin defects just lateral and inferior
to the alar base because the medial border of the flap
can be placed within the melolabial crease for maximum
scar camouflage.
Case 5
Advancement flaps used to repair cutaneous defects of the
lips are usually oriented in such a manner that their
advancement is in a horizontal plane. However, on occa­
sion, advancement flaps are best designed with a vertical
medial cheek facilitates the advancement of the island
flap because the flap is based solely on the subcutaneous
tissue beneath the skin.
A 5.5 × 3.0-cm V-Y subcutaneous tissue pedicle
advancement flap was designed so that the base of
the triangular skin island represented the inferolateral
border of the cheek defect. The width of the skin island
was equal to the greatest width of the cheek defect. The
height of the skin island was approximately twice the
height of the defect. The medial border of the flap was
designed parallel to the melolabial crease. The inferior
half of the skin island tapered to a point to facilitate
donor site closure in a V-Y fashion. The flap was dis­
sected in a manner described in the earlier portion of
FIGURE 9-19  ■  A, A 4 × 4-cm superficial melanoma marked for excision. B, Unipedicle advancement flap designed for repair of wound.
Z-plasties marked at base of flap. C, Flap in place. D, E, Postoperative views at 1 year. No revision surgery performed. (From: Baker
SR: Local Cutaneous Flaps. Otolaryngology Clin N. Am 27:1994, W.B. Saunders, p 147, Fig 5 B-E, with permission.)
A
B
C
D
E

9  ADVANCEMENT FLAPS
175
FIGURE 9-20  ■  A, A 3 × 1.5-cm skin defect of medial cheek. Unipedicle advancement flap with Z-plasty at base designed for repair of
wound. Anticipated standing cutaneous deformity marked by vertical lines lateral to defect. B, Excessive wound closure tension
caused lower eyelid retraction. This was relieved by placing small full-thickness skin graft between flap and eyelid skin.
A
B
A
B
FIGURE 9-21  ■  A-D, Same patient shown in Figure 9-20. Preoperative and 5-month postoperative views. No revision surgery
performed.
Continued

176
SECTION I  FUNDAMENTALS
C
D
FIGURE 9-22  ■  A, A 4 × 4-cm square of skin outlined by sutures and intended for resection. Broken line indicates planned unipedicle
advancement flap. B, Flap advanced after resection of square. Z-plasty performed at posterior border of flap base. C, Postoperative
view at 11 months. No revision surgery performed.
A
B
C
FIGURE 9-21, cont’d

9  ADVANCEMENT FLAPS
177
A
B
C
D
Subcutaneous tissue pedicle
E
F
FIGURE 9-23  ■  A, A 3.5 × 4-cm skin defect of medial cheek after excision of melanoma in situ. V-Y subcutaneous tissue pedicle
advancement flap designed for repair of wound. B, Flap incised and dissected. C, Flap attached to subcutaneous tissue pedicle.
D, Flap in place. E-H, Preoperative and 2-year postoperative views.
Continued

178
SECTION I  FUNDAMENTALS
full-thickness lip defect and repaired by primary wound
closure in a vertical orientation, which would have
resulted in a need to excise a considerable section of
exposed orbicularis oris. Other choices for reconstruction
included the use of a local flap in the form of transposi­
tion or advancement.
As in this case, small defects (1.5 cm or less) adjacent
to the vermilion are ideal for repair with an O-T (T-plasty)
closure. The horizontal limbs of the T-plasty are placed
along the vermilion-cutaneous border. T-plasty repre­
sents a modification of bilateral unipedicle advancement
flaps. Instead of making two parallel incisions to create
each flap, only one incision on opposing sides of the
defect is made. The two flaps are advanced and slightly
pivoted toward each other to repair the defect. A standing
cutaneous deformity develops at the defect site opposite
the position of the two incisions. In this case, the standing
cutaneous deformity was excised immediately above the
superior border of the defect. It was also necessary to
excise standing cutaneous deformities along the inferior
borders of the flaps. A limited advancement of the ver­
milion in the midline of the upper lip provided cover for
the missing vermilion.
After healing, it was noted that the Cupid’s bow was
absent. Cupid’s bow is an important aesthetic contour of
the central upper lip, especially in young women. To
restore the Cupid’s bow, revision surgery was performed
in which a midline V-Y subcutaneous tissue pedicled
vector of advancement. An example of this is shown in
Figure 9-24. Although this skin defect could have been
repaired with an O-T closure, the resulting T-plasty
would necessitate excision of a standing cutaneous defor­
mity within the philtrum. This in turn would have nar­
rowed the philtrum. For this reason it was elected to
repair the skin defect in a horizontal orientation by use
of superiorly and inferiorly based unipedicle advance­
ment flaps. The superior flap was created by making an
incision on either side of the defect along the vermilion-
cutaneous border and dissecting a superiorly based cuta­
neous flap (Fig. 9-24C). The inferior flap was created by
the same incisions and dissecting an advancement flap
consisting of vermilion and mucosa (Fig. 9-24D). The
two flaps were advanced toward each other. This repair
in essence is a primary closure of the defect. Standing
cutaneous deformities resulting from skin and mucosal
advancement were resected along the vermilion border.
The resulting repair did not compromise the width or
the topography of the philtrum.
Case 6
Advancement flaps are very useful for reconstructing skin
defects of the upper and lower lip. Figure 9-25 shows a
1.4 × 1.5-cm circular defect of the central upper lip and
vermilion after micrographic excision of a basal cell car­
cinoma. This defect could have been converted to a
G
H
FIGURE 9-23, cont’d

