Local Flaps in Facial Reconstruction

194
SECTION I  FUNDAMENTALS
A
B
C
FIGURE 10-6  ■  A, A 1 × 1-cm skin defect of nasal tip. Bilobe flap designed for repair. Anticipated standing cutaneous deformity marked
lateral to defect so scar resulting from excision will lie in alar groove. B, C, Wide undermining of flap and nasal skin essential to
reduce wound closure tension. D-G, Preoperative and 3 month postoperative views. No revision surgery performed. (From: SR Baker:
Nasal Cutaneous Flaps. In Baker SR, editor: Principles of Nasal Reconstruction. St. Louis, Mosby, 2002, p 118, fig 11, with permission.)

10  BILOBE FLAPS
195
D
E
F
G
FIGURE 10-6, cont’d

196
SECTION I  FUNDAMENTALS
FIGURE 10-7  ■  A, Basal cell carcinoma of cheek skin. B, A 5 × 4-cm skin defect after micrographic surgical excision. Modified bilobe
flap designed for repair of wound. C, Flap dissected in sub-SMAS tissue plane and transferred by pivotal and advancement tissue
movement. 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
B
C
D

10  BILOBE FLAPS
197
graft was subsequently excised and the flap transferred
into the defect (Fig. 10-9). The standing cutaneous
deformity developing from flap transfer was excised par­
allel to the melolabial crease. The postoperative views
(Fig. 10-10) show a more natural appearance of the
patient’s cheek after removal of the skin graft.
Case 3
A 72-year-old man had micrographic surgery to remove
a basal cell carcinoma from the nasal tip. The resulting
nasal defect consisted of a superficial skin defect of the
left nasal tip measuring 1.5 × 1.5-cm (Fig. 10-11). The
depth and size of the wound did not justify repair with
an interpolated paramedian forehead flap. Preferable sur­
gical options for repair of the defect included a dorsal
nasal flap (see discussion of this flap in Chapter 18), a
full-thickness skin graft, and a bilobe nasal flap. Bilobe
flaps are ideally suited for repair of skin defects 1.5 cm
or less in maximum dimension on the central or lateral
nasal tip and without extension to the ala. As in this case,
ideally the nasal defect should be at least 0.5 cm above
the margin of the nostril. All of these criteria were met
in this case. In addition, the patient’s nose was relatively
large, providing ample skin for construction of the flap.
A bilobe flap was designed with the techniques previ­
ously described in this chapter. The flap was dissected in
the subfascial plane. All of the skin of the nasal sidewall,
dorsum, and tip was completely undermined. The stand­
ing cutaneous deformity was excised in the alar groove.
Postoperatively, the patient developed a depressed scar at
the inferior border of the first lobe. The scar was mark­
edly improved by dermabrasion performed 2 months
after transfer of the bilobe flap.
A majority of patients having bilobe flaps performed
for nasal reconstruction also undergo dermabrasion of
the flap. This is accomplished in the office under local
anesthesia.
The author usually dermabrades the entire nose,
sparing the alar margins, columella, facets, and most
cephalic portion of the nasal bridge and sidewalls. The
procedure is performed with the patient supine and the
head elevated to reduce bleeding. Nerve blocks are per­
formed in the periphery of the nose with use of lidocaine
(1% with 1 : 100,000 concentration of epinephrine), and
several minutes are allowed for the block to take effect.
Anesthetic is also infiltrated as superficial as possible and
in the immediate subdermal plane of the skin marked for
dermabrasion. Intradermal infiltration blocks the numer­
ous sensory nerves that terminate in the dermis of the
skin. In most cases, dermabrasion is performed with a
5 × 5-cm coarse grade drywall sandpaper wrapped around
the surgeon’s finger. This offers the advantage of minimal
equipment; there is no need for cleaning or resterilization
of fraises, and the potential for aerosol spread of blood-
borne pathogens is avoided. Dermabrasion is carried to
the level of the upper or mid reticular dermis along the
borders of the scars. Elsewhere, the depth of dermabra­
sion is extended to the level of punctate bleeding corre­
sponding to midpapillary dermis. Digital palpation of the
flap surface and scars is performed, and palpable irregu­
larities are further abraded. Hemostasis is achieved by
was insufficient skin for construction of the first lobe of
the flap from the remaining preauricular skin. That is,
the surface area of the skin between the defect and the
auricle was too small to construct a flap that would com­
pletely cover the defect. Therefore, the first lobe, by
necessity, had to be in part advanced into the defect,
thereby recruiting skin from the inferolateral cheek skin.
The second lobe was designed to transfer skin from the
superior cervical region behind and below the auricle.
It was of sufficient size to repair the donor site of the
first lobe.
The patient smoked one pack of cigarettes each day.
The skin defect was large, and considerable wound
closure tension was anticipated. For these reasons, the
flap was dissected in the tissue plane immediately beneath
the superficial muscular aponeurotic system (SMAS).
This provided a thicker flap with greater vascularity than
if the flap had been elevated in the subcutaneous tissue
plane. The SMAS of the flap was anchored to the fascia
surrounding the skin defect. This reduced the wound
closure tension placed on the distal skin margins of the
flap. The standing cutaneous deformity resulting from
transfer of the flap into the defect was removed lateral to
the lower eyelid.
Case 2
A 56-year-old woman developed a lentigo maligna of the
cheek that was resected, and the resulting skin defect was
reconstructed with a split-thickness skin graft. She pre­
sented to the author with concerns about the unsightly
appearance of the graft. The skin graft measured 4 ×
3.8-cm and occupied the central superior portion of the
cheek, encroaching on the lower eyelid. There was con­
siderable discrepancy between the color of the graft and
the adjacent facial skin, giving a deformed appearance to
the area of the skin graft.
The surgical options for removal of the skin graft and
reconstruction of the defect with a local cutaneous flap
included the transfer of adjacent facial skin into the defect
in the form of a superolaterally based transposition flap,
a subcutaneous tissue pedicle island advancement flap
located inferior to the graft, and a bilobe flap designed
lateral to the graft. The bilobe flap was selected for
reconstruction. The first lobe of the bilobe flap was
designed to include all of the remaining cheek skin
between the skin graft and the auricle (Fig. 10-8). The
first lobe was designed larger in surface area than the skin
graft because split-thickness skin grafts contract on
healing, giving a false indication of the actual size of the
defect resulting when the graft is removed. The second
lobe was designed to recruit skin from the superior cervi­
cal region behind and below the auricle. A Z-plasty was
marked at the inferior portion of the planned incision line
but was not required for flap transfer. The planned exci­
sion of the standing cutaneous deformity resulting from
pivoting the flap was marked by horizontal lines at the
inferior aspect of the graft (Fig. 10-8). The flap was
incised and elevated first before excision of the skin graft.
This was done to ensure that the graft could be com­
pletely excised and the exposed area covered with the flap
while still achieving closure of the flap donor site. The

198
SECTION I  FUNDAMENTALS
FIGURE 10-8  ■  A-C, Bilobe flap designed to repair cheek wound after resection of skin graft. First lobe designed larger in surface area
than skin graft because split-thickness skin grafts contract on healing, giving false indication of actual size of defect resulting when
graft is removed. Z-plasty marked at inferior portion of planned incision line not used for flap transfer. Anticipated standing cutane­
ous deformity marked with horizontal lines.
A
B
C

10  BILOBE FLAPS
199
FIGURE 10-9  ■  A, B, Same patient shown in Figure 10-8. Flap incised and dissected. C, D, One day after flap transfer.
A
B
C
D
placing gauze soaked in hydrogen peroxide on the raw
surface of the wound for approximately 5 minutes. The
wound is dressed with a thick coat of petroleum-based
ointment and covered with a nonadherent dressing.
Patients are instructed to keep a generous amount of
ointment on the wound until epithelialization of the
wound is complete.
Case 4
Similar to the previous case, the patient shown in Figure
10-12 presented with a defect of the nasal tip skin. The
defect resulted from micrographic excision of a basal cell
carcinoma and measured 1.5 × 1.5-cm. The location of
the defect was ideal for repair with a bilobe nasal flap for
reasons discussed in Case 3. However, the nasal skin of
this patient was thicker, with greater sebaceous gland
hyperplasia. Figure 10-13A,C shows the 6-month
postoperative results after reconstruction with a bilobe
nasal flap. There is marked trap-door deformity and a
depressed scar surrounding the first lobe of the flap.
Patients with thick nasal skin and sebaceous gland hyper­
plasia have a greater risk for development of flap necro­
sis, trap-door deformity, and depressed scars. If these
conditions are mild, they may be improved by injection
of small volumes (0.1 to 0.5 mL) of triamcinolone ace­
tonide (10 mg/mL) beneath the flap in the subfascial
tissue plane. Marked trap-door deformity usually requires
revision surgery.
Text continued on p. 205

200
SECTION I  FUNDAMENTALS
FIGURE 10-10  ■  A-C, Same patient shown in Figure 10-8. Postoperative views at 1 year, 5 months. Flap dermabraded 2 months after
transfer.
A
B
C

10  BILOBE FLAPS
201
A
B
C
D
E
FIGURE 10-11  ■  A, A 1.5 × 1.5-cm skin defect of nasal tip. Bilobe flap designed for repair of wound. B, Flap transferred. C, Postopera­
tive view at 2 months, immediately after dermabrasion to treat depressed scar at inferior border of first lobe of flap. D-G, Before
dermabrasion and 1 month after dermabrasion.
Continued

F
G
FIGURE 10-12  ■  A, B, A 1.5 × 1.5-cm skin defect of nasal tip in patient with thick nasal skin and sebaceous gland hyperplasia. Wound
repaired with bilobe nasal flap.
A
B
FIGURE 10-11, cont’d

FIGURE 10-13  ■  Same patient shown in Figure 10-12 at 6 months and 16 months after reconstruction. A, C, The 6-month views show
depressed scar and trap-door deformity. Revision surgery necessary and included Z-plasties of depressed scar and contouring of
flap. Subsequent dermabrasion of flap also performed. B, D, Views 10 months after revision surgery show improvement in appear­
ance of nose.
A
B
C
D

FIGURE 10-14  ■  Trap-door deformity corrected with undermining of flap and adjacent skin (shaded area) and use of multiple Z-plasties.
(From Baker SR: Refinement techniques. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
45 degree skin peninsulas
SCD removed here
B
C
D
FIGURE 10-15  ■  A, A 1 × 1-cm cutaneous defect of lateral nasal tip. Bilobe nasal flap designed for repair. Each lobe is separated by
45° skin peninsula. Standing cutaneous deformity (SCD) marked in alar groove. B, Flap transposed. SCD removed. C-F, Preoperative
and 4-month postoperative views. No revision surgery performed.

