Local Flaps in Facial Reconstruction

294
SECTION I  FUNDAMENTALS
FIGURE 13-14  ■  A, A 3.5 × 2.5-cm cutaneous defect of nasal dorsum, sidewall, and medial cheek. B, Cheek advancement flap used to
repair cheek component of defect. Leading border of flap secured to periosteum of nasofacial sulcus to prevent lateral migration of
flap during healing. Paramedian forehead flap designed for repair of nose. C, Forehead flap in place. Portion of superior donor site
wound left to heal by secondary intention. D, E, Postoperative views at 2 years. No revision surgery performed.
A
B
C
D
E

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
295
A
B
C
D
FIGURE 13-15  ■  A, Melanoma in situ marked for excision. B, Template of planned excision. C, Melanoma removed. Auricular cartilage
graft placed along nostril margin for structural support. D-F, Template created and used to design paramedian forehead flap.
G, Donor defect closed by wide undermining of remaining skin in subfascial plane. H, I, Muscle and galea apposed by interrupted
sutures. J, Skin closed with running cutaneous sutures. K, After thinning, forehead flap is transferred to nasal defect and secured
with vertical mattress cutaneous sutures. L, M, Flap inset 3 weeks later. N, At 4 months after flap inset. Alar groove constructed by
contouring procedure. Template of contralateral ala fashioned. O, Template used to mark planned alar groove of reconstructed ala.
P, Cutaneous hinge flap elevated in subdermal plane. Q, Excess fat and early scar removed. Framework graft trimmed in area of
planned alar groove. R, Hinge flap sutured in place. S, Bolster sutures straddle constructed alar groove. T, Bolster dressing in place.
U-X, Six months after contouring procedure. (From Baker SR: Interpolated paramedian forehead flaps. In Baker SR, editor: Principles of
nasal reconstruction, ed 2, New York, Springer, 2011.)
Continued

296
SECTION I  FUNDAMENTALS
E
F
G
H
I
FIGURE 13-15, cont’d

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
297
proximal flap. On the sixth to seventh postoperative day,
sutures are removed. The wound is carefully checked for
flap viability and signs of infection. If all appears well and
healing is occurring as expected, the patient is scheduled
for pedicle detachment approximately 3 weeks after the
date of initial flap transfer. Although the pedicle may be
safely divided 2 weeks postoperatively, the shorter inter­
val may limit the ability to thin the more proximal flap
remaining at the recipient site when the flap is inset.
Patients are allowed to wear their eyeglasses if necessary;
however, proper positioning of the eyeglasses may be a
problem. Eyeglasses may require temporary readjust­
ment by an optometrist. Devices are also available for
suspending eyeglasses from the forehead, circumventing
the need to rest them on the nose.
Pedicle separation is accomplished under local anes­
thesia. Lidocaine 1% containing epinephrine is injected
into the base of the pedicle and circumferentially around
the flap where it attaches to the nose, followed by the
usual sterile preparation and draping. The pedicle is
separated with a scalpel at the superior margin of the
defect or higher if additional nasal skin is to be removed
from the superior aspect of the aesthetic unit (Figs. 13-17
and 13-18). An incision is made in the cephalic portion
of the old scars between the flap and adjacent nasal skin
on either side of the pedicle. The extent of this incision
should be such that it releases the cephalic quarter of the
flap from the nose. This is necessary to provide sufficient
exposure for thinning and proper trimming and inset of
the flap. The skin margins surrounding the skin defect
created by the flap release are undermined 1 cm. Thin­
ning is performed of any portion of the flap left attached
to the recipient site that was not adequately thinned at
the time of the initial flap transfer. In the case of recon­
structing skin-only nasal defects that involve the rhinion,
it may be necessary to remove all subcutaneous fat to
more accurately replicate the naturally thin skin of the
rhinion. It is often necessary to remove early scar tissue
under the flap to facilitate proper tailoring. Deep-layer
closure is unnecessary because there is no wound closure
tension. The flap is inset with interrupted vertical mat­
tress and simple 5-0 fast-absorbing plain gut cutaneous
sutures. On occasion, a cotton bolster dressing with per­
cutaneous sutures to secure the bolster is used to ensure
that the flap conforms to the skeletal framework of the
nose. An overnight compression dressing is applied if a
bolster dressing is not employed.
The base of the pedicle is returned to its donor site to
restore the normal inter-eyebrow distance. Just as with
the inset of the flap at the recipient site, it is often neces­
sary to remove early scar deposition in the donor area to
enable the pedicle to lie flat between the eyebrows. The
J
K
FIGURE 13-15, cont’d
Continued

298
SECTION I  FUNDAMENTALS
N
O
L
M
S
T
P
Flap elevated in
subdermal plane
Framework graft
trimmed
Framework graft
Remaining framework graft
Subcutaneous fat removed
Alar groove constructed
Q
R
FIGURE 13-15, cont’d

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
299
FIGURE 13-15, cont’d
U
V
W
X

300
SECTION I  FUNDAMENTALS
FIGURE 13-16  ■  Forehead flap thickness is tailored to match depth of recipient site. This usually requires complete removal of frontalis
muscle and majority of subcutaneous fat of distal flap. If vertical height of nasal defect is 2 cm or less, portion of flap covering entire
nasal defect may be thinned at time of initial transfer. For larger defects, proximal flap covering cephalic portion of defect is not
thinned until time of flap inset. A, Incision to thin flap made immediately beneath skin of distal forehead flap to create plane of
dissection. B, Frontalis muscle and subcutaneous fat dissected in subdermal plane. C, D, Another forehead flap before and after
thinning.
A
B
C
D
medial aspect of both eyebrows is undermined for several
centimeters to release all contractions (Fig. 13-18). This
maneuver enables the surgeon to position the medial
aspect of the eyebrows in proper relationship to each
other and to the superior bony orbital rims. Typically, the
medial aspect of the eyebrow on the flap side is displaced
inferiorly as a result of secondary movement from flap
transfer. The brow must be mobilized sufficiently to
correct this displacement. This is accomplished by con­
verting the proximal pedicle of the flap into a small
triangle-shaped flap incorporating in its base the medial
aspect of the eyebrow on the donor side. To accommo­
date scar contraction and inferior migration of the
eyebrow during healing, the flap is mobilized upward
until the level of the medial eyebrow is positioned 2 mm
above the level of the opposite eyebrow. Tissue should
not be returned to the forehead above the level of this
point. Excess pedicle tissue above the portion of the tri­
angular flap necessary for securing the medial eyebrow
in proper position is resected and discarded. To facilitate

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
301
FIGURE 13-17  ■  A, Pedicle of paramedian forehead flap separated 3 weeks after transfer. B, Inferior donor site wound opened and
area between eyebrows widely undermined to release wound contracture. C, Proximal pedicle converted to small triangular flap
that is advanced superiorly to restore original position of eyebrow on donor side. It is sometimes necessary to excise a Burow tri­
angle immediately above medial eyebrow on donor side. Flap inset at nose by trimming of redundant tissue. D, Wound repair
accomplished with vertical mattress cutaneous sutures. (From Baker SR: Interpolated paramedian forehead flaps. In Baker SR, editor:
Principles of nasal reconstruction, ed 2, New York, Springer, 2011.)
A
B
C
D