9  ADVANCEMENT FLAPS
179
FIGURE 9-24  ■  A, A 1.5 × 1-cm skin and vermilion defect of upper lip. B, Superiorly and inferiorly based advancement flaps planned
for repair of wound. Anticipated standing cutaneous deformities marked with vertical lines along vermilion border. C, Skin flap dis­
sected. D, Vermilion and mucosal flap dissected. E, Wound approximated. F, Postoperative view at 6 months. No revision surgery
performed.
A
B
C
D
E
F
island skin flap of the philtrum was advanced inferiorly.
After healing, the lip scars were dermabraded. Unfortu­
nately, this resulted in an unfavorable appearance because
of discrepancies of skin color and texture between the
dermabraded area and the native lip skin.
The skin defect shown in Figure 9-26 had a similar
location to that shown in Figure 9-25. Both defects were
located within the philtrum of the upper lip; however, the
defect shown in Figure 9-26 was smaller (1.6 × 1-cm) and
involved less of the cutaneous portion and more of the
vermilion portion of the lip. A V-Y subcutaneous tissue
pedicled island advancement flap is another method of
repairing skin defects of the upper lip that are 1 cm or
smaller in size and located in the midline at the vermilion
border. As shown in Figure 9-26, the island advancement
flap was based on the underlying orbicularis oris. The flap
was advanced inferiorly to the border of the diminutive
vermilion defect. No advancement of the vermilion was
necessary. The use of this flap enabled restoration of the
natural double convexity of the Cupid’s bow. The flap

180
SECTION I  FUNDAMENTALS
angles to the crease. This would have resulted in a scar
that was perpendicular to RSTLs, which would have dis­
rupted the continuity of the melolabial fold. As discussed
earlier in this chapter, skin defects involving the lip and
cheek adjacent to the alar base are effectively recon­
structed with subcutaneous tissue pedicle island advance­
ment flaps. Such a flap was selected for this repair (Fig.
9-27). Most of the remaining skin of the lateral lip aes­
thetic unit was removed to place scars in aesthetic bound­
aries. This included the removal of the narrow skin
peninsula between the superior melolabial fold and the
ala.12 An exact template was designed of the cutaneous
defect resulting from micrographic surgery and the
planned additional skin removal superior to the defect.
The template was used to design a subcutaneous tissue
also maintained the natural width of the philtrum.
Primary repair of this wound would have narrowed the
philtrum and would have eliminated the Cupid’s bow.
Case 7
A 43-year-old woman had micrographic excision of a
basal cell carcinoma of the upper lip. Her defect mea­
sured 3 × 2.5-cm and involved the skin and vermilion of
the lateral lip. The defect was confined to the aesthetic
region of the lip. The reconstructive options using a local
flap included flaps designed as transposition, rotation, or
advancement. A transposition flap harvested from the
cheek was not the best option because, by necessity, the
flap would have crossed the melolabial crease at right
FIGURE 9-25  ■  A, A 1.5 × 1.4-cm skin and vermilion defect of central upper lip. Horizontal lines along vermilion-cutaneous border
mark planned incisions for advancement flaps in T-plasty repair. Small vermilion advancement flap planned for repair of vermilion
component of defect. Anticipated standing cutaneous deformity (SCD) marked for excision. B-D, Flaps incised and approximated,
and SCD excised. E, F, Preoperative and 16-month postoperative views. Scar was dermabraded, causing hypopigmentation of central
lip skin.
A
B
C
D
Vermilion advanced
SCD removed
here
SCD removed here
E
F