10  BILOBE FLAPS
205
E
F
FIGURE 10-15, cont’d
Trap-door deformity is often the result of a small
hematoma occurring beneath the flap. It also may occur
with inadequate undermining of the skin surrounding the
periphery of the defect and in flaps that have a curvilinear
configuration, such as the bilobe flap. This type of defor­
mity is not corrected with a resurfacing procedure such
as dermabrasion. Correction of the deformity frequently
requires wide undermining of the skin of the flap and the
adjacent area and removal of underlying scar tissue.
When the scar between the flap and nasal skin is
depressed, as in this case, it may also be helpful to inte­
grate the borders of the flap with the adjacent nasal skin
by use of multiple small Z-plasties (Fig. 10-14).9 Multiple
Z-plasties were performed in this case to improve the
depressed scar and to obscure the transition between the
skin of the flap and the adjacent nasal skin. This was
accomplished by first excising the depressed scar, which
was separating the inferior border of the first lobe of the
flap and the adjacent nasal tip skin. The flap was then
widely undermined, and some scar and subcutaneous
tissue were removed to contour and thin the flap. Three
Z-plasties were designed along the length of the excised
scar. Each triangular flap of the Z-plasty measured
approximately 5 mm in length and had a 30° to 40° angle.
The flaps were transposed and secured at each apex with
a single 6-0 polypropylene suture placed through the tip
of the flap. The remaining wound was closed in a similar
fashion with simple sutures consisting of interrupted 6-0
polypropylene. Dermabrasion of the scar and adjacent
nasal skin was then performed approximately 8 weeks
after scar revision. The final results of the revision surgery
are shown in Figure 10-13B, D. The photographs are 10
months after the surgery to refine the flap. Refinement
surgery as described can be effective in converting
unsightly scars from use of a bilobe flap to scars that are
barely visible to the observer.
Case 5
A 60-year-old woman presented with a skin and soft
tissue defect of the lateral nasal tip after micrographic
excision of a basal cell carcinoma. The defect measured
1 × 1-cm. The size and location of the defect were ideal
for repair with a bilobe nasal flap, which was selected for
wound closure. The patient’s nasal skin was thin, making
the bilobe flap an even more attractive reconstructive
option. Less preferable methods of reconstructing this
patient included a dorsal nasal flap, a transposition flap
harvested from the nasal sidewall, and a full-thickness
skin graft. The bilobe flap used to repair the defect is
shown in Figure 10-15. The planned excision of the
standing cutaneous deformity was marked in the alar
groove. As can be seen, the flap is geometrically precise.
The bases of the two lobes rest on the lesser of the two
arcs marked on the nose. The height of the first lobe
extends from the lesser to the greater arc. The width of
the first lobe equals the width of the defect. This prevents
cephalic displacement of the nostril margin. The first
lobe is designed with square angles at the distal border.
Angulated borders tend to reduce the development of
postoperative trap-door deformity compared with flaps
that are designed with curvilinear borders. The second
lobe has a height of 1.5 times greater than the first lobe.
Its width is approximately one-third less than the first
lobe. The flap was dissected in a similar fashion as previ­
ously discussed. No revision surgery was necessary.

206
SECTION I  FUNDAMENTALS
FIGURE 10-16  ■  A, A 1 × 0.8-cm cutaneous and soft tissue defect of alar groove encroaching on nostril margin. Bilobe nasal flap
designed for repair. B, C, Auricular cartilage rim graft used to span caudal margin of defect. Cartilage graft and defect covered by
bilobe flap. D, E, Postoperative views at 6 months. No revision surgery performed.
A
Auricular cartilage graft
B
C
D
E
Case 6
Although bilobe flaps are usually reserved for repair of
skin defects of the nasal tip, they may also be an effective
method of reconstructing small defects located on the
caudal dorsum and sidewall of the nose. They are par­
ticularly useful for repair of defects of the alar groove
1.5 cm or less in size. The patient shown in Figure 10-16
had a 1 × 0.8-cm skin defect of the anterior portion of
the alar groove in what the author considers to be the
intermediate zone between the nasal tip and ala. A medi­
ally based bilobe flap was used to reconstruct the defect.
The standing cutaneous deformity was removed from the
medial aspect of the defect in the lateral nasal tip. The
defect encroached on the nostril margin. To prevent
cephalic retraction of the nostril, an auricular cartilage
graft measuring 1.5 × 0.3-cm was used to span the width
of the defect and to reinforce the nostril. To accommo­
date the cartilage graft, a soft tissue tunnel on either side
of the defect was created along the inferior border of the
lateral tip and ala. The graft was inserted into the tunnels
and secured to the vestibular skin with mattress sutures.
The cartilage graft prevented notching and retraction as
the wound healed.

10  BILOBE FLAPS
207
FIGURE 10-17  ■  A, A 1 × 1-cm skin defect of caudal nasal sidewall. B, Medially based bilobe flap designed for repair of wound.
C, Flap in place. D, Postoperative view at 6 months. No revision surgery performed.
A
B
C
D

A
B
FIGURE 10-18  ■  A, A 1.5 × 1.5-cm skin defect of nasal tip. Medially based bilobe flap designed for repair of wound. Anticipated stand­
ing cutaneous deformity marked with vertical lines. B, Flap in place. Standing cutaneous deformity excised between domes and
infratip segments of tip lobule.
FIGURE 10-19  ■  A-D, Same patient shown in Figure 10-18. Preoperative and 2.5-year postoperative views. Depressed scar and mild
trap-door deformity account for less than favorable aesthetic result.
B
A

10  BILOBE FLAPS
209
D
C
FIGURE 10-19, cont’d
Figure 10-17 shows a similar size defect of the caudal
nasal sidewall adjacent to the alar lobule. Similar to the
previous case, this defect was repaired with a medially
based bilobe flap recruiting skin from the dorsum and
sidewall to construct the two lobes of the flap. Although
most bilobe flaps are designed so that they are laterally
based, for defects located laterally on the nasal sidewall
or in the anterior portion of the alar groove, medially
based bilobe flaps are preferred. This design eliminates
the necessity of extending incisions into the cheek, an
independent aesthetic facial region in the case of laterally
located sidewall defects. In the case of defects in the
anterior alar groove, it eliminates the need to remove a
standing cutaneous deformity from the thick skin of the
ala. In either situation, it better facilitates the use of
midline nasal skin for construction of the flap.
Figure 10-18 shows a nasal tip skin defect in a 75-year-
old woman repaired with a medially based bilobe nasal
flap. The defect measured 1.5 × 1.5-cm and resulted from
micrographic excision of a basal cell carcinoma. The flap
was designed with the same principles used to design
laterally based flaps. However, the center point for cre­
ation of the two arcs was positioned medially at the nasal
dome opposite the defect. The standing cutaneous defor­
mity was excised at the junction of the dome and infratip.
The preoperative and 2.5-year postoperative views of the
nose are shown in Figure 10-19. This case demonstrates
the disadvantage of medially based bilobe flaps used to
repair nasal tip defects. Such flaps necessitate excision of
the standing cutaneous deformity from the skin of the
nasal tip, resulting in a portion of the scar that cannot be
hidden in the alar groove. In contrast, laterally based flaps
used to repair nasal tip defects hide the scar from excision
of the standing cutaneous deformity in the alar groove.
The alar groove offers a deep recess in which to camou­
flage scars. The patient shown in Figure 10-19 had a
small nose, relatively large skin defect, and thick porous
nasal skin. All of these factors contribute to the poor
aesthetic result of the nasal repair. A depressed scar and
a trap-door deformity account for a somewhat less than
favorable outcome of the reconstruction.
REFERENCES
1. Esser JFS. Gestielte locale Nasenplastik mit Zweizipfligem lappen
Deckung des sekundaren Detektes vom ersten Zipfel durch den
Zweiten. Dtsch Z Chirurgie 1918;143:385.
2. Zimany A. The bi-lobed flap. Plast Reconstr Surg 1953;11:424.
3. McGregor JC, Soutar DS. A critical assessment of the bilobed flap.
Br J Plast Surg 1981;34:197.
4. Zitelli JA. The bilobed flap for nasal reconstruction. Arch Dermatol
1989;125:957.
5. Burget G. Creating a nasal form with flaps and grafts. In: Bardach
J, editor. Local flaps and free skin grafts. Philadelphia: Mosby–Year
Book; 1992.
6. Marschall MA. Bilobed flap in head and neck reconstruction. In:
Bardach J, editor. Local flaps and free skin grafts. Philadelphia:
Mosby–Year Book; 1992.
7. Burget GC, Menick FJ. Repair of small surface defects. In: Burget
GC, Menick FJ, editors. Aesthetic reconstruction of the nose. St.
Louis: Mosby–Year Book; 1994.
8. Baker SR. Nasal cutaneous flaps. In: Baker SR, editor. Principles of
nasal reconstruction. St. Louis: Mosby; 2002.
9. Naficy S, Baker SR. Refinement techniques. In: Baker SR, editor.
Principles of nasal reconstruction. 2nd ed. New York: Springer;
2011.

210
C H A P T E R 1 1 
RHOMBIC FLAPS
Stephen S. Park  •  Stewart Little
INTRODUCTION
Today’s standards for aesthetic and functional results after
reconstruction of facial defects are high, requiring metic­
ulous planning and execution to achieve outcomes that
are acceptable to both surgeon and patient. Since the
advent of Mohs’ micrographic surgery for the treatment
of cutaneous malignant neoplasms, complex surgical
defects of the head and neck have become increasingly
challenging to repair with an acceptable functional and
aesthetic result.1 Primary wound closure for many skin
defects is impossible and recruitment of adjacent tissue
is required for repair. Over the years, careful study and
practice have yielded a wealth of techniques and methods
to aid the reconstructive surgeon with the repair of facial
cutaneous defects. The use of local and regional cutane­
ous flaps to achieve wound closure with minimal distor­
tion of surrounding facial landmarks is a hallmark of a
well-trained plastic surgeon.
Cutaneous defects that are too large for primary
wound closure must be addressed with grafts or flaps. In
most instances, flaps are preferred to grafts because of
their superior color and texture match with the surround­
ing skin. With proper planning, local flaps usually provide
the preferred method of repair with the best aesthetic
results and with minimal distortion of surrounding struc­
tures.2 A variety of classification schemes for local flaps
have been proposed on the basis of blood supply, flap
configuration, location, and method of transfer.2 A trans­
position flap typically has a linear configuration and
pivots toward the defect over an incomplete bridge of
skin. The base of transposition flaps is always adjacent to
the defect. The rhombic flap is one type of transposition
flap (Fig. 11-1).
A thorough understanding of vascular anatomy and
skin physiology and adherence to the principles of facial
aesthetic regions are critical to the successful implemen­
tation of any local flap. The microcirculatory system of
the superficial, dermal, subdermal, and musculocutane­
ous vascular plexuses provides a rich, redundant source
of nourishment to local flaps.2 Flap survival hinges on two
factors: the blood supplied through the base of the flap
and the growth of new vascular channels between the flap
and the recipient wound bed. Inosculation and neovascu­
larization typically occur 3 to 7 days after flap transfer.
Before this time, the flap is supplied by the perfusion
pressure provided from the base of the flap and imbibi­
tion of nutrients from the wound bed itself.3
The evaluation of a defect begins in a systematic way,
which will often aid the surgeon in the appropriate flap
selection and design. Four specific factors should be
addressed before bringing knife to skin. First, mobile
structures such as the eyelid, lip, and melolabial fold
must be accounted for in planning the flap and care
taken to avoid distortion of these structures due to unfa­
vorable vectors of tension. Second, an area of skin must
be identified with adequate tissue laxity that is best
suited for construction of a flap. Third, a careful evalu­
ation of relaxed skin tension lines (RSTLs), lines of
maximal extensibility (LME), and aesthetic boundaries
must be made to plan incisions that will maximize scar
camouflage and minimize wound closure tension.1
Fourth, scars and all vectors of tension after transfer of
a flap must be anticipated, and these are the determin­
ing factors for flap selection and orientation. By use of
this systematic approach to the analysis of cutaneous
defects, the optimal flap may be chosen for reconstruc­
tion that will result in the least functional detriment and
facial distortion.1
No single skin flap will provide the best wound repair
for every defect. A thorough understanding of the wide
array of local flaps available for reconstruction remains
essential. A rhombic flap has long been considered a
workhorse in the armamentarium of the reconstructive
surgeon. This is in large part due to the simplicity of the
flap design and the reliability with which it may be used
to reconstruct cutaneous defects. The scars from flap
transfer are predictable and typically cause minimal dis­
tortion of surrounding structures. Proper execution of a
rhombic flap requires careful presurgical planning, a
thorough understanding of the geometry of the flap, and
an understanding of how the flap will affect surrounding
tissues. When it is properly used, a rhombic flap can
provide excellent aesthetic results.
The first rhombic transposition flap was initially
described by Alexander A. Limberg in 1946 and was later
published in 1963. On the basis of extensive work with
paper models, Limberg described the use of a rhombic
transposition flap with internal angles of 60° and 120°
to fill a rhombus-shaped surgical defect with similar
internal angles.4 If the cutaneous defect did not have the
configuration of a 60°-120° rhombus, additional skin was
removed to create the rhombus. A rhombus-shaped
transposition flap with internal angles of 60° and 120° is
often referred to as a Limberg flap. By working with
paper models, the geometry of the Limberg flap can be
  Videos available online