302
SECTION I  FUNDAMENTALS
A
B
C
D
E
F
FIGURE 13-18  ■  A, At 3 weeks after transfer of paramedian fore­
head flap to reconstruct full-thickness alar defect. B, Pedicle
divided. Inverted V marked on proximal pedicle indicates loca­
tion for amputation of redundant pedicle tissue. C, Dotted line
indicates area that is undermined to restore normal anatomic
relationship of medial aspect of eyebrows. D, Redundant
pedicle amputated while preserving peninsula of muscle and
fat that is tunneled under inferior aspect of donor site scar to
prevent depressed contour. E, Peninsula sutured beneath infe­
rior aspect of forehead scar. Triangle of skin above medial
aspect of eyebrow marked for excision to elevate position of
eyebrow to level of contralateral eyebrow. F, Triangle of skin
excised and wound closure completed.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
303
G
H
G, H, Flap inset after thinning cephalic portion and trimming flap so wound closure is without tension. Soft
tissue resting on nasal sidewall represents tissue removed during process of flap contouring.
FIGURE 13-18, cont’d  ■
superior advancement of the triangular flap and thus the
medial eyebrow on the donor side, it is sometimes neces­
sary to excise a small crescent or triangular segment
of skin just lateral to the base of the flap along the supe­
rior medial border of the eyebrow (see Figs. 13-17 and
13-18). This maneuver removes the standing cutaneous
deformity that forms from advancement. This in essence
serves as a direct browlift limited to the extreme medial
portion of the eyebrow. The muscle on the deep aspect
of the triangular flap is preserved to prevent a postopera­
tive depressed contour. In addition, it is often helpful to
create a tongue of muscle and subcutaneous tissue extend­
ing 0.5 cm beyond the apex of the triangular flap (see Fig
13-18D). This tissue is tunneled under the most inferior
portion of the forehead scar where it meets the apex of
the flap triangle. The tissue tongue prevents contour
depression at this point. The deep layers of the wound
are closed with 4-0 absorbable sutures, and the skin is
closed with 5-0 fast-absorbing plain gut sutures placed in
vertical mattress fashion.
Postoperative care after pedicle detachment consists
of cleaning the suture lines with a hydrogen peroxide
solution and application of an antibacterial ointment
twice daily for 3 days, followed by petroleum ointment
for another 3 days. Sutures are removed in 5 to 7 days.
Full physical activities may be resumed 1 week after
surgery. The patient is advised to avoid excessive sun­
light exposure to the forehead and face region for 3
months to prevent postinflammatory hyperpigmentation
of the scars. Patients are instructed that extremes of heat
or cold may cause temporary color changes in the flap
skin at the recipient site for several months. Revision
surgery, such as thinning of the flap, is delayed 3 to 4
months to allow complete wound healing, wound con­
tracture, and the beginning of scar maturation. Revision
surgery is occasionally necessary to create or to refine an
alar groove (see Fig. 13-15) or to remove persistent hair
follicles transferred from the scalp. These revisions are
accomplished with use of local anesthesia. The author
has not found it necessary or advantageous to perform
an intermediate stage consisting of more proximal thin­
ning of the flap before pedicle division. Although an
intermediate stage may be advisable for a patient addicted
to tobacco, in most patients it is not necessary and does
not enhance the final aesthetic appearance of the recon­
struction. Depending on the circumstance, the majority
of the distal portion of a paramedian forehead flap may
be thinned to the subdermis at the time of flap transfer.

304
SECTION I  FUNDAMENTALS
flaps to provide a supporting framework. A template is
fashioned that will provide ample skin to line the recon­
structed nose, including the dorsum, sidewalls, tip, and
alae. Unlike the forehead flap used for covering the exte­
rior of the nose, a forehead flap used as a lining flap is
incised and hinged downward without pivoting the base
of the flap. This enables the raw undersurface of the flap
to face outward. The pedicle may be tunneled under the
glabellar skin or delivered superficial to the intervening
skin between forehead and defect in such a fashion that
it will not prevent the plating of bone grafts to the nasal
process of the frontal bone (Fig. 13-20). When the nasal
bones are intact, the flap may on occasion be transferred
to the nasal defect from a lateral approach, which may
necessitate a temporary nasal fistula. The sidewall dehis­
cence allowing the admittance of the lining flap is closed
in layers when the flap is inset. The entire lining flap,
except for the base of the pedicle, is thinned to the level
of the subcutaneous tissue plane.
The lining flap may be transferred to the nose before
or after construction of the nasal framework, depending
on the circumstance. It is usually preferable to transfer
the lining flap to the nose before attaching the frame­
work. An incision is made at the mucocutaneous junction
around the perimeter of the nasal defect. Adjacent skin is
reflected sufficiently to expose the bone of the frontal
The remainder of the flap left attached to the nose can
be contoured at the time of pedicle division. Performing
a contouring procedure as an intermediate stage before
the pedicle of the flap is divided subjects the patient to
another 2 to 3 weeks of deformity as a result of the flap’s
crossing from the eyebrow to the nose. This delays the
patient from returning to work and resuming social
activities.
THE PARAMEDIAN FOREHEAD FLAP
AS A LINING FLAP
Forehead skin is rarely required for lining full-thickness
nasal defects. Septal mucoperichondrium and turbinate
mucosa are preferred for this purpose and are generally
in adequate supply. However, in total or near-total nasal
defects that include the nasal septum, the surgeon must
look to other sources of lining. A microsurgical flap of
skin or temporoparietal fascia or fascia lata29,30 is a source
of internal lining for reconstruction of major full-
thickness nasal defects. Another alternative is the simul­
taneous use of two paramedian forehead flaps. One flap
provides internal lining, and the other provides external
cover (Fig. 13-19).31 Bone from the calvarium and carti­
lage grafts from rib or auricle are placed between the two
FIGURE 13-19  ■  In cases of total or near-total loss of nose where nasal septum is absent, a paramedian forehead flap may be used
to provide internal nasal lining. (From Baker SR: Interpolated paramedian forehead flaps. In Baker SR, editor: Principles of nasal recon­
struction, ed 2, New York, Springer, 2011.)
A
B

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
305
FIGURE 13-20  ■  A, Bilateral paramedian forehead flaps designed for repair of full-thickness defect of nasal dorsum and sidewall.
B, Contralateral forehead flap used to line defect delivered to nasal passage through tunnel beneath glabellar skin. C, Cartilage or
bone used for structural support placed over exposed raw surface of lining flap. Ipsilateral paramedian forehead flap transferred as
covering flap. (From Baker SR: Interpolated paramedian forehead flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New
York, Springer, 2011.)
A
B
C

306
SECTION I  FUNDAMENTALS
processes of the maxillae. This provides access to attach
bone grafts for skeletal support of the upper and middle
nasal vaults. The mucosa along the perimeter is reflected
sufficiently to provide a flap of tissue. The mucosal
margins are approximated to the margins of the forehead
lining flap with 3-0 running polyglactin suture. Bone or
costal cartilage grafts are shaped and contoured to provide
a framework for the dorsum and sidewalls. In cases in
which the nasal bones are absent, a dorsal bone graft can
be plated to the frontal bone at the level of the planned
nasal-frontal junction. This creates strong stable skeletal
support for the upper and middle nasal vaults. Additional
cranial bone is fashioned into two rectangular grafts. The
length of the grafts is sufficient to extend from the maxilla
to the level of the lower nasal vault. The grafts are plated
to the dorsal bone graft and to the adjacent maxillae and
serve as the framework for the nasal sidewalls. Several
holes are drilled through the bone grafts, and horizontal
mattress polyglactin sutures are placed through the holes
and the lining flap to appose the exposed raw surface of
the lining flap against the undersurface of the bone grafts.
Cartilage grafts are then used to create the framework for
the lower nasal vault. The grafts may be stabilized to the
caudal end of the bony sidewall grafts with sutures passed
through holes drilled in the bone. Once the framework
for the lower vault has been constructed, mattress sutures
are used to approximate the forehead lining flap against
the undersurface of the cartilage grafts. It is important
that the lining flap completely cover the undersurface of
the bone and cartilage grafts so they are not exposed to
the nasal passage.
When the framework has been constructed and secured
to the maxillae and the lining flap has been apposed to the
framework, a template is fashioned to design a covering
flap using a second paramedian forehead flap. The second
flap is usually based on the ipsilateral supratrochlear
artery (Fig. 13-21). The second flap is pivoted toward the
midline, and the distal two-thirds of the flap is thinned and
used to cover the entire framework. The caudal border of
this flap is sutured to the caudal border of the lining flap,
completely enveloping the cartilage grafts used for the
lower nasal vault framework. The lateral borders of the
covering flap are sutured to the surrounding skin edges of
the nasal defect. A few bolster sutures passing through
both the covering and lining flaps may be used to coapt
the undersurfaces of the two flaps, eliminating dead space
between the flaps. The forehead donor site is large when
bilateral paramedian forehead flaps are used and can only
partially be closed. The remaining forehead wound is
allowed to heal by secondary intention.
When dual paramedian forehead flaps are used to
provide lining and cover to the nose, pedicle detachment
is delayed for 2 months as both flaps depend on vascular­
ization across a circumferential scar at the perimeter of
the reconstructed nose. The pedicle of the lining flap is
detached first, and the nasal fistula is closed. It is impor­
tant to remove all of the skin of the portion of the pedicle
that is beneath the covering flap and not exposed to the
reconstructed nasal passage. This is to prevent develop­
ment of skin line cysts and subsequent infection and
drainage. The covering flap is inset 2 months after inset
of the lining flap. At the time of pedicle division, the
proximal pedicles of the two forehead flaps are returned
to the forehead in their entirety and without trimming.
Returning all of the skin and soft tissue composing the
proximal pedicles of the flaps restores all of the forehead
skin between the eyebrows as well as most of the skin of
the central forehead. This will provide the inferior central
forehead with a natural appearance (Fig. 13-22).
Forehead Expansion
Tissue expansion of the forehead in anticipation of using
a paramedian forehead flap is not recommended because
of the additional morbidity of the expansion process. In
addition, forehead donor wounds that cannot be closed
primarily heal by secondary intention and result in an
acceptable-appearing scar. However, tissue expansion
may have a role in patients who require dual paramedian
forehead flaps, which will require removal of the majority
of the central forehead skin.32 The patient must be
informed that expansion of the forehead will be an addi­
tional surgical procedure and will cause an increasingly
noticeable deformity of the forehead for several weeks
before nasal reconstruction can be initiated.
Tissue expanders are Silastic balloons with self-sealing
valves or reservoirs that are inserted beneath the skin.
They are available in many different sizes and shapes, such
as round, rectangular, and elliptical, and in volumes
ranging from a few cubic milliliters to several thousand
cubic milliliters. Tissue expanders are implanted by per­
forming a ring block with lidocaine 1% and epinephrine
(1:100,000 concentration). An access incision for insertion
of the expander is oriented vertically 3 cm behind the
hairline in the paramedian position. The length of the
incision should be limited to approximately half the length
of the width of the expander. A recipient pocket is created
by blunt dissection between the periosteum and the deep
fascia of the frontalis muscle. The pocket should be large
and extend inferiorly to the level of the superior bony
orbital rims. An endoscope may be inserted through a
separate scalp incision to assist in visualizing the dissec­
tion. The pocket is irrigated with a solution containing an
antibiotic. A 250-mL rectangular tissue expander is folded
on itself and inserted into the pocket through the access
incision. The expander is unfolded within the pocket and
manipulated until the base lies flat against the frontal bone
without kinking. The injection port is tunneled posteri­
orly beneath the parietal scalp. Anchoring sutures to
prevent migration of the expander are not necessary. The
expander is partially expanded (approximately 25 mL for
a 250-mL expander) with saline before wound closure to
obliterate dead space and to assist with hemostasis con­
comitantly. The incision is closed in layers with perma­
nent sutures to approximate both the galea and the skin.
Inflation begins 2 weeks after implantation of the
expander. After the injection site is prepared with an
alcohol swab, saline is infused by percutaneous puncture
of the injection port with a 23-gauge scalp needle attached
to a 50-mL syringe. The volume of injection depends on
the tensile strength and tension of the skin overlying the
expander and the amount of the patient’s discomfort. If
it is not precluded by the patient’s discomfort, the fore­
head is expanded until slight blanching is observed in the