9  ADVANCEMENT FLAPS
181
FIGURE 9-26  ■  A, A 1.6 × 1-cm skin and vermilion defect of upper lip. V-Y subcutaneous tissue pedicle island advancement
flap designed for repair of wound. Mucosal advancement flap marked. B, C, V-Y flap incised. Proximal and distal thirds of flap are
freed from underlying muscle attachments. Flap advanced inferiorly to recipient site. Planned mucosal advancement flap not used.
D-G, Preoperative and 7-month postoperative views. No revision surgery performed.
A
B
C
V-Y wound
closure
D
E
F
G

182
SECTION I  FUNDAMENTALS
FIGURE 9-27  ■  A, A 3 × 2.5-cm skin and vermilion defect of lateral upper lip. Skin superior to defect marked for excision to place scar
in alar-facial sulcus. V-Y subcutaneous tissue pedicle advancement flap designed from template of opposite lip aesthetic unit for
repair. Oral mucosa advanced outward (white arrow) to reconstruct missing vermilion. B-D, Island flap based on subcutaneous
tissue pedicle advanced to recipient site. Mucosal advancement flap sutured to inferior border of island flap. E-H, Preoperative and
31-month postoperative views. Contouring of flap and several scar revisions including Z-plasties performed.
B
C
D
A
Template of
opposite lip
segment use
to design flap
Mucosal advancement
Skin peninsula
removed
Vermiliocutaneous
junction
E
F

9  ADVANCEMENT FLAPS
183
G
H
FIGURE 9-27, cont’d
pedicled V-Y advancement flap. The vermilion compo­
nent of the defect was repaired with a mucosal advance­
ment flap developed from the oral aspect of the lip.
The flap was undermined in the subcutaneous plane
to release the attachments between the flap skin and the
orbicularis oris. The flap was left attached to the subcu­
taneous fat lateral to the modiolus. This fat served as the
pedicle of the flap and had sufficient mobility to allow
advancement of the flap into the defect. The mobility of
the flap on its fat pedicle is well demonstrated in Figure
9-27C. The flap was dissected by the methods discussed
in detail in an earlier section of this chapter. Because of
the complexity of this defect, the patient required subse­
quent contouring of the V-Y advancement flap and revi­
sion of the vertical portion of the lip scar.13 By replacement
of the skin peninsula between the melolabial fold and the
ala, scars are better camouflaged than if the skin penin­
sula is not replaced with the V-Y advancement flap.
The V-Y subcutaneous tissue pedicle advancement
flap is particularly well suited for reconstruction of lateral
skin defects of the upper lip. All scars are confined or
parallel to the aesthetic region of the upper lip. Because
the flap is harvested from the remaining skin of the lateral
upper lip and cheek skin immediately adjacent to the lip,
the best possible skin color and texture match is obtained.
In men, the flap contains hair-bearing skin with the same
downward orientation of hair growth as in the remaining
upper lip.
Case 8
A 63-year-old woman was treated for a recurrent basal
cell carcinoma of the lower lip by micrographic surgery.
Resection of the tumor left a 3 × 2.5-cm skin defect of
the central lip. An option for reconstruction included
converting the defect to a full-thickness excision and per­
forming primary wound closure. This had the advantage
of not requiring a flap for repair, but it would have sig­
nificantly reduced the size of the oral stoma. For this
reason, bilateral unipedicle advancement flaps were
designed, placing borders of the flaps along the vermilion
and within the mental crease (Fig. 9-28). The flaps were
elevated in the subcutaneous plane, releasing flap skin
from its tightly adherent attachments to the orbicularis
oris. Standing cutaneous deformities were excised along
the superior border of the flaps within the vermilion on
either side of the midline. The standing cutaneous defor­
mities at the inferior border of the flaps were excised
together in the midline, causing the scar to extend down­
ward slightly into the chin. Because the repair was under
considerable wound closure tension, some hypertrophic
scarring occurred, necessitating a subsequent scar revi­
sion. The final result of the reconstructive effort is seen
in Figure 9-28C.
Defects of the lower lip of similar size to this case may
often be repaired in the very elderly by converting the
defect into a full-thickness wedge excision of the lip and
closing the wound primarily. Elderly patients have a
greater redundancy of lip tissue, and resection of one-
third to one-half of the total width of the lower lip is
frequently possible without causing microstomia. An
example of this is shown in Figure 9-29. A 2 × 2-cm skin
defect of the lower lip in a 79-year-old man was con­
verted to a full-thickness elliptical excision and primary
wound closure was performed. Although the vertical scar
is lengthy, the aesthetic result is acceptable.
Case 9
A 45-year-old woman presented with a 1.5 × 1.5-cm skin
defect of the chin after micrographic surgery for a basal
cell carcinoma (Fig. 9-30). This defect could have been
repaired with bilateral unipedicle advancement flaps in
the form of an H-plasty or O-T repair (T-plasty) or by
an O-Z repair using bilateral rotation flaps. Perhaps
imprudently, bilateral V-Y subcutaneous tissue pedicle
island advancement flaps were used for the repair.
Although the superior scar resulting from the reconstruc­
tion is in RSTLs, the inferior scar is not. The scars have
a depressed contour, and considerable trap-door defor­
mity is present. The author has learned from experience
that small (less than 2 cm) skin defects of the chin are not
ideal for repair with island advancement flaps. This may
be related to the topography of the chin. It may also be
related to the tightly adherent skin attachments to the
underlying musculature of the chin. However, larger