11  RHOMBIC FLAPS
211
LIMBERG FLAP
When a Limberg flap is planned, the defect is modified
to create a rhombus-shaped defect with internal angles
of 60° and 120°. The 60°-120° rhombus may be thought
of as two 60° equilateral triangles aligned base to base.
Thus all sides of the defect are of equal lengths, which
are in turn equal to the short diagonal of the defect.5 To
design a Limberg flap, the line of the short diagonal of
the defect is extended, bisecting one of the internal 120°
angles. The line is extended a length equal to the short
diagonal. This creates the first side of the flap (Fig. 11-1).
The second side of the flap is designed by marking a
second line of the same length as the first, parallel to the
adjacent side of the rhombic defect, creating a 60° angle
at the flap’s apex. The designed flap is equal in size to the
defect. Four possible rhombic flaps can be designed for
any rhombus-shaped defect. After transfer of a Limberg
flap, the greatest wound closure tension is at the donor
site.10 The tension vector runs roughly parallel to the
original border of the defect adjacent to the flap. There
is minimal tension across the other portions of the wound
(Fig. 11-3).1 This is an important consideration when
distortion of surrounding tissues must be avoided. There­
fore, it is the axis of the maximal wound closure tension
vector in relationship to LME that is the greatest deter­
minant of flap selection. The scar that results from the
appreciated as having a precise and exacting design.5
Paper lacks the distensibility of normal tissue, and there­
fore the standing cutaneous deformities produced from
Limberg’s paper models are less forgiving than those in
clinical practice (Fig. 11-2).
The use of the flap described by Limberg had some
limitations, which gave rise to a number of variations,
including those designed by Dufourmentel, Becker, and
Webster.6-8 These modifications addressed issues of
wound closure tension, the need to discard skin to create
a rhombus-shaped defect, and standing cutaneous defor­
mities. In 1962, Dufourmentel expanded on Limberg’s
model and described a method to close any acute-angled
rhombus-shaped defect. In 1977, Webster published
another significant modification of the Limberg flap. He
used a narrower 30° angled flap coupled with a W-plasty
at the flap’s base to facilitate wound closure. This design
required less excision of normal tissue to achieve repair
of a defect. It also created less wound closure tension on
the flap donor site.
The rhombic flap is a cutaneous, random vascular pat­
terned flap that is transferred primarily by transposition
with some limited advancement movement. The flap is
dependent on its dermal and subdermal plexuses for sur­
vival.9 As with any random flap, care must be taken when
undermining and transferring the flap to ensure that the
dermal and subdermal plexuses are not injured.
FIGURE 11-1  ■  Proper orientation of two rhombic flaps to take advantage of lines of maximal extensibility (LME) of facial skin. Both
sides of defect (B-C and A-D) are parallel to LME. Short diagonal is extended equal to its length, and cutback lines G-H and E-F are
drawn parallel to nearest side of defect. Theoretical lines H-B and D-F complete equilateral triangles with bases on LME.
H
G
B
C
LME
LME A D F
E
60º
120º

212
SECTION I  FUNDAMENTALS
A
Diagonal extended
SCD removed here
B
C
D
E
FIGURE 11-2  ■  A, A 2 × 2-cm melanoma in situ marked for excision. Rhombic flap designed for repair after excision. Anticipated
standing cutaneous deformity (SCD) marked for excision. B, C, Melanoma excised and wound repaired. D-G, Preoperative and
6-month postoperative views. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)

11  RHOMBIC FLAPS
213
internal angles, in contrast to those with angles limited
to 60° and 120°.7 In addition, for defects that are more
“square,” less normal tissue is sacrificed when this flap
design is used. Like the Limberg flap, the Dufourmentel
flap can be used to repair only skin defects in which all
sides of the defect are equal. However, the length of the
short diagonal will vary on the basis of the acuteness of
the internal angles of the defect.5 To design the flap, two
lines are created. The first line is an extension of the short
diagonal of the defect, and the second is an extension of
one side of the defect. The angle created by these two
lines is bisected by a third line to create the first side of
the flap, which is equal in length to the sides of the defect.
The second side of the flap is drawn parallel to the long
diagonal of the defect and is also of equal length to the
defect’s sides (Fig. 11-5). The Dufourmentel flap has the
advantage of a lesser arc of pivot, thus creating a smaller
standing cutaneous deformity than is observed with the
Limberg flap. Like the Limberg flap, the Dufourmentel
flap must be oriented with respect to LME. The flap
covers the defect completely, thus minimizing tension
and distortion of tissue surrounding the defect. A limited
standing cutaneous deformity must be excised, so some
normal skin is discarded in the process of reconstructing
the defect. As with the Limberg flap, not all lines of the
resultant scar will fall within RSTLs (Fig. 11-5).
Limberg flap is highly predictable and consists of straight,
precise lines, not all of which run parallel to RSTLs. The
surgeon can easily visualize the anticipated scar configu­
ration and approximate vector of maximum wound
closure tension by drawing the flap and then covering the
two parallel sides of the flap with his or her fingers.
The Limberg flap has been used to repair defects of
the cheek, temple, eyelids, nose, lip, chin, and neck (Fig.
11-4).9 The horizontal parallel furrows of the forehead
make this region of the face particularly unsuitable for
use of rhombic flaps. Disadvantages of the Limberg flap
include the formation of a standing cutaneous deformity
and the need to discard normal skin to convert the defect
into a rhombus if the defect does not already have the
configuration of a 60°-120° rhombus. In addition, a
portion of the scar resulting from the flap does not lie in
RSTLs, and thus scar camouflage is not as good as when
certain alternative flaps are used.
DUFOURMENTEL FLAP
The Dufourmentel modification of the Limberg flap was
introduced as a method of broadening the application of
the rhombic flap. Dufourmentel flaps enable the repair
of rhombus-shaped defects with any combination of
F
G
FIGURE 11-2, cont’d

214
SECTION I  FUNDAMENTALS
of the transposition flap is 30°. The width of the base of
the flap is half the greatest width of the defect. The
Webster 30° transposition flap allows a more even dis­
tribution of wound closure tension but is more likely to
distort neighboring structures.8 This is because the
surface area of the flap is less than the surface area of
the defect that the flap is designed to repair. Thus sec­
ondary tissue movement is necessary to assist the flap
with closure of the primary defect. Furthermore, care
must be taken to ensure that the angle created between
the flap and the adjacent side of the defect is at least
110°.5 A lesser angle may result in vascular compromise
of the repair. The Webster modification results in
an irregular closure line because of the W-plasty
but does so at the expense of an additional limb of scar
(Fig. 11-6B).
WEBSTER 30° FLAP
The Webster 30° flap uses two modifications in an
attempt to decrease wound closure tension at the donor
site and to reduce the size of the standing cutaneous
deformity that forms from pivoting the flap. First, the
excision of the standing cutaneous deformity is per­
formed as a W-plasty to limit the length of the excision
of the deformity. Second, the apex of the flap is designed
with an angle of 30° (Fig. 11-6). This design creates a
narrow-angled donor site that facilitates closure with
minimal wound closure tension. The Webster 30° flap,
also known as the 30° rhombic flap, is designed by
approximately halving an equilateral triangle. The
height of the triangle is designed with a height equal to
the length of a side of the defect. The angle of the apex
FIGURE 11-3  ■  A, Limberg flap design. B, Defect is modified so configuration is 60°-120° rhombus. C, Flap transposed. Standing
cutaneous deformity excised. D, Primary vector of tension is approximately parallel to original border of defect adjacent to flap
(opposing arrows). Standing cutaneous deformity excised at base of flap.
120°
60°
y
x
x'
y
x
x'
A
C
D
B

11  RHOMBIC FLAPS
215
A
Length of flap borders = to
length of short diagonal
Flap border parallel
to defect border
B
C
D
E
F
FIGURE 11-4  ■  A, A 1.5 × 1.5-cm melanoma in situ marked for excision. Rhombic flap designed for wound repair after excision. Flap
designed by extending short diagonal a length equal to length of diagonal. Second side of equal length drawn parallel to defect
border. B-D, Melanoma excised. Wound repaired. E-H, Preoperative and 4-month postoperative views. No revision surgery per­
formed. (Courtesy of Shan R. Baker, MD.)
Continued

216
SECTION I  FUNDAMENTALS
after use of a Limberg flap (Fig. 11-8). Examples of the
use of this modification of the Limberg flap are shown
in Figures 11-9 and 11-10. The authors note three dis­
tinct advantages of this cutaneous flap design: (1)
depending on the location of the defect, the flap may be
designed anywhere along the circumference of the cir­
cular defect; (2) this enables a relatively unlimited choice
of donor sites about the defect, allowing scars to be
positioned as inconspicuously as possible; and (3) there
is limited sacrifice of normal tissue because the configu­
ration of the defect is not modified and only a standing
cutaneous deformity is excised.
There are some disadvantages with the method
described by Quaba and Sommerlad.11 The surface area
of the flap is less than the defect; therefore, more wound
closure tension is on the tissues surrounding the defect
when the flap is transferred than when a Limberg flap is
used. This may lead to distortion of critical facial land­
marks and must be considered before flap design. Fur­
thermore, standing cutaneous deformities were noted in
22% of their series of 175 patients treated by use of this
flap.11 By creation of a flap smaller in surface area than
the defect, the flap’s donor site wound closure is sub­
jected to less tension and therefore closes more easily
than when the Limberg or Dufourmentel flap is used.
Thus this modification of flap design allows greater ver­
satility at the expense of additional tension placed on
VARIATIONS OF FLAP DESIGN
In 1987, Quaba and Sommerlad described a modifica­
tion of the rhombic flap that used a flap smaller than
the surface area of the defect and without conversion of
the defect into a rhombus.11 Their design could be used
to repair circular defects with an angular flap. This
“square peg into a round hole” technique was intro­
duced in an effort to spare skin wasted in an attempt to
create a defect with a rhombic configuration and to
minimize the size of the flap. Their modification of the
rhombic flap is similar to the note flap described in
Chapter 8. The flap is designed by selecting a diameter
of the defect based on the area of greatest tissue laxity
and the desired location for placement of flap donor site
scars. To create the first side of the flap, the line of the
diameter is extended beyond the defect for a distance
approximately two-thirds of the length of the diameter.
The second limb of the flap, of equal length to the first,
is drawn from the end of the first line, creating a 60°
angle. The line follows the curve of the adjacent border
of the defect (Fig. 11-7). Care is taken to avoid narrow­
ing the flap’s base as the line parallels the curved border
of the defect. After dissection of the flap and appropri­
ate undermining of adjacent skin, the flap is transferred
to the defect and key sutures are placed to distribute
wound closure tension. The scar resulting from flap
transfer tends to look remarkably like that occurring
G
H
FIGURE 11-4, cont’d
Text continued on p. 220