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
307
A
B
C
D
FIGURE 13-21  ■  A, Patient with near-total rhinectomy. B, C, Cranial bone grafts secured in place for nasal framework. D, Foam rubber
used to fashion template for internal lining flap.
Continued

308
SECTION I  FUNDAMENTALS
E
F
G
E, Foam rubber used to fashion template
for external covering flap. F, A 7 × 5-cm template for external
covering flap and 4 × 4-cm template for internal lining flap.
G, Bilateral paramedian forehead flaps designed.
FIGURE 13-21, cont’d  ■
skin overlying the expander. Saline is then withdrawn
until the blanching disappears. However, tightness or
pain is usually the limiting factor. Usually 25 to 30 mL
of saline may be injected into a 250-mL volume expander
on a weekly interval. The discomfort from inflation
resolves within 24 to 48 hours, and the patient remains
comfortable until the next inflation. Inflation is con­
ducted once a week; more frequent expansion is associ­
ated with a greater risk of expander extrusion.
The volume of injected saline is recorded with each
inflation. If weekly visits to the office for inflation are not
possible, the patient or a family member may be taught
the inflation technique. In-home expansion is facilitated
by a written list of instructions. A small amount of methy­
lene blue dye may initially be injected into the expander
at the time the expander is implanted. Before inflation,
the person performing the inflation may aspirate a small
quantity of saline through the injection port. Proper
placement of the needle has been achieved if blue solu­
tion is returned.
As expansion proceeds, the dermis becomes thinner,
and a capsule forms around the expander. This often
results in a reversible blue or red hue of the expanded
skin. Dilated subcutaneous veins are frequently observed.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
309
H
I
J
H, Internal lining flap delivered to nose
through temporary opening in cephalic sidewall. Borders of flap
sutured to borders of mucosal defect. Flap suspended to deep
surface of bone grafts with sutures passing through holes
drilled in bone. I, External flap transferred to cover bone grafts.
Forehead donor site partially closed. J, Internal lining flap
sutured to external covering flap along nostril margin.
FIGURE 13-21, cont’d  ■
The presence of the veins is not an indication of cyanosis
or infection. Expansion continues until the circumfer­
ence of the dome of the expanded skin measures two or
three times the width of the anticipated defect. For nasal
reconstruction, 6 to 8 weeks of expansion are required to
achieve this goal.
The second surgical stage requires removal of the
expander and proceeding with reconstruction. The
expander is deflated and removed through one of
the incisions used to create the two paramedian forehead
flaps. The capsule surrounding the expander provides an
excellent blood supply to the flaps and is not disturbed
unless thinning of the flap is necessary to achieve optimal
results. A suction drain tube is employed at the donor
site, which can usually be closed primarily. Wound closure
and postoperative care are similar to those used for stan­
dard flap surgery. It is important that the expanded fore­
head skin be supported by a rigid nasal framework to
prevent flap contraction and loss of contour. The flaps
should not be oversized but designed to reflect accurately
the exact surface area required of the lining and cover for
the missing nose.

310
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 13-22  ■  Same patient as shown in Figure 13-21. A-F, Preoperative and 1.5-year postoperative views. No revision surgery
performed.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
311
Hematomas that do develop beneath the distal
portion of the flap frequently cause a greater amount of
swelling than expected and give the flap the appearance
of early trap-door deformity. Usually, hematomas are
not discovered until the pedicle of the flap is detached
and the flap is inset. The exposed hematoma is managed
by evacuating the accumulated blood and sharply scrap­
ing and débriding the fibrinous tissue deposited under
the flap.
Advantages
The advantages of the excellent blood supply of the para­
median forehead flap far exceed the problems of an occa­
sional postoperative hematoma beneath the flap. In a
review of the University of Michigan Mohs database
from 1993 to 1999, 147 patients underwent forehead
flap repair of nasal defects after micrographic (Mohs)
surgery.33 Secondary procedures after flap inset were per­
formed in 79 patients (54%), with 1 procedure in 56
patients, 2 procedures in 22 patients, and 3 procedures in
1 patient. These procedures consisted of contouring of
the flap in 68 patients, dermabrasion in 40, Z-plasty scar
revision in 11, additional cartilage grafting in 2, and sus­
pension suture for opening of the nasal valve in 1. High
aesthetic and functional goals were achieved in all patients
(Figs. 13-23 and 13-24). No tumor recurrence or signifi­
cant episodes of local bleeding or infection occurred.
Complications
Complications arising from the use of paramedian fore­
head flaps are rare as this is the “golden” flap of nasal
reconstruction. The superficial axial blood supply of the
flap provides ample nourishment, making distal flap
necrosis unlikely. The superb vascularity of the flap also
markedly reduces the risk of wound infection. However,
this vascularity accounts for the most common complica­
tion observed with paramedian forehead flaps: the devel­
opment of small hematomas under the distal flap.
Hematomas develop at the time of initial flap transfer. The
rich vascularity of the flap creates a tendency for the
undersurface of the portion of the flap thinned of its
muscle and subcutaneous fat at the time of transfer to
bleed postoperatively. The potential dead space between
the flap and the underlying nasal framework will accom­
modate small hematomas because there are usually no
adhesions or sutures that attach the covering flap to the
framework. To reduce the development of hematomas,
careful hemostasis is achieved over the entire raw under­
surface of the thinned portion of the flap. This portion
requires special attention because it may ooze blood con­
tinually for a few hours after surgery. Compression dress­
ings secured with a few bolster sutures passing full thickness
through the flap to the nasal passage and back again may
be placed judiciously if bleeding is profuse (see Fig. 13-13).
Bolster dressings, however, are not used routinely because
they risk impairment of the circulation to the distal flap.
E
F
FIGURE 13-22, cont’d

312
SECTION I  FUNDAMENTALS
A
B
C
D
E
FIGURE 13-23  ■  A, Cutaneous defect of nasal tip and columella. Paramedian forehead flap designed for repair. Remaining skin of
aesthetic tip unit marked for excision. B, C, Flap in place. Portion of superior donor site left to heal by secondary intention.
D-I, Preoperative and 9-month postoperative views. No revision surgery performed.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
313
F
G
H
I
FIGURE 13-23, cont’d

314
SECTION I  FUNDAMENTALS
A
B
C
D
FIGURE 13-24  ■  A-F, A 2.4 × 2.3-cm cutaneous defect of nasal tip, sidewall, and dorsum repaired with an obliquely oriented parame­
dian forehead flap. Preoperative and postoperative views at 1 year, 8 months. No revision surgery performed.