FIGURE 9-28  ■  A, A 3 × 2.5-cm skin defect of lower lip. Bilateral
unipedicle advancement flaps designed for repair of wound.
Superior border of flaps designed along vermilion-cutaneous
border. Inferior border of flaps designed in mental crease.
B, Flaps approximated. Standing cutaneous deformities excised
superiorly in vermilion on either side of midline and inferiorly
at midline. C, Postoperative view at 9 months. Revision of scars
performed 4 months after initial reconstruction.
A
B
C
FIGURE 9-29  ■  A, A 2 × 2-cm skin defect of lower lip. Primary wound closure planned. B, Defect converted to full thickness to facilitate
wound repair. C, Wound repaired. D, Postoperative view at 2 months.
A
B
C
D
Converted to full thickness

9  ADVANCEMENT FLAPS
185
FIGURE 9-30  ■  A, A 1.5 × 1.5-cm skin defect of chin. Bilateral V-Y
subcutaneous tissue pedicle advancement flaps designed for
repair of wound. B, Flaps approximated. C, Postoperative view
at 6 months. No revision surgery performed.
A
B
C
FIGURE 9-31  ■  A, A 6 × 5-cm skin defect of chin. Bilateral V-Y subcutaneous tissue pedicled advancement flaps designed for wound
repair. Vertical lines represent planned skin excision. B, C, Flaps incised and advanced.
A
B
C
defects of the chin may be reconstructed with V-Y sub­
cutaneous tissue pedicled advancement flaps with accept­
able aesthetic results. These flaps recruit the remaining
skin of the chin in addition to adjacent cheek skin to
create larger flaps compared with flaps confined solely to
the chin aesthetic region (Fig. 9-31). Large island flaps
tend to develop less trap-door deformities than smaller
flaps of similar design.
Small to medium-sized (3 cm) cutaneous defects con­
fined to the chin are best repaired with bilateral uni­
pedicle advancement flaps. An example of this is shown
in Figure 9-32. The defect measured 1.5 × 1.5-cm and
was closed by an O-T repair. The skin of the chin is
inelastic, which may cause wound repair to be under rela­
tively high wound closure tension. In addition, the chin
has a convex surface. Flaps advanced over this convexity
require greater skin movement for a given size defect
than for a defect of the same dimension located on a flat
surface, such as the cheek. Figure 9-32B demonstrates
this fact. The effective length of the two advancement
flaps was reduced by the convexity of the chin, leaving a
secondary defect superior to the flaps. The secondary
defect was repaired by wide undermining and inferior
advancement of the skin of the lower lip.