11  RHOMBIC FLAPS
217
FIGURE 11-5  ■  A, Dufourmentel modification of rhombic flap. B, Flap can be used to repair square defect. C, Flap transposed. Stand­
ing cutaneous deformity excised at base of flap. D, Opposing arrows indicate point of maximum wound closure tension.
a
b
c
c'
d
e
a
b
c
e
d
f
f
A
C
D
B

218
SECTION I  FUNDAMENTALS
FIGURE 11-6  ■  A, Webster 30° modification of rhombic flap. B, W-plasty preserves skin at base of flap. C, Two triangle-shaped flaps
are created, which are pivoted together. D, Opposing arrows indicate point of maximum wound closure tension.
x
y
x
y
60°
30°
30°
30°
x
y
A
C
D
B

11  RHOMBIC FLAPS
219
FIGURE 11-7  ■  A, Design of Limberg flap for 60°-120° rhombic defect. B, Modified flap design for circular defect. In contrast to Limberg
flap, surface area of modified flap is less than surface area of defect.
B
A
C
D
A'
B'
C'
D'
60°
60°
60°
BC = 2/3 CD
A
B
FIGURE 11-8  ■  Modified rhombic flap used to repair circular defect. First side of flap is two-thirds of length of diameter of circle.
Second side is equal in length to first side and forms 60° angle at apex of flap. Standing cutaneous deformity excised at base of
flap.
x
x
y
y
1
2
4
3

220
SECTION I  FUNDAMENTALS
flap geometry and design are the same as for a single flap.
Use of two rhombic flaps enables the surgeon to use
redundant skin at two different locations about the defect.
Because two flaps are used, each flap is required to cover
only half of the defect, so each flap can be designed
smaller than if a single flap were selected for repair. This
method of wound closure results in additional scar limbs,
albeit in an irregular line, that may be more aesthetically
undesirable.
Desciak and Eliezri have proposed the use of bilateral
rhombic flaps to close large defects of the nasal dorsum
tissues surrounding the defect for which the flap repair
is designed.
BILATERAL RHOMBIC FLAPS
Johnson and colleagues describe the use of bilateral
rhombic flaps to facilitate closure of larger cutaneous
defects (Fig. 11-11).12 By visualization of the defect as two
adjacent rhombuses, two separate rhombic flaps are
designed to fill a single defect. The principles of rhombic
FIGURE 11-9  ■  A, Skin lesion marked for excision. Modified Limberg flap designed for repair. B, Lesion excised. C, Flap in place.
(Courtesy of Shan R. Baker, MD.)
A
B
C
FIGURE 11-10  ■  A, A 2.5 × 2-cm skin defect of cheek. Modified Rhombic flap designed for repair. B, Flap transposed. C, Postoperative
view at 2 months. (Courtesy of Shan R. Baker, MD.)
A
B
C

11  RHOMBIC FLAPS
221
used to remove crown alopecia.5 The triple rhombic flap
technique is based on the visualization of a circular defect
as a hexagon with equal sides. The sides of the flaps are
designed so that their length equals the radius of the
defect. The flaps are created at alternating corners of the
hexagon (Fig. 11-13). This design prevents the flaps from
sharing a common side. In this manner, the tension of
the wound closure is divided equally by the three flaps.
All three flaps are pivoted in the same direction, which
may lead to distortion of surrounding tissue when this
method of reconstruction is used.
Some modifications of the Limberg flap aim to extend
the clinical applicability of rhombic flaps. An example is
the use of Z-plasties to expand the base of the rhombic
flap for larger cutaneous defects.15 Johnson and Bennett
describe the use of multiple Z-plasties at the base of
rhombic flaps (Fig. 11-14).15 This modification allows
greater mobility of the flap at the expense of an additional
length of the scar. The technique has been shown to be
both reliable and predictable when one encounters restric­
tion in tissue movement during initial flap transfer.
CASE REPORTS
Case 1
A 47-year-old man underwent excision of a melanoma in
situ located on the right temple. After adequate margins
had been resected, the resulting circular defect measured
2 × 2-cm, with the anterior border of the defect 1 cm
lateral to the lateral orbital bony rim (Fig. 11-15). Key
factors influencing cutaneous flap selection and design
are highlighted by this example. The lateral border of
the periorbita represents an aesthetic boundary that must
be protected from distortion from undue wound closure
tension. Any distortion of the eyelid or eyebrow could
result in an unsatisfactory functional and aesthetic
outcome. Similarly, the anterior hairline should not be
retracted inferiorly. With these factors in mind, an
and tip.13 They describe visualizing the defect as two
overlapping, equally sized rhombuses, each representing
approximately half the total surface area of the defect.
The rhombuses overlap in the center of the defect. By
design of the flaps superiorly and symmetrically posi­
tioned on either side of the nose, the resulting wound
closure tension vectors are identical. This prevents asym­
metric distortion of the nasal base (Fig. 11-12). Further­
more, the tip is often elevated by the wound closure,
which can be functionally advantageous in patients with
tip ptosis. Superior and inferior midline Burow triangles
are removed to facilitate wound closure. The medial
corners of the flaps will overlap in the midline and are
trimmed. The resultant scar line is irregular and well
suited to the nasal dorsum. Bilateral rhombic nasal flaps
allow reconstruction of larger (2 cm) midline nasal defects
with local skin that possesses maximum color and texture
match for the repair. Bilateral rhombic flaps that are
based in opposite directions can also be used to repair
skin defects of the nasal dorsum. Each flap is responsible
for repair of half of the defect, and each pivots in opposite
(clockwise and counterclockwise) directions.
Turan and associates have described the use of four
60° rhombic flaps to close large wounds of the trunk and
extremities that would normally require a skin graft.14
Four Limberg flaps are designed an equal distance around
a central defect, so that the two opposing flaps pivot in
opposite directions, one clockwise and the other coun­
terclockwise.14 Care is taken during flap design to prevent
one flap from restricting the base of another. By use of
this design, wound closure tension is distributed in four
directions rather than in one, and the orientation of the
flaps can be designed to use LME and available tissue
reserves. The technique produces additional scars, com­
pared with a single flap, but may be a better alternative
to skin grafts. This technique may be used with defects
of moderate size of the cheek and scalp.
Other examples of the use of multiple rhombic flaps
are described in the medical literature. Limberg himself
described the use of three rhombic flaps to close defects
of the forehead and scalp.4 A similar technique has been
FIGURE 11-11  ■  Bilateral rhombic flaps designed for repair of large defect. Defect divided into two adjacent rhombuses to assist with
design of rhombic flaps.
A
A
B
B
Text continued on p. 225

222
SECTION I  FUNDAMENTALS
FIGURE 11-12  ■  A-C, Bilateral rhombic flaps designed for repair of circular defect of nasal dorsum and tip. Defect visualized as two
overlapping, equally sized rhombuses, each representing half of surface area of defect. Superior and inferior midline Burow triangles
removed. Medial corners of flaps trimmed to prevent overlap.
A
y
x
B
y
x
C

11  RHOMBIC FLAPS
223
FIGURE 11-13  ■  Circular cutaneous defect conceptualized as hexagon. Sides of hexagon are equal to radius of circle. First side of flap
created by direct extension equal in length to radius at alternate corners to prevent sharing of common sides. Second side of flap
designed parallel to adjacent side of hexagon.
r
r
r
FIGURE 11-14  ■  The 60° and 90° Z-plasties used at base of rhombic flap to facilitate greater advancement of skin as flap is transposed
into defect.
w
x
y
z
w
x
y
z

224
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 11-15  ■  A, Melanoma in situ, right temple. B, Lesion excised. Limberg flap designed for repair of 2 × 2-cm defect.
C, D, Dufourmentel flap designed and transferred to defect.

11  RHOMBIC FLAPS
225
E
E, Postoperative view at 1 week.
FIGURE 11-15, cont’d
lateral to the left oral commissure. The resulting defect
measured 5.5 × 3.5-cm and abutted the commissure (Fig.
11-16). Orbicularis muscle was exposed in the depths of
the defect. It was elected to use a Dufourmentel flap for
wound closure. The flap was designed with regard to
preventing distortion of the oral commissure foremost in
mind. It was oriented so that the apex of the flap was
transposed toward the medial superior border of the
defect, thus minimizing inferior traction on the commis­
sure. The labiomandibular crease, which was resected
with the specimen, was partially restored by the border
of the flap, thus preserving this aesthetic boundary. The
inferior medial cheek provided the source for the flap.
This area of the face has the greatest skin redundancy and
serves as the preferred location for harvesting of trans­
position cheek flaps. Postoperatively, the patient demon­
strated oral symmetry.
Case 3
A 76-year-old man underwent a square technique (see
Chapter 8, Case 5) to establish disease-free margins
around a melanoma in situ of the cheek. Once disease-
free margins were confirmed, the involved area had a
rhombus configuration (Fig. 11-17). In this circumstance,
a logical surgical plan to reconstruct the cheek after exci­
sion of the melanoma was to use a rhombic flap. An
inferiorly based rhombic flap provided an excellent
method of reconstruction.
Case 4
Similar to the patient discussed in Case 3, a 57-year-old
man developed melanoma in situ of the cheek. Tumor-
free margins were established by the square technique,
resulting in a skin area with a rhombus configuration.
The planned excision was located in the preauricular
region of the cheek. There is less skin laxity and redun­
dancy in this region of the face compared with the medial
cheek or temple. For this reason, a Dufourmentel flap
was used to repair the cutaneous defect after excision of
the melanoma (Fig. 11-18). Similar to the Limberg flap,
the Dufourmentel flap can be used to repair only skin
defects in which all sides of the defect are equal. However,
the Dufourmentel flap has the advantage of a lesser arc
of pivot compared with the Limberg flap, thus creating
a smaller flap donor site. A smaller donor site requires
less skin advancement to repair the donor site, an impor­
tant consideration in areas where facial skin is less redun­
dant, as in the preauricular region.
Case 5
A 27-year-old woman developed a basal cell carcinoma
of the malar eminence. Review of the histopathologic
features of a biopsy specimen of the lesion showed an
aggressive growth pattern. The tumor was treated by
micrographic excision, resulting in a 4 × 4-cm circular
cutaneous defect. Figure 11-19A, B shows two modified
rhombic flaps designed for repair. Their corresponding
anticipated standing cutaneous deformities are marked
with horizontal lines. One advantage of raising rhombic
inferiorly based rhombic flap was designed to recruit skin
from the adjacent cheek while avoiding tension around
the primary defect. A Dufourmentel flap was designed
for repair to decrease the pivotal arc of the flap. The flap
was based posteriorly, enabling the recruitment of cheek
skin along LME. The surface area of the Dufourmentel
flap is the same as that of the primary defect it is designed
to repair; therefore, there is minimal wound closure
tension at the recipient site. The immediate postopera­
tive photographs demonstrated preservation of complete
eyelid closure and no distortion of the eyebrow. The
appropriate orientation of the created rhombus defect
and the flap resulted in scar lines that in part paralleled
RSTLs, as seen in the scars lateral to the malar eminence
and along the lateral bony orbital rim. The multiple scar
lines resulting from reconstruction with a rhombic flap
typically prevent all the scars from lying in a favorable
position. In fact, approximately half of the entire length
of the scar that results from wound repair with a rhombic
flap is not parallel to and does not lie in RSTLs.
Case 2
A 39-year-old man underwent micrographic surgical
excision of a large recurrent basal cell carcinoma located