13  INTERPOLATED PARAMEDIAN FOREHEAD FLAPS
315
8. Baker SR. Regional flaps in facial reconstruction. Otolaryngol Clin
North Am 1990;23:925.
9. McDowell F, Valone JA, Bronn JB. Bibliography and historical note
on plastic surgery of the nose. Plast Reconstr Surg 1952;10:149.
10. Shumrick KA, Smith TL. The anatomic basis for the design of
forehead flaps in nasal reconstruction. Arch Otolaryngol Head
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11. Millard DR. Total reconstructive rhinoplasty and a missing link.
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12. Kazanjian VH. The repair of nasal defects with the median fore­
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Obstet 1946;83:37.
13. Gillies HD. Plastic surgery of the face. London: Frowde, Hodder,
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14. Converse JM. Reconstructive plastic surgery. 2nd ed. Philadelphia:
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18. Burget GC. Aesthetic reconstruction of the nose. Clin Plast Surg
1985;12:463.
19. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth
dimension. Plast Reconstr Surg 1986;78:145.
20. Mangold V, Lierse W, Pfeifer G. The arteries of the forehead as
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(Basel) 1980;107:18.
21. McCarthy JG, Lorenc ZP, Cuting L, et al. The median forehead
flap revisited: the blood supply. Plast Reconstr Surg 1985;76:866.
22. McCarthy JG. Acquired deformities of the nose in plastic surgery.
3rd ed. Philadelphia: WB Saunders; 1990. p. 1925.
23. Burget GC. Current therapy in plastic and reconstructive surgery.
New York: BC Decker; 1989. p. 400–12.
Perhaps the most significant finding of this study was that
not a single case of significant flap necrosis occurred. Two
patients (1%) did develop superficial partial-thickness
necrosis. One case was related to a lengthy flap that was
markedly thinned for the purpose of destroying hair fol­
licles in an extended portion of the flap used to recon­
struct the columella. The other case occurred in an
oblique forehead flap that was harvested 3 to 4 cm lateral
to the axis of the supratrochlear artery. Epidermolysis and
superficial necrosis occurred in the center of the distal
flap. Fortunately, the area healed without impairing the
appearance of the reconstructed nose.
REFERENCES
1. Burget GC, Menick FJ. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg 1989;84:189.
2. Conley JJ, Price JC. Midline vertical forehead flap. Otolaryngol
Head Neck Surg 1981;89:38.
3. Jackson IT. Local flaps in head and neck reconstruction. St. Louis:
Mosby; 1985.
4. Converse JM. Reconstructive plastic surgery. Philadelphia: WB
Saunders; 1964. p. 797.
5. Converse JM. Reconstructive plastic surgery. 2nd ed. Philadelphia:
WB Saunders; 1977. p. 694.
6. Mazzola RF, Marcus S. History of total nasal reconstruction with
particular emphasis on the folded forehead flap technique. Plast
Reconstr Surg 1983;72:408.
7. Menick FJ. Aesthetic refinements in use of the forehead flap for
nasal reconstruction: the paramedian forehead flap. Clin Plast Surg
1990;17:607.
E
F
FIGURE 13-24, cont’d

316
SECTION I  FUNDAMENTALS
30. Seth R, Revenaugh PC, Scharpf J, et al. Free anterolateral thigh
fascia lata flap for complex nasal lining defects. JAMA Facial Plast
Surg 2013;15:21.
31. Baker SR. Principles of nasal reconstruction. 2nd ed. New York:
Springer; 2011. p. 51–3.
32. Baker SR, Swanson NA. Tissue expansion of the head and neck:
indications, techniques and complications. Arch Otolaryngol Head
Neck Surg 1990;116:1147.
33. Boyd CM, Baker SR, Fader DJ, et al. The forehead flap for nasal
reconstruction. Arch Dermatol 2000;136:1365.
24. Barton FE. Aesthetic aspects of nasal reconstruction. Clin Plast
Surg 1988;15:155.
25. Hart NB, Goldin JM. The importance of symmetry in forehead
flap rhinoplasty. Br J Plast Surg 1984;37:477.
26. Converse JM, Wood-Smith D. Experiences with the forehead
island flap with a subcutaneous pedicle. Plast Reconstr Surg
1963;31:521.
27. Baker SR. Oblique forehead flap for total reconstruction of the
nasal tip and columella. Arch Otolaryngol Head Neck Surg
1985;111:425.
28. Baker SR, Alford EL. Mid-forehead flap. Op Tech Otolaryngol
Head Neck Surg 1993;4:24.
29. Winslow CP, Cook TA, Burke A, et al. Total nasal reconstruction:
utility of the free radial forearm fascial flap. Arch Facial Plast Surg
2003;5:159.

317
C H A P T E R 1 4 
Z-PLASTY
John L. Frodel  •  Sachin S. Pawar  •  Tom D. Wang
INTRODUCTION
The principle of Z-plasty is one of the most versatile
concepts in reconstructive surgery. The dynamics of
tissue movement that occur with Z-plasty is particularly
suited for certain types of scar revision. A clear under­
standing of the underlying principles of Z-plasty will
allow the reconstructive surgeon to apply this technique
to a wide array of clinical situations.
The history of Z-plasty has been reviewed by Borges1
and Davis and Renner.2 Classically, this technique involves
designing a Z with three limbs of equal length that form
two triangular flaps of equal angles. The triangles repre­
sent angular flaps that are interchanged with each other
by both pivotal and advancement tissue movement.
Although the initial description of transposing equilateral
triangular flaps was by Berger3 in 1904, numerous other
descriptions have been recorded. In the 1800s, Fricke,4
Horner,5 Serre,6 and Denonvilliers7 described the trans­
position of cheek and temporal skin to correct eyelid
ectropion and regional defects. However, in these case
descriptions, the triangular flaps transposed did not have
equal angles, nor were they the same size. In the late
1920s, Limberg elucidated the geometric principles
involved with Z-plasty.8 He also noted that Z-plasties as
well as the related Limberg or rhombic flap are best
described as having both pivotal and advancement com­
ponents. Whereas the classic Z-plasty follows specific
geometric guidelines, Limberg demonstrated the flexibil­
ity of double transposition flaps that have a Z-plasty
design. It is this flexibility that allows the wide-ranging
applications and variations from the classic description.
A Z-plasty is used to accomplish one or more of three
changes in the nature of a scar: change of scar direction,
interruption of scar linearity, and release of scar contrac­
ture (lengthening of scar). Z-plasty should be considered
when it is optimal to change the direction of a scar so
that a portion of it is more easily concealed either within
relaxed skin tension lines (RSTLs) or in a border between
facial aesthetic regions. Similarly, with Z-plasty, a long
straight scar may be divided into smaller irregular seg­
ments to allow better scar camouflage. Scars that cause
distortion of facial features secondary to contracture may
be lengthened with Z-plasty techniques, correcting or
improving the distortion. As with other methods of scar
revision that interrupt a straight scar, the scar resulting
from Z-plasty will counter forces of scar contracture.
This is because of the very nature of the Z-shaped scar
that occurs from Z-plasty. Each segment of the Z con­
tracts in a different direction. Z-plasty is particularly
useful in treating contracted or webbed scars and scars
that distort anatomic facial landmarks. A main advantage
of Z-plasty over other techniques, such as W-plasty, is
that it does not require skin excision for the procedure
to be performed.
Mastery of the principles of Z-plasty allows its imple­
mentation in a number of situations. Correction of scars
that cross the melolabial crease represents an ideal appli­
cation of Z-plasty. In this circumstance, the central limb
of the Z-plasty, which consists of the original scar, is
moved into the crease. Wide or confluent scars treated
with excision and primary closure often lead to significant
wound closure tension. Z-plasty used along the wound
margins to create an irregular scar has the effect of dis­
persing wound tension. Short (less than 2 cm) scars that
do not rest in RSTLs are often best managed by Z-plasty.
Contracted or webbed scars located in concavities are
amenable to correction by Z-plasty. This includes vertical
scars located in the concave areas of the neck, radial
contractures that traverse the concavities of the auricle,
and scar bands that cross the concave medial canthal
region. Ectropions and retractions of the lower eyelid
caused by vertically oriented scar contracture are often
best corrected with Z-plasty because of its ability to
release scar contracture. Similarly, lip scars are often con­
tracted and require Z-plasty to lengthen the scarred
segment and to restore a normal contour to the vermilion
border. This listing of indications for use of Z-plasty is
far from inclusive. For optimal results, many situations
require a combination of scar revision techniques, such
as W-plasty or geometric broken-line closure, in addition
to Z-plasty.
GEOMETRY AND DESIGN
The classic description of Z-plasty consists of a design in
which the central limb and two peripheral limbs are in
the shape of a Z such that two triangle-shaped flaps of
equal size are created. All three limbs are of identical
length, and the central limb consists of the scar that is to
be lengthened or realigned. In the standard 60° Z-plasty
(Fig. 14-1), a protractor may be used to measure the
angles. However, a more practical means of estimating
 Videos available online