186
SECTION I  FUNDAMENTALS
FIGURE 9-32  ■  A, A 1.5 × 1.5-cm skin defect of chin. Bilateral unipedicle advancement flaps (T-plasty) designed for repair. Anticipated
standing cutaneous deformity marked with horizontal lines. B, Flaps dissected and apposed with single suture. Effective length of
flaps reduced by convexity of chin, causing secondary defect to develop superior to flap borders. C, Secondary defect closed by
inferior advancement of lower lip skin.
A
B
C
REFERENCES
1. Johnson TM, Nelson BR. Aesthetic reconstruction of skin cancer
defects using flaps and grafts. Am J Cosmetic Surg 1992;9:253.
2. Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown;
1987.
3. Salache SJ, Grabski WJ. Flaps for the central face. New York:
Churchill Livingstone; 1990.
4. Juri J, Juri C. Cheek reconstruction with advancement-rotation
flaps. Clin Plast Surg 1981;8:223.
5. Bennett RG. Local skin flaps on the cheeks. J Dermatol Surg Oncol
1991;17:161.
6. Salache SJ, Jarchow R, Feldman BD, et al. The suspension suture.
J Dermatol Surg Oncol 1978;13:973.
7. Burget GC, Menick FJ. Aesthetic restoration of one-half the upper
lip. Plast Reconstr Surg 1986;78:583.
8. Khan JA. Subcilial sliding skin muscle flap repair of anterior lamella
lower eyelid defects. J Dermatol Surg Oncol 1991;17:167.
9. Skouge JW. Upper lip repair: the subcutaneous island pedicle flap.
J Dermatol Surg Oncol 1990;16:63.
10. Anderson KW, Baker SR, Lowe L. Treatment of head and neck
melanoma, lentigo maligna subtype. Arch Facial Plast Surg
2001;3:202.
11. Anderson KW, Baker SR. Management of early lentigo maligna
and lentigo maligna of the head and neck. Facial Plast Surg Clin
North Am 2003;11:93.
12. Burget G, Hsiao YC. Nasolabial rotation flaps based on the upper
lateral lip subunit for superficial and large defects of the upper lip.
Plast Reconstr Surg 2012;130:556.
13. Griffin GR, Weber S, Baker SR. Outcomes following V-Y advance­
ment flap reconstruction of large upper lip defects. Arch Facial
Plast Surg 2012;14:193.

187
C H A P T E R 1 0 
BILOBE FLAPS
Shan R. Baker
INTRODUCTION
The original design of the bilobe flap is attributed to
Esser,1 who described its use in 1918 for reconstruction
of nasal tip defects. Zimany2 and others expanded the use
of the flap to reconstruct defects on the trunk and soles.
However, most authors now share the opinion that this
flap is most useful for facial reconstruction, particularly
of the nose.
Esser’s original design required that the angle of tissue
transfer be 90° between each lobe of the flap, for a total
pivotal movement of more than 180°. An example of this
design for repair of a nasal tip defect would be the first
lobe of the flap harvested from the nasal sidewall and the
second lobe from the glabella. This design maximizes the
distance that skin can be moved, but the wide angles
between the two lobes (90°) also maximize the standing
cutaneous deformities and the likelihood of creating
trap-door deformities of both first and second lobes.
These were common problems with the original flap
design and limited the use of the bilobe flap for facial
reconstruction.
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 arc of movement
about their pivotal points, the larger are the standing
cutaneous deformities.
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 sec­
ondary movement of surrounding skin through direct
advancement. The relationship between the surface area
of the first lobe and the size of the defect depends on the
location of the defect on the face and the elasticity of skin
surrounding the defect. On the caudal 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 general elasticity and redundancy of
the skin surrounding cheek defects. The 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.
BIOMECHANICS
The bilobe flap would appear to be a modified rotation
flap with some component of transposition. However,
during transfer of the flap, there is noticeably less restric­
tion of tissue movement than would be present with a
pure rotation flap. This ease of tissue movement of the
first lobe is the result, in part, of transposing the triangle-
shaped peninsula of skin located between the defect and
the first lobe of the flap. The transposition of this skin
peninsula adjacent to the distal portion of the first lobe
of the flap in essence represents a modified Z-plasty (Fig.
10-1). Likewise, there is a triangular peninsula of skin
that forms between the first and second lobes that is also
transposed during closure of the donor site of the second
lobe. Thus, the bilobe flap in some ways represents a
modified double Z-plasty. This results in repositioning of
the skin adjacent to the defect and the two lobes of the
flap. This in turn results in an overall reduction in wound
closure tension compared with use of a single transposi­
tion or rotation flap.
Bilobe flaps expand the use of transposition flaps. The
major advantage of bilobe flaps is the ability to recruit skin
for construction of a flap from areas of skin redundancy
that are not adjacent to the defect. On the cheek, this skin
redundancy may be located at some distance from the
defect and may be difficult to transfer to the recipient site
by other surgical approaches. Defects that cannot be easily
repaired with a single transposition flap without excessive
wound closure tension causing distortion of facial struc­
tures may often be reconstructed with a bilobe flap. This
is because the second lobe of the transposition flap reduces
overall wound closure tension and provides additional skin
to the proximity of the reconstruction. Furthermore,
bilobe flaps transfer the tension of wound closure through
a 90° arc, which is more than the usual 45° to 60° arc of
transfer of a single transposition flap. This greater distri­
bution of wound closure tension helps minimize distor­
tion of structures surrounding the primary defect.
  Videos available online