226
SECTION I  FUNDAMENTALS
FIGURE 11-16  ■  A, A 5.5 × 3.5-cm skin and soft tissue defect adjacent to oral commissure. B, Illustrations showing how defect can be
visualized as rhombus and Dufourmentel flap designed for repair. C, Flap transposed. D, Postoperative result.
A
B
C
D
flaps to repair facial cutaneous defects is the opportunity
to often position the flap in variable positions at the
periphery of the defect. This increases the number of
options available to the surgeon and enables the selection
of the preferred location for placement of the secondary
defect. In this case, the superiorly based flap was selected
for wound repair (Fig. 11-19). The repair was accom­
plished under moderate wound closure tension because
of the large size of the defect relative to paucity of redun­
dant skin for construction of the flap. As a result, some
scar hypertrophy developed at the flap donor site.
SUMMARY
Since Limberg’s initial description of the rhombic flap in
1946, many advances in our understanding of wound
healing, wound tension vectors, and aesthetic facial
boundaries have been made.1 Despite these advances, the
rhombic flap and its derivatives remain useful for
the plastic surgeon. The geometry and reliability of the
rhombic flap allow the surgeon to proceed with an accu­
rate knowledge of the expected scar lines and the effects
Text continued on p. 230

11  RHOMBIC FLAPS
227
FIGURE 11-17  ■  A, A 4 × 3-cm melanoma in situ marked for excision. Rhombic (Limberg) flap designed for wound repair after exci­
sion. Anticipated standing cutaneous deformity (SCD) marked for excision. B, Melanoma excised and wound repaired. C, D, Preop­
erative and 4-month postoperative views. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
SCD removed here
Extend diagonal
B
C
D

228
SECTION I  FUNDAMENTALS
FIGURE 11-18  ■  A, A 2 × 2-cm melanoma in situ marked for excision. Dufourmentel flap designed for wound repair after excision.
Lines of defect border and short diagonal extended to create angle that is bisected by third line. Third line equal in length to sides
of defect. Third line is first side of flap. Second side of flap equal in length to first side is drawn parallel to long diagonal of defect.
B, Melanoma excised and wound repaired. C, D, Postoperative views at 2 months. (Courtesy of Shan R. Baker, MD.)
A
This border parallel
to long diagonal
Line bisects
angle
Extend defect
border
Extend diagonal
Superior wound
closed primarily
B
C
D

11  RHOMBIC FLAPS
229
FIGURE 11-19  ■  A, B, A 4 × 4-cm cutaneous defect of malar eminence. Two modified rhombic flaps designed for repair. Their cor­
responding anticipated standing cutaneous deformities are marked with horizontal lines. C, D, Superiorly based rhombic flap selected
for repair of wound. E, Postoperative view at 1 year. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

230
SECTION I  FUNDAMENTALS
of wound closure on surrounding structures. When it is
planned properly, this technique can provide excellent
results with minimal distortion of surrounding facial fea­
tures and predictable scar lines.
When contemplating the repair of a cutaneous defect,
the surgeon must guard against an overzealous proce­
dure. If a simple primary closure will suffice, it will often
produce the most acceptable result. Untoward outcomes
are usually related to poor flap design or surgical tech­
niques rather than an inherent failing of the flap used for
repair. With proper surgical judgment and appropriate
case selection, the rhombic flap and its derivatives repre­
sent a versatile tool for cutaneous reconstruction.
REFERENCES
1. Park SS. Local and regional cutaneous flaps. In: Papel ID, editor.
Facial plastic and reconstructive surgery. 2nd ed. New York:
Thieme; 2002. p. 528.
2. McNay AT, Ostad A, Moy RL. Surgical pearl: modified rhombic
flap. J Am Acad Dermatol 1997;37(Pt 1):256.
3. Clark JM, Wang DW. Skin flaps, design, October 2003. Available
at Accessed August 19, 2004.
4. Limberg AA. Design of the local flaps. In: Gibson T, editor.
Modern trends in plastic surgery. Sevenoaks, England: Butter­
worth; 1966.
5. Bray DA. Rhombic flaps. In: Baker S, Swanson NA, editors. Local
flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 151.
6. Becker FF. Rhomboid flap in facial reconstruction. New concept
of tension lines. Arch Otolarygol 1979;105:10.
7. Dufourmentel C. An L-shaped flap for lozenge-shaped defects.
In: Transactions of the Third International Congress of Plastic
Surgery. Amsterdam: Excerpta Medica; 1964.
8. Webster RC, Davidson TM, Smith RC. The 30-degree transposi­
tion flap. Laryngoscope 1978;88:85.
9. Tollefson TT, Murakami CS, Kriet JD. Cheek repair. Otolaryngol
Clin North Am 2001;34:627.
10. Larrabee WF Jr, Trach R, Sutton D. Rhomboid flap dynamics.
Arch Otolaryngol 1983;107:755.
11. Quaba AA, Sommerlad BC. “A square peg into a round hole”: a
modified rhomboid flap and its clinical application. Br J Plast Surg
1987;40:163.
12. Johnson TM, Wang TS, Fader DJ. The birhombic transposition
flap for soft tissue reconstruction. J Am Acad Dermatol 1999;41:232.
13. Desciak EB, Eliezri YD. Bilateral rhombic flaps for defects on the
nasal dorsum and supra-tip. Dermatol Surg 2003;29:1163.
14. Turan T, Kuran I, Ozcan H, Bas L. Geometric limit of multiple
local Limberg flaps: a flap design. Plast Reconstr Surg 1999;104:1675.
15. Johnson SC, Bennett RG. Double Z-plasty to enhance rhombic
flap mobility. J Dermatol Surg Oncol 1994;20:128.

231
C H A P T E R 1 2 
MELOLABIAL FLAPS
Shan R. Baker
INTRODUCTION
The melolabial crease delineates the cheek from the
caudal nose and from the upper and lower lips. It is
created by the insertion of the superficial muscular apo­
neurotic system into the skin at the junction of the cuta­
neous lips and the cheek. Medial to the crease, the skin
of the lips is tightly attached to the orbicularis oris and
there is minimal subcutaneous fat. Lateral to the crease,
the skin of the cheek is loosely attached to the deep mus­
cular fascia and there is an abundance of subcutaneous
fat. With time, the forces of muscle contraction, gravity,
and aging result in a progressive deepening of the melo­
labial crease. The subcutaneous fat immediately lateral to
the crease forms the melolabial fold. The melolabial
crease serves as a facial divide separating the lips from the
cheeks and represents one of the most important facial
aesthetic boundaries.
Because of the proximity of the melolabial fold to the
nose and lips, melolabial flaps have long been used to
repair these structures.1,2 During the 19th and 20th cen­
turies, many varieties of melolabial flaps were described.3
In the past, such flaps have been called nasolabial flaps,
but the term melolabial is more accurate in description
as the prefix melo- refers to the cheek and the suffix
-labial refers to the lips. Thus, it is more accurate to use
the term melolabial crease rather than nasolabial crease
because the crease separates the lips from the cheek, not
the nose from the lip. This chapter discusses only cuta­
neous flaps harvested from the mound of skin immedi­
ately lateral to the melolabial crease and known as the
melolabial fold.
Melolabial cutaneous flaps are skin flaps harvested
from the melolabial fold lateral to the melolabial crease.
The cheek skin in this region of the face has a rich blood
supply from perforating branches of the facial artery and
is drained by the facial angular vein. Because of the exten­
sive vascularity of the medial cheek skin, melolabial flaps
may be based either superiorly or inferiorly. Skin of the
melolabial fold including the jowl area is the most redun­
dant of all areas of the face. There is usually sufficient
skin to enable the transfer of sizable flaps for reconstruc­
tion and at the same time allow closure of the donor site
of the flap. In addition, the closure line of the flap donor
defect can be positioned in or parallel to the melolabial
crease to provide maximum scar camouflage. Because of
proximity, the color, texture, and thickness of the skin of
the melolabial fold closely match those of the lips and the
caudal lateral nose. Therefore, melolabial flaps are par­
ticularly suited for repair of cutaneous defects of these
areas of the face. In contrast, the skin of the nasal dorsum
and cephalic portion of the nasal sidewall is thin and
tends to have less sebaceous glandularity than the skin of
the melolabial fold. As a consequence, melolabial flaps
are less well suited for repair of cutaneous defects located
in these areas of the nose. The skin of the melolabial fold
is particularly similar in sebaceous glandularity and
texture to the skin of the ala. It is for this reason that skin
defects of the ala are preferably repaired with skin from
the melolabial fold. This is usually accomplished by use
of an interpolated cheek flap that crosses the alar-facial
sulcus and requires subsequent detachment of the flap’s
pedicle. Crossing over rather than through the sulcus
maintains a perfectly natural alar-facial sulcus, an impor­
tant facial aesthetic boundary.
Local cutaneous flap classification and terminology are
discussed in detail in Chapter 6, but a brief summary here
is helpful in understanding the mechanisms of movement
of flaps harvested from the melolabial fold. Classification
of flaps by method of transfer, which is to say by tissue
movement, is usually the most convenient way of discuss­
ing flaps relative to their use in repair of facial cutaneous
defects.4-6 It also contributes to the understanding of
where standing cutaneous deformities develop and where
the maximum wound closure tension occurs during
wound repair. By use of this classification, melolabial
flaps may be categorized as pivotal, advancement, and
hinge. Melolabial hinge flaps are rarely used and are not
discussed in this chapter. Advancement in the majority of
situations depends on stretching the flap skin in the direc­
tion of flap movement. Such flaps are subjected to an
increase in wound closure tension. In contrast, pivotal
flaps rotate about a point at their base and in their purest
form are not stretched. Thus, they are not subjected to
wound closure tension greater than the natural tension
of the remaining facial skin, although the repair of the
donor site of the flap is subjected to increased tension.
There are three types of pivotal flaps: rotation, transposi­
tion, and interpolated. Transposition and interpolated
flaps may be transferred on a cutaneous pedicle or sub­
cutaneous tissue pedicle. In the latter case, the flap is
referred to as an island flap because it has no cutaneous
connection to the donor site. Island transposition pivotal
flaps are occasionally harvested from the melolabial fold
  Videos available online