318
SECTION I  FUNDAMENTALS
Z-plasty angles is to mark out a 90° angle and to divide
it into thirds. A caliper or ruler is useful in the design of
limbs of equal lengths. Transposition of the triangular
flaps (angles ABC and BCD in Fig. 14-1) results in the
following changes: the axis of the central limb is rotated
90° (in the example, a vertical scar is changed to a hori­
zontal orientation); the distance between the points
labeled B and C of the original central limb is increased;
and the final scar is changed from a straight line to a
nonlinear Z configuration. The overall length of the new
scar created by the Z-plasty is increased by the sum of
the length of the peripheral limbs of the Z.
Although a 60° Z-plasty is perhaps the most common
design, angles between 30° and 90° are possible. Chang­
ing the angle of the flaps will cause a change in the length
gained in the axis of the original central limb (B-C in Fig.
14-1). Theoretically, the percentage gain in length
increases with larger angles (Fig. 14-2 and Table 14-1).
However, the amount of lengthening noted in actual
practice is usually less.
The degree of directional change of the central limb
of the Z-plasty (B-C in Fig. 14-2) is also variable. In the
60° Z-plasty, the orientation of the central limb is changed
90° from its original orientation. In the 45° Z-plasty, the
orientation of the central limb is changed approximately
60° from its original position. In the 30° Z-plasty, the
change is approximately 45° (see Fig. 14-2). This rela­
tionship between the angle of the Z-plasty and the change
in orientation of the central limb of the Z-plasty is
an extremely important consideration in planning of
Z-plasty (Table 14-2).
FIGURE 14-1  ■  Design of 60° Z-plasty.
A
B
C
D
60°
60°
FIGURE 14-2  ■  Length gained in contracted scar and change in orientation of central limb of Z relative to Z-plasty angle. Greater
Z-plasty angle causes greater change in scar orientation.
A
B
C
D
A
B
C
D
A
B
C
D
60°
30°
45°
90°
60°
45°
75%
50%
25%
TABLE 14-1  Theoretical Increase in Length of
Central Limb of Z-Plasty
Z-Plasty Angles
Gain in Length (%)
30°-30°
25
45°-45°
50
60°-60°
75
75°-75°
100
90°-90°
125
From Frodel JL, Wang TD: Z-plasty. In Baker SR, Swanson NA,
editors: Local flaps in facial reconstruction, St. Louis, Mosby,
1995.
TABLE 14-2  Direction of Peripheral Limbs of Z
in Relationship to RSTLs and
Z-Plasty Design
Variance to RSTLs
Z-Plasty Design
90°
60° Z
60°-90°
60° Z (try to follow RSTLs as much
as possible)
30°-60°
Parallel to RSTLs
30°
Fusiform excision best
From Davis WE, Renner GJ: Z-plasty. In Thomas JR, editor: Scar
revision, St. Louis, Mosby–Year Book, 1989.
RSTLs, relaxed skin tension lines.

14  Z-PLASTY
319
The initial length of the central limb affects the final
outcome of Z-plasty. As the central limb of the Z is
increased in length, so too is the gain in linear length
between the points marking the ends of the central limb
(points B and C in Fig. 14-1).9 Unfortunately, as the three
limbs of the Z-plasty become longer, there is also a
greater likelihood of a more apparent scar (Fig. 14-3).
Multiple Z-plasties with shorter limbs to replace a single
large Z-plasty with long limbs can circumvent this
problem (Fig. 14-4). In this instance, a single long scar is
divided into several smaller Z-plasties, usually with 60°
angles.10 A single large 60° Z-plasty provides more gain
in length than multiple small 60° Z-plasties along the
same central limb.11 However, the aesthetic consequences
and tissue availability for construction of the Z-plasty
flaps often preclude the use of a single, large Z-plasty. On
the face, limb length is usually limited to 1 cm or less.
On the neck, limb length should not exceed 2 cm.
In addition to the ability to vary limb length and angles
of a Z-plasty, the actual design of a Z-plasty can be modi­
fied. One example is the four-flap Z-plasty. This tech­
nique increases the gain in length of the central limb by
using four triangular flaps that are interposed between
each other. A 90° Z-plasty is first designed, and then the
90° angle is bisected to design two 45° triangular flaps
that are transposed (Fig. 14-5). Even greater gain in
length of the central limb of a Z-plasty can be obtained
by using 120° angles, which subsequently are bisected
into four 60° flaps (Fig. 14-6). There are a number of
variations on this theme, including a six-flap Z-plasty.
However, the greater the number of flaps created, the
greater is the total number of limbs and thus scars
and the greater is the number of standing cutaneous
deformities that develop when the flaps are transposed.
Z-plasty may also be modified by use of flaps that have
FIGURE 14-3  ■  Length gained in contracted scar relative to length of Z-plasty limbs. Longer limbs are associated with greater scar
lengthening.
A
B
C
D
E
F
1 cm
1.75 cm
2 cm
3.5 cm
3 cm
5.25 cm
FIGURE 14-4  ■  Multiple Z-plasties. Limbs of Z are limited to less
than 1 cm on face.
a
a
b
b
c
c
d
d
e
e
f
f
60°
A
B

320
SECTION I  FUNDAMENTALS
FIGURE 14-6  ■  The 60° compound four-flap Z-plasty.
x
x
y
y
z
z
w
w
60°
A
B
FIGURE 14-7  ■  Unequal-angled Z-plasty.
90°
30°
A
B
FIGURE 14-5  ■  The 45° compound four-flap Z-plasty.
x
y
z w
x
z
y
w
z
x
w
y
A
B
C
45°
unequal angles. In such situations, the flap with the more
acute angle is pivoted in a greater arc than that of the
larger angled flap (Fig. 14-7). Minimal gain in length of
the central limb will occur with unequal-angled Z-plasties.
The main purpose of such designs is to transpose skin of
the smaller angled flap to a more desirable location.2
SURGICAL APPLICATION AND TECHNIQUE
The discussion to this point has involved theoretical con­
cerns about the classic geometry of Z-plasty. An under­
standing of the classic design is critical, but practical
clinical considerations are even more important. Whereas
length in the direction of the central limb is gained when
a Z-plasty is used, it is usually not increased to the degree
calculated.9 A number of studies have shown that the
increase is considerably less in the clinical situation com­
pared with the calculated gain.11 Similarly, there is a limit
to the angles of the Z-plasty flaps that may be useful.
Z-plasties less than 30° generally should not be used
because of concern for vascularity of the narrow triangu­
lar flaps created by these acute angles. In the design of
acutely angulated flaps, the width of the flap may be
broadened by curving the limbs of the flap (Fig. 14-8).
This modification may be useful in skin with an impaired
blood supply, such as scar contracture associated with a
burn or previous irradiation. Conversely, triangular flaps
with angles greater than 75° will commonly produce
standing cutaneous deformities that require excision.
Thus, such large angled Z-plasties should be avoided
whenever possible.
In designing a Z-plasty, evaluation of the surrounding
skin and facial structures is necessary. Skin laxity at the
base of each triangular flap of the Z-plasty must be ade­
quate to allow proper pivotal movement of the flaps. If
skin is contracted in a direction perpendicular to the
central limb, Z-plasty may not be possible. Likewise, if a