188
SECTION I  FUNDAMENTALS
repair large defects located on the cheek in lieu of larger
cervical-facial rotation advancement flaps. They may also
be used to transfer skin from the postauricular area to
cover helical rim defects that might otherwise require
skin grafting.
The bilobe flap is best suited for reconstruction of
circular defects on the caudal third of the nose. In this
location, reconstruction with other types of nasal cutane­
ous flaps is difficult. The bilobe nasal flap enables the
surgeon to repair defects using adjacent skin without
causing nasal distortion. The aesthetic result is usually
excellent and often surpasses the result with use of full-
thickness skin grafts. This is especially true for deep nasal
cutaneous defects. As a consequence, the bilobe flap is a
preferred flap for reconstruction of the nose in the area
of the tip and caudal dorsum.
The primary disadvantage of the bilobe flap is that
most of the incisions necessary to create the flap
produce scars that do not parallel relaxed skin tension
lines (RSTLs). On the nose, incisions for the flap do
not lie within boundary lines separating nasal aesthetic
units. 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. On the nose, trap-
door deformity may be minimized by extensive periph­
eral undermining of the nasal skin as far laterally as the
cheek. Designing the lobes of the flap with angles, such
as with rectangular- or rhombic-shaped lobes, may also
reduce the incidence of trap-door deformity. Adjusting
the thickness of the first lobe so that it matches the
depth of the recipient site is accomplished by thinning
the flap if necessary, and it may be helpful in prevent­
ing the deformity.
FLAP DESIGN
McGregor and Soutar3 altered the design of bilobe flaps
and noted that the degree of pivotal movement could be
varied greatly from the original 90° between each lobe.
In 1989, Zitelli4 published his experience using the bilobe
flap for nasal reconstruction. He emphasized the use of
narrow angles of transfer, 45° between each lobe, so that
the total pivotal movement of tissue occurs over no more
than 90° to 100°. This eliminated the need to excise
standing cutaneous deformities, and trap-door deformi­
ties were frequently avoided. Burget5 confirmed the
excellent results with this design for reconstruction of the
nose. Other surgeons also advocated a similar design for
repair of skin defects of the cheek, chin, and lips.6,7 They
used narrow angles between the lobes of the flap and
achieved better results than with use of traditionally
designed bilobe flaps that are transposed through an arc
of 180°.
Limiting the angle between the axis of the first and
second lobes of the bilobe flap is more important on the
nose than on the cheek. When bilobe flaps are used on
the cheek, the primary determinants of the position of
the first and second lobes of the flap are the location
of the defect and the availability of donor skin for con­
struction 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 maxi­
mized. This may on occasion necessitate design of the
second lobe along an axis that is 180° to the axis of the
defect.
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 (Fig. 10-2).
The lobes of the flap may be designed with rhombic
shapes for smaller defects. Bilobe flaps may be used to
FIGURE 10-1  ■  A, B, Bilobe flaps are modified Z-plasties that reposition skin adjacent to defect and two lobes of flap. This results in
greater distribution of wound closure tension than with single-lobe transposition flaps.
A
B

10  BILOBE FLAPS
189
FIGURE 10-2  ■  A, B, C, Variations of bilobe flap used to repair caudal nasal cutaneous defects.
A
B
C
FIGURE 10-3  ■  A, B, Bilobe flaps useful for
repair of cutaneous cheek defects when simple
rotation or transposition flaps will not provide
sufficient tissue for repair.
A
B
CLINICAL APPLICATIONS
Cheek
The bilobe flap may be used to repair medium-sized
(3-6 cm) skin defects of the cheek. It is particularly useful
when simple rotation or transposition flaps will not
provide sufficient tissue for repair. This occurs when the
defect is large and located in the midcheek away from the
central part of the face. In this situation, the amount of
remaining adjacent cheek skin available for construction
of a local flap may be insufficient to cover the cheek
defect and still enable closure of the flap donor site.
Instead, a bilobe flap designed to recruit upper cervical
skin can be useful. Obviously, the lines of wound closure
do not fall in RSTLs on the cheek, but the advantage of
reducing wound closure tension outweighs the disadvan­
tages of the curvilinear scar created by use of the flap.
Like all transposition flaps, bilobed flaps take advantage
of lax skin adjacent to the defect to assist in wound
closure. The flap is designed to resemble a mitten (Fig.
10-3). The first lobe adjacent to the cheek defect is
designed slightly smaller than the defect, and the second
lobe is designed to be even smaller. The flap is raised in
the subcutaneous tissue plane and transposed into posi­
tion. The trick is to make sure the donor defect of the
second lobe can be closed primarily. This is determined
by the pinch test to see if the skin in the proposed area
of the second lobe is sufficiently loose to permit primary
wound closure. The test is accomplished by gathering the
skin of the designed second lobe between the thumb and
index finger. If sufficient skin laxity is present, the pinch
test should enable the surgeon to approximate the antici­
pated borders of the second lobe defect.
Bilobed flaps may be used anywhere on the cheek;
however, care should be taken in using the flap because