232
SECTION I  FUNDAMENTALS
from its donor site in a second surgical procedure. This
is the greatest disadvantage of such flaps. On occasion,
the pedicle can be de-epithelialized or reduced to subcu­
taneous tissue only (island flap) and brought under the
intervening skin to allow a single-stage reconstruction.
Passing flaps through a subcutaneous tunnel may com­
promise the vascularity of the pedicle or create a contour
deformity along its path. The major advantage of inter­
polated flaps compared with transposition flaps is the
ability to recruit skin for construction of the flap at a site
that is more removed from the facial defect. The inter­
polated melolabial flap is frequently used for nasal recon­
struction because of the proximity of the melolabial fold
to the nose and its similar color and texture to the skin
of the nose.
MELOLABIAL TRANSPOSITION FLAPS
Transposition flaps are the most common type of melo­
labial flaps used in facial reconstruction. Transposition
flaps are pivotal flaps with a linear configuration. They
may be based inferiorly or superiorly and have a number
of different configurations; however, their linear dimen­
sion is always longer than their width. Typically, the
linear axis of a melolabial transposition flap is oriented
directly above and parallel to the linear axis of the angular
artery. Although the flap is rarely elevated as a true axial
flap incorporating the angular artery, many small periph­
eral branches of the artery are probably included in the
base of melolabial flaps.
The majority of melolabial transposition flaps are
designed as a rectangle, parabola, or rhombus. The axes
of these flaps are usually oriented along or are parallel to
the axis of the melolabial fold (Fig. 12-1). Closure of the
flap donor site is within or parallel to the melolabial crease.
but are uncommonly used and are not discussed. Rota­
tion flaps are pivotal flaps with a curvilinear configura­
tion. They must be designed immediately adjacent to the
defect and are best used to close triangular defects. In the
author’s practice, local flaps in the form of rotation are
rarely designed in the area of the melolabial fold because
their curvilinear incision frequently creates a scar that
crosses the melolabial crease perpendicular to relaxed
skin tension lines (RSTLs). For this reason, rotation flaps
are not discussed.
In contrast to rotation flaps, which must be designed
adjacent to the defect, transposition flaps provide the
surgeon the ability to construct a flap at some distance
from the defect with its axis independent of the linear axis
of the defect. The only requirement is that the base of
the flap be contiguous with the defect the flap is designed
to repair. This is one of the greatest advantages of trans­
position flaps. This fact enables the surgeon to recruit
skin from the melolabial fold that may be a considerable
distance from the defect. Skin elasticity and redundancy
are greater in the area of the melolabial fold than in any
other location on the face, providing a resource for har­
vesting sizable flaps. The linearity of transposition flaps
can be designed so that they parallel the melolabial fold,
and this in turn enables the donor site to be closed paral­
lel to or in the melolabial crease. Because of these advan­
tages, transposition is the most common design of local
flaps harvested from the area of the melolabial fold.
The interpolated flap, like the transposition flap, is
transferred by pivotal movement and has a linear configu­
ration so that it can be designed to conform to the linear
axis of the melolabial fold. Interpolated flaps differ from
transposition flaps in that their bases are not contiguous
with the defect. Thus, the pedicle must cross over or
under intervening tissue. If the pedicle passes over inter­
vening tissue, the flap must subsequently be detached
FIGURE 12-1  ■  A, Skin defects of medial cheek can be repaired with melolabial transposition flaps. Broken line outlines incision for
flap. B, Standing cutaneous deformities removed from base of flap and cheek donor site on flap transfer and closure of donor site.
A
B

12  MELOLABIAL FLAPS
233
FIGURE 12-2  ■  A, B, When used to repair skin defects of superomedial cheek, melolabial advancement flaps are usually designed
with a single long incision placed in or parallel to the melolabial crease. Skin is undermined lateral to crease.
y
x
x
y
A
B
The flap may be lengthy relative to its width, which facili­
tates closure of the donor defect without excessive wound
closure tension. Melolabial transposition flaps used to
repair small (2 cm or less) cutaneous defects of the medial
cheek may be based superiorly or inferiorly. However,
transposition flaps used to repair medial cheek defects
larger than 3 cm should be based superiorly because there
is more redundancy of facial skin in the inferior cheek, in
the region of the jowl. In older patients, this redundancy
can provide a source for a large flap and still enable
primary closure of the donor site. Flaps should be designed
so that whenever possible, closure of the donor site is in
the melolabial and labial mandibular creases. When supe­
riorly based melolabial transposition flaps are used, the
standing cutaneous deformity is removed just medial or
lateral to the superior border of the defect, depending on
whether the flap is pivoted medially or laterally.
Transposition flaps are pivotal flaps, and the greater
the arc of pivotal movement, the greater will be the size
of the standing cutaneous deformity and the less will be
the effective length of the flap (see discussion in Chapter
8). The reduction in effective length must be accounted
for in designing melolabial transposition flaps so that
greater pivoting requires a longer design of the flap. To
limit this restricting factor, whenever possible, melolabial
transposition flaps should be designed to pivot no more
than 90°.
MELOLABIAL ADVANCEMENT FLAPS
Advancement flaps have a linear configuration and are
moved by sliding toward the defect. This involves stretch­
ing the skin of the flap. Thus, advancement flaps work
best in areas of greater skin elasticity and redundancy, like
the melolabial fold. The most basic advancement flap is
the simple linear layered closure, which involves under­
mining and direct side-to-side advancement of tissue to
close the defect primarily. Sizeable (3 cm) skin defects of
the medial cheek can be closed this way by advancing skin
from the melolabial region in such a fashion that the
resulting standing cutaneous deformities can be excised
parallel to the melolabial crease. However, the term
advancement flap usually refers to a flap created by inci­
sions that allow a sliding movement of tissue. Tissue
transfer is achieved by moving the flap on its pedicle in
a single vector. The greatest wound closure tension is
perpendicular to the distal border of the flap. Advance­
ment flaps may be categorized as unipedicle, bipedicle,
V-Y, Y-V, and island. Only unipedicle and island advance­
ment flaps are discussed in this chapter because they are
the most common melolabial advancement flaps used in
facial reconstruction.
Melolabial Unipedicle Advancement Flaps
Unipedicle advancement flaps are created by parallel
incisions that allow a sliding movement of skin in a single
vector toward the defect. This movement is in one direc­
tion, and the flap advances directly over the defect. As a
consequence, the flap must be developed adjacent to the
defect, and one border of the defect becomes the leading
border of the flap. Melolabial advancement flaps are not
frequently designed with two parallel incisions. When
they are used to repair skin defects of the superomedial
cheek, melolabial advancement flaps are usually designed
by making only one long incision in the melolabial crease
and undermining the skin of the fold lateral to the inci­
sion (Fig. 12-2). Skin is then advanced upward in a vector
parallel to the melolabial crease with some additional
slight pivotal movement. The pivotal movement, although
limited, eliminates the need to make the second incision
parallel to the first incision to create and to move the flap.
A standing cutaneous deformity is excised lateral to the
skin defect parallel to the inferior bony orbital rim.
Melolabial Island Advancement Flaps
The melolabial V-Y subcutaneous tissue pedicle island
advancement flap is an option for repair of medial cheek

234
SECTION I  FUNDAMENTALS
island, beveling slightly away from the skin island down
to the level of the fascia overlying the facial muscles. This
frees the elastic subcutaneous tissue pedicle from its
medial and lateral fibrous attachments to the surrounding
cheek fat while preserving its vascular supply, which is
derived from its deep attachments. The skin island is then
advanced toward the defect by placing a skin hook at its
leading border. At this point, the pedicle can be narrowed
to facilitate the advancement of the flap. This is accom­
plished by back cutting the peripheral borders of the flap
in the subcutaneous tissue plane, leaving at least one-third
of the total flap surface area attached to the underlying
subcutaneous tissue. Further thinning of the subcutane­
ous tissue of the undermined leading border of the flap
may be performed to create an appropriate thickness
match between the border of the flap and the recipient
site. A central pedicle attached to at least one-third of the
total skin island surface area will adequately perfuse the
flap. Further subcutaneous undermining of the skin adja­
cent to the flap is required if puckering of the peripheral
facial skin occurs with flap mobilization (see Fig. 12-3).
Subcutaneous undermining is also performed at the recip­
ient site. In addition, the recipient site’s depth and shape
may be modified by removing skin and subcutaneous
skin defects at or below the level of the nasal alae.7 The
flap is particularly well suited for skin defects located
immediately adjacent to the alae (Fig. 12-3). A triangle-
shaped skin island is designed with the base of the tri­
angle formed by the inferior margin of the defect.
Optimally, the vector of flap advancement is designed
parallel to the melolabial crease. The width of the skin
island should equal the width of the defect at its widest
point. The height 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 flap is
therefore sometimes referred to as a V-Y island advance­
ment flap. The skin island may extend as far as the infe­
rior 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 their scars
are parallel to or in borders of aesthetic regions.
The perimeter of the skin island is incised to the level
of the superficial subcutaneous fat. Undermining of the
adjacent facial skin for a distance of 2 cm is performed at
this level. Blunt and sharp dissection is then carried
through the subcutaneous tissue surrounding the skin
FIGURE 12-3  ■  Melolabial subcutaneous tissue pedicle island advancement flaps are particularly suited for repair of skin defects
adjacent to alar base. A, Defect enlarged to remove peninsula of skin between ala and melolabial fold. Island flap designed to replace
skin peninsula. B, Flap is based on subcutaneous fat of melolabial fold. C, Superior and lateral portions of wound closure suture
lines are in aesthetic boundaries.
B
Replaces
peninsula
A
C