14  Z-PLASTY
321
FIGURE 14-8  ■  Z-plasty with curved limbs to maximize vascular supply to tip of flaps.
x
y
B
A
y
x
FIGURE 14-9  ■  Release of scar beneath skin to facilitate transposition of Z-plasty flaps.
A
B
C
D
x
y
y
x
facial structure such as the eyelid, oral commissure, lip,
or nasal ala is in proximity of the Z-plasty, distortion of
these structures may occur. In planning of Z-plasty, it is
also important to assess the degree of scar tissue in the
central limb of the Z. The scar must be adequately
resected or released to reduce resistance to transposition
of the Z-plasty flaps (Fig. 14-9). Accordingly, it is essen­
tial to release and commonly to remove subcutaneous
scar tissue.
A 60° Z-plasty will reposition the central limb 90°;
more acutely angled Z-plasties will position the central
limb less than this. An understanding of this concept will
assist in proper positioning of Z-plasty limbs in relation
to RSTLs. To reposition the central limb of a Z-plasty
in RSTLs, the angles of the Z should be calculated
accordingly. With scars located approximately 90° to
RSTLs, a 60° Z-plasty is required to reposition the
central limb parallel to RSTLs. As the axis of a scar in
relationship to RSTLs becomes more acute, Z-plasty
angles should become more acute to position the central
limb and the two peripheral limb scars as parallel as pos­
sible to RSTLs (see Table 14-2).2 For scars less than 30°

322
SECTION I  FUNDAMENTALS
An example of a wide scar oriented perpendicular to
the melolabial crease can be used to illustrate the surgical
technique of Z-plasty (Fig. 14-11). Improvement in the
appearance is achieved by realigning the scar by a Z-plasty
to translocate the scar (central limb of the Z) into RSTLs,
in this case the melolabial crease. Because the scar is
aligned 90° to the crease, a 60° Z-plasty is the preferred
design. This will change the axis of the central limb of
to RSTLs, Z-plasty may not be necessary for scar realign­
ment. For every scar, there are always two choices for
alignment of the peripheral limbs of a Z-plasty used to
revise the scar. These are mirror images of one another.
Both options should be considered. For scar camouflage,
the selection of one of the alternatives is usually a better
choice than the other because of the orientation of the
resulting scar (Fig. 14-10).
FIGURE 14-10  ■  Two alternatives for design of Z-plasty: A-B and C-D. A-B is the preferred alternative as it best aligns scars with RSTLs.
A
B
C
D
A
A
B
B
C
C
D
D
RSTL
FIGURE 14-11  ■  Two alternatives for design of Z-plasty to correct scar perpendicular to melolabial crease (A-C and D-E). The first
alternative is preferred.
A
B
C
D
E

14  Z-PLASTY
323
first option is optimal. Figure 14-12 shows the use of
Z-plasty to align a scar with the melolabial crease. Because
of the length of the scar, two Z-plasties were used to
accomplish the reorientation of the scar. Whereas the
overall scar length has been increased by the length of
four peripheral limbs, the original scar (central limb of
the Z) is transposed directly into the melolabial crease for
maximal scar camouflage.
To perform a Z-plasty, the design is marked on the skin
before injection of local anesthetic to avoid distortion of
the scar 90° to its original axis. Note that two options
exist for the 60° Z-plasty design (see Fig. 14-11). Figure
14-11A illustrates the preferred design option. After
transposition of the flaps, the central limb lies within the
melolabial crease, and the two peripheral limbs approxi­
mate RSTLs of the lateral upper lip and medial cheek
(Fig. 14-11C). Conversely, even though the mirror image
Z-plasty (Fig. 14-11D) also realigns the central limb
appropriately, the peripheral limbs of the Z-plasty have
an undesirable orientation to RSTLs. Accordingly, the
FIGURE 14-12  ■  A, Scar with unfavorable orientation. B, Two Z-plasties designed to align scar with melolabial crease. C, Flaps trans­
posed and wound repaired. D, Postoperative view at 6 months. (Courtesy Shan R. Baker.)
A
B
C
D

324
SECTION I  FUNDAMENTALS
vermilion border is distorted by scar tissue. Such a condi­
tion may occur from a deep laceration of the upper lip or
after cleft lip repair. Because additional length is required
in the direction of the axis of the scar, a Z-plasty is
designed with the central limb oriented along the axis of
the scar. Transposition of the Z-plasty flaps results in an
increased lip length in the scarred region and realign­
ment of the vermilion border.
Similar to scars that restrict movement of the lip, long
scars on the neck can impair the freedom of movement
of the head (Fig. 14-14). A long, webbed scar on the neck
is ideal for treatment with single or multiple Z-plasties.
Z-plasty not only lengthens scars and corrects webbing
but may also position scars in a better relationship
to obliquely oriented RSTLs. Although a single large
Z-plasty may provide maximum lengthening of a neck
scar, the resulting scar will tend to be noticeable because
of the long peripheral limbs of the Z. Accordingly,
multiple Z-plasties are preferred in most circumstances
(Fig. 14-14C, D).
Multiple Z-plasties may be of value in treating fore­
head scars by repositioning portions of the scar into hori­
zontal forehead furrows (Fig. 14-15). Whereas the
four-flap Z-plasty has few indications in the head and
neck, it is occasionally useful for correction of lower
eyelid ectropion or retraction (see Fig. 14-15). Multiple
Z-plasties are also useful for improving the contour of
curvilinear flaps that have trap-door deformities, such as
might occur with a cheek transposition flap (Fig. 14-16).
These deformities essentially result from scar contrac­
ture. Thus, an effective method of correcting trap-door
deformity is scar lengthening achieved with Z-plasty and
simultaneous contouring of the flap.
Z-plasties may be designed with unequal angles. The
more acutely angulated flap is transposed in a greater arc
than the larger angled flap. Variations on such unequal
Z-plasties can be used to treat asymmetric facial features.
An example is when a scar contracture distorts the oral
commissure (Fig. 14-17). In such cases, the larger flap
consisting of the commissure is undermined only a
limited degree and the smaller flap is transposed into the
tissue void created by release of the contracted commis­
sure. This facilitates transfer of the oral commissure to a
more natural position.
the skin. Proper limb length is precisely measured with a
ruler or caliper. A sterile solution is used to prepare the
skin, followed by injection of a local anesthetic. Signifi­
cant undermining of the skin surrounding the flaps may
be necessary to allow transposition of the flaps without
distortion of facial structures, such as the lip, commissure,
and alar base. Therefore, local anesthetic is injected to the
extent of the anticipated undermining. After a 7- to
10-minute pause to ensure the maximal vasoconstrictive
effect of the epinephrine contained in the anesthetic, the
scar is excised. In cases in which the scar is wide, it is
occasionally useful to temporarily suture the wound
together to facilitate the design of the peripheral limbs of
the Z-plasty. Incision of the peripheral limbs follows and
is best accomplished with skin fixation and incision from
the base of the triangular flap toward the apex. Because
of skin retraction after release of the central limb scar,
there is a tendency to incise the tips of the Z-plasty flaps
such that they become overly narrowed. This tendency
can be countered by slightly rounding and widening the
incision where the peripheral limb joins the central limb
of the Z-plasty. Conversely, the peripheral limbs may be
incised before the central limb is. The flaps are dissected
beginning at their tips. The tips are delicately retracted
with a skin hook, and meticulous sharp dissection is per­
formed in a tissue plane just within the subdermal fat.
Dissection continues well beyond the flap bases. After
appropriate undermining, the flaps are easily transposed
by retraction of the ends of the central limb with skin
hooks (Fig. 14-11B). On occasion, tension prohibits ade­
quate transposition and necessitates further undermining
and extension of the incision at the base of one or both of
the flaps. The flaps are sutured in place beginning with
placement of several subcutaneous sutures made of an
absorbable material. However, the number of sutures
should be limited so as not to compromise the vascularity
of the flaps. Skin incisions are closed with fine (5-0 or 6-0)
suture material by meticulous, atraumatic, wound-
everting techniques. Cutaneous sutures are removed 3 to
5 days postoperatively.
Lengthening of a contracted scar is often necessary,
particularly if the scar is causing distortion of a facial
structure and impairing function. An example of this is
illustrated in Figure 14-13. In the illustration, the
FIGURE 14-13  ■  Z-plasty used to correct irregularity of vermilion border.
1
2
A
C
B
1 2