190
SECTION I  FUNDAMENTALS
development of flap necrosis, trap-door deformity, and
depressed scars.
Bilobe flaps of the nose must be geometrically precise
and are designed by the following method (Figs. 10-4 and
10-5).8 The radius of the defect is measured. For laterally
based flaps, a point lateral to the border of the defect is
marked in the alar groove that is the distance of the
length of the radius. This point is used to design both
lobes of the flap. Two arcs are drawn with their centers
at the marked point. The first arc makes a tangent with
the border of the defect most distal to the point, and the
second arc passes through the center of the defect. Cali­
pers and rulers are not used to draw the arcs because
these devices measure straight-line distances. In contrast,
the topography of the nose is convex in the area of the
tip and dorsum. Therefore, a flexible measuring device is
used. A needle with an attached suture is passed full thick­
ness through the nose at the point marked in the alar
groove. A knot is tied in the suture inside the nasal ves­
tibule. The suture is draped from the point across the
defect, and a clamp is applied to the suture at the periph­
ery of the defect. The clamp with attached suture is then
rotated about its pivotal point to indicate the first arc,
which is marked with a pen. The clamp is advanced along
the suture to the center point of the defect, and a second
arc is drawn through the center of the defect and parallel
to the first arc (Fig. 10-5B). The bases of the two lobes
are designed to rest on the lesser arc. The height of the
first lobe extends to the greater arc, so its height is equal
to the distance between the two arcs. The width of the
first lobe is equal to the width of the defect. The width
of the second lobe is the same as or slightly less than that
of the first lobe. The height of the second lobe is approxi­
mately 1.5 to 2.0 times greater than the height of the first
lobe. The first lobe has the configuration of the defect,
and the second lobe is triangular. The linear axes passing
through the center of each lobe are positioned at approxi­
mately 45° from each other, with the axis of the first lobe
positioned 45° from the central axis of the defect. This
orientation of the lobes inevitably positions the axis of
the second lobe along the center of the nasal sidewall or
diagonally at the junction of the sidewall with the dorsum.
The design also creates a triangular peninsula of skin
between each lobe with a 45° angle. A triangle represent­
ing the eventual standing cutaneous deformity resulting
from the pivot of the first lobe is marked with its apex
pointing laterally and one side parallel to or in the alar
groove. The base of the triangle is the lateral border of
the defect, and the height of the triangle is equal to the
radius of the defect.
The flap is elevated after local anesthetic is injected.
Like other nasal cutaneous flaps, it is dissected in the
tissue plane between the nasal muscles and underlying
perichondrium and periosteum. The flap and the remain­
ing skin of the entire nose are completely undermined,
sometimes extending the dissection into the cheek a
short distance. Wide peripheral undermining of all the
nasal skin is essential to reduce wound closure tension,
to facilitate flap transfer, and to minimize trap-door
deformity (Fig. 10-6). The donor site for the second lobe
is closed first by primary approximation of the muscle
layer. The first lobe is then transposed to the nasal defect
not all the incisions required to create the flap lie parallel
to the natural lines of the face, and the aesthetic result
could be disappointing. The flap is best used to repair
large to moderate-sized defects of the central cheek. In
such cases, the remaining lateral preauricular skin is used
to construct the first lobe, and the posterior auricular or
superior cervical skin is the source of the second lobe.
Ear
The bilobe flap has limited usefulness on the ear because
of the lack of lax skin to recruit for construction of the flap.
The flap may be used for some helical rim defects in which
skin is recruited from the medial surface of the auricle and
the postauricular sulcus. Even in these cases, free grafts,
helical rim advancement flaps, or pedicle flaps are often
more useful for reconstruction than the bilobe flap.
Nose
The nose has unique characteristics that a surgeon must
consider when choosing a local flap for reconstruction.
The topography is complex, with multiple adjacent convex
and concave surfaces. The free margins of the alar rims
are mobile and easily elevated or displaced. The skin over
the caudal third of the nose has limited mobility, restrict­
ing its recruitment for local flaps. Skin texture is unique
so that only nearby skin will provide an adequate match.
The bilobe flap is well suited for reconstruction of the
nose. Many surgeons with experience using bilobe flaps
report that it is best suited for use on the caudal third of
the nose. In one review of 400 nasal reconstructions, the
bilobe flap was the most commonly used flap.4 With little
wound closure tension on the first lobe, there is little or
no distortion when the flap is used for repair of defects
located near the alar rim, provided the first lobe is made
sufficiently large. The use of skin adjacent to the defect
allows excellent skin color and texture match. The donor
site of the second lobe is closed primarily. This is possible
because the second lobe is harvested from the lax skin of
the upper dorsum and nasal sidewall, where primary
approximation of the donor site of the second lobe can
occur.
Whenever possible, the nasal bilobe flap is based later­
ally. Medially based flaps are hardy, although the vascular
supply is not as abundant as that of flaps based laterally.
Bilobe flaps are ideally suited for repair of defects less
than 1.5 cm in maximum dimension on the central or
lateral nasal tip and without extension to the ala. Ideally,
the defect should be at least 0.5 cm above the margin of
the nostril. The flap recruits skin from the mid and upper
dorsum and sidewall, where more generous skin laxity is
present. Defects of the cephalic half of the nose are not
well suited for reconstruction with a bilobe flap unless
they are 0.5 cm or less in size. This is because bilobe flaps
harvested in this area necessitate use of skin from the
region of the medial canthus, which is thin and immobile.
Bilobe flaps are most useful in patients with thin skin
and an ample degree of skin laxity along the nasal side­
wall. The surgeon may estimate laxity by pinching the
lateral nasal skin between the thumb and index finger.
Patients with thick sebaceous skin have a higher risk for