12  MELOLABIAL FLAPS
235
have the advantage of maintaining a lymphatic drainage
route through the pedicle of the flap, which remains in
continuity with cheek skin. They also avoid a circumfer­
ential scar, which in part accounts for trap-door defor­
mity. Why not use a transposition flap instead of an
interpolated flap for ala repair? Both flaps have the
advantage of using skin with color, texture, sebaceous
glandularity, and thickness similar to those of the natural
skin of the ala. Both flaps leave an acceptable donor scar
in the depth of the melolabial crease. The main reason
for not using a melolabial transposition flap is that it
deforms the alar-facial sulcus and lateral portion of the
alar groove. A portion of the flap by necessity must pass
through the superior aspect of the alar-facial sulcus,
which represents an important topographic junction
between the facial aesthetic regions of the nose, cheek,
and upper lip. Whenever possible, local flaps should be
designed so that they do not cross borders that separate
aesthetic regions. This is especially true if the border has
a concave topography, like that of the alar-facial sulcus.9
Too often, this sulcus has been violated by transposition
flaps harvested from the cheek to reconstruct lower
lateral nasal defects. The flap passes through the sulcus,
obliterating the valley between the ala and cheek. When
this happens, it is extremely difficult to restore the valley
to a completely natural contour. For this reason, an inter­
polated melolabial flap is recommended for reconstruc­
tion of the ala. The pedicle of the flap does not extend
through the alar-facial sulcus, it crosses over the sulcus.
The pedicle may consist of skin and subcutaneous fat or
subcutaneous fat only and is detached from the cheek 3
weeks after the initial transfer to the nose. Although 3
weeks is a lengthy period for the patient to endure the
deformity caused by the attachment of the flap’s pedicle
to the cheek, this interval enables the surgeon to thin and
sculpt the subcutaneous tissues of the distal flap at the
time of flap transfer and the proximal portion of the flap
at the time of pedicle detachment and flap inset. On inset
of the flap, the patient is left with a completely natural
alar-facial sulcus because no incision or dissection has
been performed in this region. Because of this advantage,
I recommend the choice of an interpolated design when
a pivotal cheek flap is planned for reconstruction of a
defect of the ala and the defect does not extend laterally
to the alar-facial sulcus (Fig. 12-4).10
The nasal-alar unit is highly contoured, has a free
margin, and functions as the external nasal valve. In
reconstructing the ala, consistent results require a carti­
lage subsurface framework to resist the forces of scar
contraction, to provide a stable external valve, and to
serve as a scaffold for contour. The framework in the
form of a cartilage graft must be used at the time of the
initial reconstructive procedure and requires vascularized
tissue superficial and deep to the graft, totally enveloping
the cartilage. Adequate function of the nose requires a
thin internal layer most appropriately supplied by vascu­
larized mucosa.11 The external covering flap is provided
by an interpolated cheek or forehead flap. Lining flaps
and structural grafts for defects of the nose are discussed
in detail in Chapter 18.
The porous and sebaceous nature of medial cheek skin
closely resembles that of the caudal third of the nose, so
tissue so that scars will be positioned along aesthetic
boundary lines and the defect will more appropriately
accommodate the thickness of the advancement flap. The
leading border of the skin island is fixed in place, and the
wound surrounding the remaining perimeter of the flap
is subsequently closed such that wound closure tension is
equally distributed over the entire length of the flap. The
flap 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 by suturing on a bias
(see Chapter 6).
In addition to repair of medial cheek defects as dis­
cussed, subcutaneous tissue pedicle island advancement
flaps are ideally suited for repair of skin defects of the
lateral upper lip. They do not work as well for defects of
the lower lip. The flap is dissected in a fashion similar to
the method discussed for its use in repair of medial cheek
defects except that the flap is freed from its orbicularis
muscle attachments near the commissure and is based
solely on the abundant subcutaneous fat just lateral to the
commissure. This is only when the flap is sufficiently
large to necessitate the incorporation of skin of the melo­
labial fold into the flap.
For sizeable (2-3 cm) lip skin defects 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.8 The peninsula is then
reconstructed by appropriately designing the island flap
so that the superior portion of the flap replaces the pen­
insula (see Fig. 12-3). This technique provides the best
scar camouflage because the superior border of the flap
is positioned within the aesthetic boundaries of the alar-
facial sulcus and melolabial crease. When this peninsula
is not replaced, the flap must cross the base of the pen­
insula and may mar an otherwise excellent result.
The major advantage of subcutaneous tissue pedicle
melolabial advancement flaps used to repair cutaneous
defects of the medial cheek and upper lip is that there is
no need to resect standing cutaneous deformities because
these do not develop with this flap. For this reason, they
are particularly advantageous compared with transposi­
tion and cutaneous pedicled advancement flaps, which
often have sizable deformities that must be resected and
discarded. There is no wasted skin with the island flap.
Another important advantage of the island flap is that
there is considerably less dead space beneath the flap as
well as beneath skin surrounding the donor defect com­
pared with use of cutaneous pedicled flaps. Less dead
space means less space available for collection of blood
and serum. Therefore, there is less risk for development
of a hematoma compared with use of other types of flaps.
The major disadvantage of the island flap is a tendency
to development of trap-door deformity, especially for
smaller flaps (smaller than 3 cm).
MELOLABIAL INTERPOLATED
SUBCUTANEOUS TISSUE PEDICLE FLAPS
Melolabial transposition flaps have frequently been used
for reconstruction of the ala and nasal sidewall. They

236
SECTION I  FUNDAMENTALS
FIGURE 12-4  ■  A, Skin defect of ala. Remaining skin of aesthetic unit removed. B, Auricular cartilage graft used for structural support
of ala. Interpolated melolabial flap designed for covering of cartilage graft. Flap pivots toward midline. C, Subcutaneous tissue
pedicle of flap crosses over alar-facial sulcus, necessitating subsequent division of pedicle. D, Second stage consists of division of
pedicle and flap inset.
x
Auricular cartilage
y
z
x
y
z
A
B
C
D
an interpolated melolabial flap is generally the preferred
covering flap for alar reconstruction. The flap is based
superiorly on the rich vascular supply in the region of
the alar-facial sulcus described by Herbert.12 At this loca­
tion, perforating branches from the angular artery pene­
trate the levator labii muscle. Other perforating vessels
on both borders of the midportion of the zygomatic major
muscle assist in supplying the cheek skin adjacent to the
ala. The flap may be designed as a peninsular flap based
superiorly on a cutaneous pedicle or as an island based on
a subcutaneous tissue pedicle. In most circumstances, I
prefer to design the flap as a crescent-shaped island of skin
based on a subcutaneous tissue pedicle. The superior
extent of the island remains 5 mm below the alar-facial
sulcus, preserving this important aesthetic area.9
An exact template of the alar unit is made from the
contralateral normal side with a malleable material such
as foil or a thin sheet of foam rubber. The template is
reversed to design the interpolated cheek flap. When the
defect extends beyond the confines of the ala into another
nasal aesthetic unit, the template is designed slightly
smaller than the defect to accommodate the phenomenon

12  MELOLABIAL FLAPS
237
the plane extends deeper to facilitate development of the
subcutaneous tissue pedicle. The pedicle of fat is freed
from the surrounding cheek fat by incising through the
borders of the pedicle perpendicular to the surface of the
skin. The depth of the incision is carried to the level of
the superficial surface of the zygomatic major and levator
labii muscles. On reaching the zygomatic major muscle,
blunt dissection continues upward on the surface of the
muscle, releasing the attachments of the pedicle to deeper
structures until the flap can reach the recipient site
without undue tension. To aid in reducing tension, it is
sometimes helpful to place a 4-0 polypropylene suture
between the superior skin edge of the donor incision and
the alar base. This has the effect of pulling the pedicle
upward toward the ala without the need to place addi­
tional traction on the subcutaneous tissue pedicle. The
suture is released when the pedicle is divided at the time
of flap inset.
To close the donor wound after transfer of an inter­
polated cheek flap, the skin adjacent to the incision is
undermined peripherally for a distance of 2 cm in the
superficial subcutaneous plane, and the standing cutane­
ous deformity that develops inferiorly from advancement
of wound margins is removed. Depending on the shape
of the flap, the lateral border of the donor site may be
considerably longer than the medial border. If this is the
situation, it may be necessary to excise an additional
standing cutaneous deformity (an equalizing Burow tri­
angle) at right angles to the axis of the melolabial wound
closure. This is accomplished at the inferior pole of the
wound. The donor wound is repaired with 5-0 subcuticu­
lar sutures and a continuous simple 5-0 cutaneous suture.
The cheek flap is turned toward the midline and sutured
to the nasal skin by 5-0 polypropylene cutaneous inter­
rupted vertical mattress sutures. A more precise epider­
mal approximation between the margins of the flap and
the adjacent nasal skin is achieved with a continuous 5-0
or 6-0 absorbable cutaneous suture. Subcuticular sutures
are not used. The inferior border of the flap is sutured
to the vestibular skin or lining flap with a continuous 5-0
suture.
Cheek flaps are inset 3 weeks after transfer. For sub­
cutaneous tissue pedicled flaps, the pedicle is transected
at the base, and the cheek skin is undermined for a dis­
tance of 2 cm around the periphery of the wound. After
freshening of the skin margins with a scalpel, the wound
is closed by advancing the borders together. As this is
accomplished, it is usually necessary to open the superior
end of the donor site scar to facilitate excision of redun­
dant subcutaneous tissue and a small standing cutaneous
deformity that often forms as the wound margins are
approximated. Subcuticular sutures of 5-0 polyglactic fol­
lowed by a continuous 5-0 absorbable cutaneous suture
complete the repair.
The lateral portion of the flap attached to the nose is
released from attachments to the adjacent nasal skin for
a distance of 0.5 to 1.0 cm to achieve sufficient freedom
to unfurrow the flap. Release enables the surgeon to
remove excessive subcutaneous fat not trimmed at the
time of flap transfer. The residual skin of the alar unit is
excised if present. However, a 1-mm fringe of skin at the
junction of the ala and the alar-facial sulcus is preserved.
of distraction of wound margins, which creates an open
wound that is larger than the surface area of the skin
removed. If excision of additional skin is indicated to
resurface an adjacent nasal aesthetic unit, the template is
fashioned before the remaining skin is removed because
of this same phenomenon. Alternatively, the contralateral
intact nasal aesthetic unit can be used to design the
template.
When the ala is reconstructed with a melolabial flap,
the entire ala is resurfaced with the cheek flap, except for
1 mm of alar skin just anterior to the alar-facial sulcus
(see Fig. 12-4). This small skin tag preserves the alar-
facial sulcus and often provides a better scar than when
the flap extends to the sulcus. This approach is similar to
the method recommended by Sheen and Sheen13 for
performing a type II Weir excision to reduce the size of
the nasal base. Maintaining the excision outside of the
alar-facial sulcus lessens the risk for development of a
depressed scar. This approach also avoids the technically
challenging requirements of integrating the flap into the
nasal sill at the time of flap inset. When using cheek flaps
for repair, I often delay excision of the extreme lateral
portions of the residual alar skin until the time of pedicle
detachment and flap inset. This delay reduces the wound
tension on the flap at the time of initial transfer.
The fashioned template is placed on the melolabial
fold so that the center of the flap is positioned 1 cm
above the horizontal plane of the oral commissure. The
template is positioned so that the medial border of the
designed flap lies in the melolabial crease. This arrange­
ment ensures that the flap is harvested from the cheek,
not the lip, and that the donor site wound closure will lie
within the melolabial crease, providing maximum scar
camouflage. The flap is designed to pivot 90° toward the
midline in a clockwise direction when it is harvested from
the left cheek and counterclockwise when it is harvested
from the right cheek. Thus, the template is positioned to
design the flap with a specific orientation. As the flap is
pivoted and transferred to the recipient site, the medial
border of the in situ flap is sutured to the cephalic border
of the nasal defect. This in turn causes the inferior border
of the in situ flap to join the anterior border of the defect.
The lateral border of the in situ flap becomes the inferior
border of the reconstructed ala (see Fig. 12-4).
A tracing is made around the template. A triangle of
skin is marked superior and inferior to the tracing to
fashion a crescent-shaped island of skin. The two trian­
gles extending from the template tracing represent stand­
ing cutaneous deformities that will form when the cheek
donor site is closed. The lower triangle of skin is excised
and discarded at the time of flap transfer, and the upper
triangle is transferred with the skin of the flap and is
discarded at the time of pedicle detachment and inset of
the flap. The superior triangle of skin is minimized to
reduce loss of tissue from the upper melolabial fold where
the fold is well developed. Removal of skin from the
upper portion of the fold may result in considerable
asymmetry of the medial cheeks.
The flap is incised, and the distal portion is elevated
in the subcutaneous plane. The distal third of the flap is
thin, leaving 1 to 2 mm of subcutaneous fat attached to
the undersurface. As the dissection proceeds superiorly,