14  Z-PLASTY
325
FIGURE 14-14  ■  Z-plasty used to correct
webbed neck scar. A, B, Single
Z-plasty. C, D, Multiple Z-plasties.
A
B
C
D
1
2
1
2
1
2
3
4
5
6
1
2
3
4
5
6
FIGURE 14-15  ■  Multiple Z-plasties
used to improve camouflage of ver­
tical forehead scar and to correct
contracted lower eyelid and cheek
scar.
1
2
3
4
5
6
1
2
3
4
2
1
4
3
5
6
3
1
4
2
A
B

326
SECTION I  FUNDAMENTALS
facial structures. Classic indications for Z-plasty include
realignment of scars that are not parallel to RSTLs, cor­
rection of scars that cause contracted webbing of the
neck, repositioning of an oral commissure or eyelid that
is malpositioned from scarring, and correction of con­
genital or post-traumatic epicanthal folds.12,13 Z-plasty is
also helpful in the repair of a primary cleft palate.14,15 It
is impossible to list all of the reported uses of Z-plasty
described in the literature. Suffice to say that with a
thorough understanding of its principles, Z-plasty is an
extremely powerful tool in the reconstructive surgeon’s
armamentarium.
SUMMARY
Z-plasty is one of the oldest concepts in plastic surgery
and remains a prevalent and important technique. An
understanding of its geometric principles is critical to its
successful application. Z-plasty is a double transposition
flap technique that is used to lengthen contracted scars,
to change the orientation of scars for better alignment
with RSTLs, or to interrupt straight scars for better cam­
ouflage. Z-plasty is also helpful in the repair of some
cutaneous defects and for realignment of malpositioned
FIGURE 14-16  ■  Multiple Z-plasties used to correct trap-door deformity.
A
B
2 1
4 3
6 5
8 7
9
10
1
3
5
2
4
6
7
9
8
10

14  Z-PLASTY
327
Case 3
Figure 14-20A shows a patient with an oblique forehead
scar extending through the medial aspect of the right
eyebrow and into the right upper eyelid. Revision surgery
to improve camouflage of the forehead component of this
scar required excision of the existing widened scar tissue
and realignment of the oblique portions of the scar in an
axis more parallel to the horizontal RSTLs of the fore­
head. An example of this technique is illustrated in Figure
14-15. Figure 14-20B demonstrates the planned excision
of the forehead scar and two Z-plasties designed. The
irregular line drawn on the right side of the patient’s
forehead represents the anticipated final appearance of
the suture line after scar excision and completion of the
two Z-plasties. The anticipated appearance of the suture
line closely resembles the true incision line after transpo­
sition of the Z-plasty flaps (Fig. 14-20C). The outcome
1 year postoperatively showed an improvement of scar
camouflage (Fig. 14-20D).
Case 4
A patient presented with a contracted lateral neck scar
that limited movement of the head and neck (Fig. 14-21A).
A single large Z-plasty might have been effective in
releasing the contraction, but it was elected to use two
Z-plasties designed similar to the three Z-plasties illus­
trated in Figure 14-14C, D. The two options for design
of the Z-plasties were drawn on the neck skin (Fig.
14-21B). The design on the right was selected, although
either option would have been appropriate in this case.
The flaps were elevated, followed by resection of the
dense subcutaneous scar band marked in purple in Figure
14-21C. After resection of the scar and completion of the
double Z-plasty, the contraction was released, creating a
more natural contour of the lateral neck (Fig. 14-21D,
E). The Z-plasties were successful in releasing the con­
tracted scar (Fig. 14-21F).
CASE REPORTS
Case 1
The vertical, mature, widened and thickened tracheot­
omy scar shown in Figure 14-18A is ideal for scar revision
by Z-plasty. A 60° Z-plasty was planned and marked with
use of a caliper for precise measurement and alignment.
The central limb of the Z-plasty consisted of the thick­
ened scar. A 60° Z-plasty was used to reposition the verti­
cally oriented scar 90° so it would lie in RSTLs. In the
anterior neck, RSTLs are horizontally oriented as dem­
onstrated by the curvilinear dotted line bisecting the scar
in Figure 14-18B. The circle marked with a dotted line
in Figure 14-18C represents the extent of subcutaneous
undermining of the skin required for transposition of the
Z-plasty flaps. Note the horizontal alignment of the
central limb (original scar) after transposition of the flaps
(Fig. 14-18D). The final result is shown 1 year postop­
eratively in Figure 14-18E.
Case 2
A patient presented with a contracted scar disrupting the
contour of the concavity of the scapha of the left ear (Fig.
14-19A). Z-plasty was an ideal solution to this problem
because the technique offered a method of improving the
contracture and eliminating the web of scar that was
deforming the concave contour of the scapha. Figure
14-19B shows the planned incision. Note the orientation
of the peripheral limbs of the Z-plasty, which are aligned
with the vertical axis of the concavity of the scapha. The
mirror image of this planned Z-plasty would be less desir­
able because the peripheral limbs would conform less
optimally to the vertically oriented surrounding ear
structures. Figure 14-19C shows the flaps incised and
transposed. Note the horizontal release of the scar con­
tracture. The result 1 year after surgery was satisfactory
(Fig. 14-19D).
FIGURE 14-17  ■  Unequal Z-plasty used to reposition oral commissure.
A
B
Unequal
Z-Plasty

328
SECTION I  FUNDAMENTALS
FIGURE 14-18  ■  A, Vertical hypertrophic tracheotomy scar. B, C, Z-plasty designed. Curvilinear line represents RSTL. Circle marked
by dotted line represents extent of undermining of adjacent skin. D, Z-plasty flaps transposed. E, Postoperative view at 1 year.
A
B
C
D
E

14  Z-PLASTY
329
FIGURE 14-19  ■  A, Scar of scapha. B, Z-plasty marked. C, Z-plasty flaps transposed. D, Postoperative view at 1 year.
A
B
C
D

330
SECTION I  FUNDAMENTALS
FIGURE 14-20  ■  A, Oblique forehead scar extending to upper eyelid. B, Double Z-plasty combined with scar excision. Markings on
patient’s right forehead indicate anticipated configuration of suture line after scar revision. C, Z-plasties completed. D, Postoperative
view at 1 year.
A
B
C
D
A
B
C
FIGURE 14-21  ■  A, Contracted vertical neck scar selected for double Z-plasty scar revision. B, Two alternative designs for Z-plasty.
Design on right was selected. C, Superior Z-plasty flaps retracted to expose underlying scar marked in purple, which was removed
to facilitate release of contracture.