10  BILOBE FLAPS
191
FIGURE 10-4  ■  A, Distance equal to radius of defect (r) measured from lateral border of defect to point marked in alar groove. Two
arcs drawn with centers at point. One arc passes through center and the other tangential to defect. Bases of both lobes of flap arise
from lesser arc. Height of first lobe extends to second arc. Width of first lobe equals width of defect. Width of second lobe is the
same as or slightly less than that of first lobe. Height of second lobe is twice height of first lobe. B, Axis of defect and two lobes of
flap are approximately 45° apart. C, Donor site of second lobe closed first. First lobe transposed and standing cutaneous deformity
removed. Second lobe transposed and trimmed. D, Skin incisions repaired with vertical mattress sutures. (From Baker SR: Nasal
cutaneous flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
B
r
2r
3r
45°
45°
Trim last
1st: Close
3rd: Remove
2nd: Suture
in place
r
C
D

192
SECTION I  FUNDAMENTALS
A
Greater arc tangent to defect
Lesser arc bisects defect
B
Width of lobe = width of defect
C
Wide subfascial dissection
D
SCD excised here
Second lobe trimmed here
E
F
FIGURE 10-5  ■  A, B, Suture rotated about point marked in alar groove is used to mark two arcs for design of bilobe flap. C, Width
of defect equals width of first lobe. Base of each lobe arises from lesser arc. Height of first lobe extends to greater arc. Height of
second lobe is twice height of first lobe. Width of second lobe is slightly less than width of first lobe. D, Wide undermining of flap
and adjacent nasal skin is necessary. E, Standing cutaneous deformity (SCD) forms in alar groove and is excised. Second lobe is
trimmed to precisely fit donor site of first lobe. F, Flap in place.
and secured with a few deep dermal sutures. Next, the
standing cutaneous deformity is removed in or cephalad
and parallel to the alar groove. The second lobe is trans­
posed, trimmed of its excess height so that it fits snugly
without redundancy in the donor defect of the first lobe.
If the thickness of the first lobe is greater than the depth
of the defect, the undersurface of the lobe may be
trimmed even to the level of the subdermis if necessary
to match the skin thickness of the recipient site. Typi­
cally, the second lobe is thinner than the depth of the
donor site for the first lobe because it is derived from
the thinner skin of the cephalic nasal sidewall. This may
create a mismatch in thickness that may cause a depressed
contour over the nasal bridge. To prevent this, muscle
and subcutaneous tissue commonly trimmed from the
undersurface of the first lobe are used as free grafts. The
grafts are sutured to the deep surface of the second lobe.
When tissue is not removed from the first lobe, addi­
tional soft tissue augmentation of the second lobe may
be accomplished with free grafts of muscle and fat har­
vested from the subcutaneous tissue at the junction
between the nasal sidewall and the cheek.
Skin incisions are approximated with 5-0 fast gut verti­
cal mattress and simple sutures. A compression dressing
is applied overnight. Dermabrasion 6 weeks after flap
transfer is recommended for the majority of patients.
This is accomplished in the office with local anesthesia.
The entire flap and adjacent nasal skin are abraded.