238
SECTION I  FUNDAMENTALS
sufficient vascular supply. The cheek wound is closed by
a method identical to that for the island flap.
Similar to the island flap, the peninsular flap remains
attached to the cheek for 3 weeks to enable the establish­
ment of collateral vascularity. The pedicle is divided at a
second stage, and the proximal portion of the pedicle is
inset in the cheek by opening the superior portion of the
donor site scar 1 to 2 cm. The wound edges are spread
widely, creating a space to accommodate the proximal
pedicle. The skin adjacent to the opened wound is under­
mined for 2 cm. This allows the cheek skin to retract,
assisting in enlarging the wound. The pedicle stump is
then trimmed to precisely fit the wound and inset in the
melolabial fold, creating a V-shaped wound closure (see
Fig. 12-5). Returning most of the skin of the proximal
pedicle to the cheek helps maintain the natural fullness
observed in the upper portion of the melolabial fold.
Alternatively, the proximal pedicle may be amputated in
an elliptical configuration and the cheek wound closed
primarily. This has the advantage of a linear donor site
scar within the melolabial crease. The distal portion of
the flap left attached to the nose is thinned and inset by
methods similar to those for the island flap. Less aggres­
sive sculpturing of subcutaneous fat is recommended for
patients who use tobacco products.
The greatest advantage of using the melolabial flap in
the form of an interpolated rather than a transposition
flap for resurfacing of the ala is the preservation of the
aesthetically important alar-facial sulcus. The technique
also minimizes flattening of the upper melolabial fold
because the majority of skin removed from the cheek is
from the middle and lower portions of the fold. Another
advantage over the more conventional transposition flap
is evident when necrosis of the distal flap occurs. In this
instance, the interpolated flap may be dissected away
from the defect, trimmed of devitalized tissue, and reat­
tached to the nose, provided there is sufficient remaining
tissue to allow this.
A disadvantage of the interpolated melolabial flap is
the necessity for a two- or even three-stage procedure.
However, when standard transposition cheek flaps are
used to reconstruct the ala, revision surgery is frequently
necessary to restore the superior portion of the alar-facial
sulcus and lateral aspect of the alar groove commonly
deformed by the flap. This is the case even when the
pedicle of the flap is designed well above the sulcus in an
attempt not to deform it. A disadvantage of all cheek flaps
in men is the transfer of hair-bearing skin to the nose.
This is particularly true for the interpolated flap because
it is harvested in the hair-bearing midportion of the
melolabial fold. A surgical procedure is nearly always
required in men to remove the hair follicles. This is per­
formed as a third stage concomitant with contouring of
the flap. This is usually performed 3 months after the
second-stage flap inset.
CASE REPORTS
Case 1
A 56-year-old man presented with a 7 × 3.5-cm skin
defect of the lower medial cheek after micrographic
The flap is precisely trimmed to fit the skin defect and
sutured in place with simple interrupted 5-0 absorbable
cutaneous sutures (see Fig. 12-4). When the alar base is
absent, the flap is tailored to replace the missing base and
is integrated with the nasal sill. When the sill requires
reconstruction, the flap is trimmed so that it has a tapered
end that may serve as the sill. The end is turned medially
and sutured to the upper lip.
MELOLABIAL INTERPOLATED
CUTANEOUS PEDICLE FLAPS
A cutaneous pedicle interpolated melolabial flap is a pen­
insular flap with a linear axis centered on a cutaneous
pedicle that connects the flap to the cheek. This is in
contrast to the subcutaneous tissue pedicle (island) flap,
which does not have a cutaneous pedicle and is connected
to the cheek by subcutaneous fat. Whether a peninsular
or island flap is used, the pedicle of the flap is developed
at the superior aspect of the melolabial fold.
In most cases, I prefer to design cheek flaps on a sub­
cutaneous tissue pedicle because this design limits the
quantity of skin in the superior aspect of the melolabial
fold that is included in the flap or excised to facilitate
closure of the donor site. The island design has a greater
freedom to pivot on its pedicle and may have a better
blood supply by incorporating within the pedicle of the
flap a greater number of perforating vessels arising from
the angular artery. The pedicle of the island flap does not
require tailoring after inset of the flap. The subcutaneous
pedicle is simply excised; the skin edges surrounding the
pedicle are freshened, and the wound is closed primarily.
However, harvesting of the island flap is technically more
difficult than harvesting of the peninsular flap because the
plane of dissection is considerably deeper, placing the
branches of the facial nerve supplying the zygomatic
major and minor muscles at greater risk of injury.
The peninsular flap depends on the dermal and sub­
dermal vascular plexuses of the cutaneous pedicle to
provide vascularity to the distal flap (Fig. 12-5). The
cutaneous pedicle must have sufficient width and depth
to ensure this vascularity. In designing a peninsular flap,
the orientation of the template remains the same as for
designing an island flap. The width of the cutaneous
pedicle is approximately the width of the template,
although it may be narrower than the template when a
wide (more than 2 cm) flap design is required. The pen­
insular flap is elevated in a subcutaneous tissue plane,
maintaining 3 mm of fat on the undersurface of the cuta­
neous pedicle. This is in contrast to the island design,
based on a subcutaneous tissue pedicle that may be as
much as 1.5 cm thick. Thus, the plane of dissection for
the cutaneous pedicle flap is considerably more superfi­
cial. Like the island flap, the peninsular flap pivots 90°
toward the midline and is sutured to the nose in a fashion
similar to that described for the island flap. Care is taken
not to kink the pedicle on transferring the flap. Like the
island flap, the distal half of the peninsular flap may be
thinned as necessary to replicate the thickness of the
recipient site. The proximal portion of the flap bridging
between the cheek and nose is not thinned to ensure a

12  MELOLABIAL FLAPS
239
FIGURE 12-5  ■  A, Skin defect of nostril margin in zone between tip and ala. Cutaneous pedicle interpolated melolabial flap designed
for repair. B, Flap transferred. Cutaneous pedicle crosses over alar-facial sulcus and ala. C, Second stage consists of division of
pedicle and flap inset.
A
B
C
surgery for a basal cell carcinoma (Fig. 12-6). The defect
was large and on initial inspection would indicate the
need for a sizable local flap for repair, designed as either
an advancement or a transposition flap. The medial infe­
rior cheek has the greatest skin laxity of the face and
provides a valuable source from which to transfer melo­
labial flaps. Manual manipulation of the margins of the
defect suggested that primary wound closure was possi­
ble. The skin on either side of the wound was widely
undermined in the subcutaneous tissue plane and the
wound closed primarily. Standing cutaneous deformities
resulting from the side-to-side advancement were excised
parallel to the melolabial and labial mandibular creases.
Advancement flaps are most effective in areas of greatest
skin elasticity and redundancy like the melolabial fold and
jowl. The most basic advancement flap is the one dis­
cussed in this case, in which simple linear layered wound
closure in a side-to-side approximation is accomplished
to close the defect primarily. No incision to create a flap
is made.
When incisions are required to create a unipedicle
melolabial advancement flap to repair skin defects of the
superomedial cheek, usually only one incision is neces­
sary. This is made in or parallel to the melolabial crease.
The skin of the fold is undermined in the subcutaneous
tissue plane and advanced superiorly (see Fig. 12-2).
Depending on the location of the cheek defect, the
advancement flap may also be pivoted slightly to facilitate
moving skin from the melolabial fold into the defect. An
example of this is shown in Figure 12-7. The defect
shown occurred after micrographic surgery to remove a
basal cell carcinoma in an 83-year-old woman. The defect
measured 3 × 2.5-cm. An advancement flap was designed
to repair the wound by making a single incision parallel
to the melolabial crease. The large standing cutaneous
deformity forming as a result of the advancement of skin

240
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 12-6  ■  A, A 7 × 3.5-cm skin defect of cheek repaired by advancement of wound borders. Anticipated standing cutaneous
deformities marked by horizontal lines. B, Deformities excised and wound closed. C-F, Preoperative and 1.5-year postoperative
views. No revision surgery performed.

12  MELOLABIAL FLAPS
241
between the cheek and the upper lip. The defect had
an elliptical configuration, but primary wound closure
would have been difficult because the defect abutted the
alar base. Removal of the standing cutaneous deformity
developing at the superior pole of the defect on wound
closure would have necessitated excision of a portion of
the alar base. For this reason, a Webster 30° triangulated
transposition flap was used to reconstruct the defect. The
majority of the wound closure suture line remained paral­
lel to the melolabial crease.
The note flap described by Walike and Larrabee is an
angular transposition flap that, when designed, looks like
a musical eighth note.14 There is a detailed discussion of
the note flap in Chapter 8. Melolabial note flaps enable
the surgeon to close circular defects with a triangle-
shaped transposition flap that maximizes the use of sur­
rounding tissue.15 The flap is designed by first drawing a
tangent on either side of a circular skin defect parallel to
RSTLs. The tangent should have the length of 1.5 times
the diameter of the defect. At the end of the tangent line,
a 50° to 60° angled flap is designed with the second side
of the flap having a length approximately equal to the
diameter of the circle.15 The flap is transposed into the
defect, and the distal tip of the flap may be trimmed so
that there is no wound closure tension. Figure 12-11
demonstrates how a modified inferiorly based melolabial
transposition note flap was used to repair a 3 × 2-cm skin
defect of the medial cheek. The design of the flap was
was excised lateral to the defect. This repair used a modi­
fied unipedicle advancement flap in which only one inci­
sion was made to dissect and advance the skin of the flap.
Case 2
Transposition is the most common form of transferring
skin of the melolabial fold as a local flap. Small to very
large transposition flaps can be harvested from the melo­
labial fold, and closure of the flap donor site can usually
be positioned in the melolabial crease (Fig. 12-8). Large
transposition flaps are based superiorly to transfer skin
from the inferior portion of the fold and the jowl region
of the face where skin is more redundant. However, small
skin defects of the medial cheek may be repaired with
inferiorly or superiorly based melolabial transposition
flaps. In such circumstances, depending on the direction
of the pivot, the standing cutaneous deformity that forms
from transposition can be excised in the melolabial crease.
When the defect is positioned at the extreme superior
and medial cheek near the lower eyelid and nose, the
transposition flap must be based superiorly. In this cir­
cumstance, there is insufficient skin to construct an infe­
riorly based flap without extending the flap on the sidewall
of the nose (Fig. 12-9).
An inferiorly based melolabial transposition flap was
used to repair the skin defect shown in Figure 12-10. The
defect measured 1.8 × 1-cm and occupied a position
E
F
FIGURE 12-6, cont’d

242
SECTION I  FUNDAMENTALS
FIGURE 12-7  ■  A, A 3 × 2.5-cm skin defect of medial cheek. B, Modified unipedicle melolabial advancement flap designed with only
one side and with Z-plasty at base. Anticipated standing cutaneous deformity marked at superolateral border of defect. C, Flap in
place. D, Postoperative view at 6 months. No revision surgery performed.
A
B
C
D