14  Z-PLASTY
331
nasal airway (Fig. 14-24A). The constricted nasal vesti­
bule was caused by a contracted web of scar extending
from the inferolateral nasal wall to the apex of the vesti­
bule. For correction of the deformity, it was necessary to
remove scar tissue and to eliminate the web. Accordingly,
a three-dimensional Z-plasty was designed, as marked in
Figure 14-24B. The flap labeled A, designed on the pos­
terior aspect of the stenotic scar, was interchanged with
the flap labeled B, marked on the anterior aspect of
the stenotic scar. The vertically oriented scar web was
made the central limb of the Z-plasty to lengthen this
dimension after transposition of the Z-plasty flaps. It was
necessary to excise scar tissue deep to the flaps. The
postoperative result at 4 months is shown in Figure
14-24C.
Case 8
A patient presented with a torn right earlobe, or cleft,
after ear piercing (Fig. 14-25A, B). A three-dimensional
Z-plasty was designed for repair with the central limb
positioned along the skin covering the interior of the
cleft. The cleft scar and the skin covering the scar were
excised, and the triangular flaps of the Z-plasty were
transposed (Fig. 14-25C). Figure 14-25D shows the
wound closure. Note that the central limb of the designed
Z-plasty was oriented perpendicular to the inferior
margin of the earlobe to minimize notching once the
Z-plasty flaps were transposed. The 4-month postopera­
tive result is shown in Figure 14-25E.
Case 9
A 3-year-old boy presented with bilateral congenital
macrostomia (Fig. 14-26A). To reduce the size of the oral
stoma and to close the lateral clefts of skin, mucosa, and
Case 5
The patient shown in Figure 14-22 underwent cleft lip
repair as an infant. She presented with concerns about
her lip deformity. Examination of the lip revealed a con­
tracted depressed scar and notching of the vermilion
border (Fig. 14-22A). A Z-plasty was designed (Fig.
14-22B) with the intention of inferiorly transposing the
vermilion border lateral to the scar. The second flap of
the Z-plasty was designed to superiorly transpose the skin
of the lip medial to the scar to better align the border of
the vermilion. The small notch in the wet line of the
vermilion was corrected by direct excision and reapproxi­
mation of the vermilion muscle. The Z-plasty and orbi­
cularis muscle realignment within the substance of the
vermilion were successful in improving the appearance of
the lip (Fig. 14-22C).
Case 6
The man shown in Figure 14-23A sustained a gunshot
wound causing damage to the cheek, lip, and maxilla. He
presented with a long, wide scar. There was a trap-door
deformity involving the portion of the scar on the upper
lip. A scar revision with Z-plasty was planned to interrupt
the linearity of the scar and to reposition a portion of the
scar in the nasofacial sulcus (Fig. 14-23B, C). Figure
14-23D shows improvement in the appearance of the scar
6 months postoperatively.
Case 7
An 8-year-old child underwent a combined craniofacial
approach, including facial degloving, to remove a large
maxillary, orbital, and skull base tumor. This resulted in
a significant stenosis of the anterior aspect of the right
D
E
F
D, Superior Z-plasty flaps transposed. E, Inferior Z-plasty flaps transposed and wound repaired. F, Postopera­
tive view at 6 months.
FIGURE 14-21, cont’d  ■

332
SECTION I  FUNDAMENTALS
FIGURE 14-22  ■  A, Contracted, depressed upper lip scar and notching of vermilion border. B, Z-plasty designed. C, Six months after
Z-plasty of lip scar.
A
B
C
FIGURE 14-23  ■  A, Wide scar of medial cheek and upper lip. Trap-door deformity of lip scar. Z-plasty designed to reduce scar linearity.
B, Scar excised. Z-plasty flaps incised.
A
B

14  Z-PLASTY
333
C
D
C, Z-plasty flaps transposed and wound repaired. D, Postoperative view at 6 months.
FIGURE 14-23, cont’d  ■
FIGURE 14-24  ■  A, Right nasal vestibular stenosis. B, Flap A (dotted line) outlined on posterior aspect of scar web. Flap B outlined
on anterior aspect. Deep scar was excised, and flaps were transposed in Z-plasty fashion. C, Postoperative view at 4 months.
A
B
B
C
A

334
SECTION I  FUNDAMENTALS
FIGURE 14-25  ■  A, Cleft of earlobe. B, Earlobe rotated outward to visualize medial and lateral aspect and Z-plasty designed to repair
cleft. C, Cleft excised, followed by transposition of Z-plasty flaps. D, Wound repaired. E, Postoperative view at 4 months.
A
B
C
D
E
soft tissue at the oral commissures, the borders of the
clefts were excised to create a fresh wound. The mucosa
and muscle layers of the clefts were approximated to
reduce the horizontal width of the mouth. Repair of the
skin wounds in a straight-line closure would have created
scars perpendicular to the melolabial creases. To better
align the skin closure line, Z-plasties of the skin wound
were designed (Fig. 14-26B). The Z-plasties facilitated
the creation of scars of the cheek skin that paralleled
RSTLs (Fig. 14-26C, D).
Case 10
After trauma, a patient developed substantial loss of soft
tissue of the left oral commissure and upper lip. Scar
contracture and tethering of the lower lip due to scarring
across the inferior labial sulcus also occurred (Fig.
14-27A). The patient underwent three scar revision sur­
gical procedures, each of which used Z-plasties as part of
the surgical approach. The first surgical stage consisted
of a left commissuroplasty to lateralize the deformed
commissure. The cheek skin was incised laterally to the
desirable position for the new commissure, which is
marked with an asterisk in Figure 14-27B. Scar tissue was
removed and a Z-plasty was designed to transpose mucosa
from the inner aspect of the left upper lip to the superior
area of the constructed commissure. Flap A was inter­
changed with flap B, providing a mucosal lining for the
commissure. An identical procedure was also performed
on the lower lip, harvesting mucosa from the inner aspect
of the lower lip and transferring it in the form of a
Z-plasty to the inferior aspect of the oral commissure. Six

14  Z-PLASTY
335
FIGURE 14-26  ■  A, Bilateral congenital macrostomia. B, Left cheek Z-plasty designed. C, Z-plasty flaps transposed. D, Postoperative
view 1 year after bilateral Z-plasties of lateral commissures.
A
B
C
D
A
B
A
*
B
C
FIGURE 14-27  ■  A, Upper and lower lip tissue deficiencies after gunshot wound. B, First-stage commissuroplasty. After horizontal
lateral skin incision to site of planned new commissure (*), upper lip mucosal Z-plasty was used to transfer flap A to lateralized
commissure. C, Six months after first stage.
Continued

336
SECTION I  FUNDAMENTALS
Unequal Z-plasty
of nasal sill
Advancement of
lateral lip skin
Unequal Z-plasty to
align vermilion
and commissure
E
F
G
H
D
D, Second-stage scar revision. Z-plasty at
superior limit of upper lip scar and advancement of lateral lip skin
medially. Z-plasty designed to correct distorted vermilion of
lower lip. E, Illustration demonstrating second stage. F, Second
stage completed and wounds closed. Note improvement in posi­
tion of lower lip vermilion border and commissure. G, Third
stage. Z-plasty of upper and lower lip scars. H, One year after
third stage.
FIGURE 14-27, cont’d  ■

14  Z-PLASTY
337
FIGURE 14-28  ■  A, Incomplete cleft palate. Solid lines indicate incisions for oral flaps and dashed lines indicate nasal mucosal inci­
sions. Curved arrows show direction of oral flap elevation. B, Immediate postoperative result after completed Furlow palatoplasty
repair. C, Sequence of illustrations outlining the steps in double opposing Z-plasty repair of a cleft palate (Furlow palatoplasty).
A
B
B
B
A
A
C
C
D
D
B
B
A
A
C
C
D
D
C

338
SECTION I  FUNDAMENTALS
months postoperatively, the patient had a reasonable res­
toration of the left commissure (Fig. 14-27C).
The patient continued to have a foreshortened upper
lip, disruption of the vermilion border of the lower lip,
and trap-door deformity of the lower lip scar. A second
surgical procedure was planned in which a Z-plasty was
used to correct a depressed scar below the nasal sill. The
entire vertical scar of the upper lip was excised, and the
lip skin lateral to the scar was advanced medially to
increase the availability of skin in the area of the resected
scar. A Z-plasty was also performed on the lower lip in
an effort to correct distortion of the left commissure (Fig.
14-27D, E). Figure 14-27F shows the suture line imme­
diately after the second surgical stage. Note the improved
alignment of the left commissure and vermilion of the
lower lip as a result of the Z-plasty.
Six months after the second surgical stage, it was
evident that there was a persistent contracted vertical scar
of the upper lip causing distortion of the vermilion
border. A third surgical procedure was performed to
correct the contracted upper lip scar and to treat the
trap-door deformity of the lower lip scar that had not
been addressed by the previous two procedures. The
third surgical stage consisted of two Z-plasties of the
upper lip scar and a single Z-plasty of the inferior aspect
of the lower lip scar. The lower lip Z-plasty disrupted the
curvilinear scar that was the primary cause of the trap-
door deformity. The large Z-plasty at the superior aspect
of the upper lip scar served to lengthen the contracted
scar and better align the vermilion border. A second
smaller Z-plasty designed in the scar line at the vermilion
border of the upper lip served to improve the continuity
of the vermilion (Fig. 14-27G). The final outcome 1 year
postoperatively is shown in Figure 14-27H. Z-plasties
performed in three separate surgical procedures were
instrumental in lengthening the upper lip scar, correcting
the trap-door deformity of the lower lip scar, and realign­
ing the vermilion borders of both lips.
Case 11
Figure 14-28A shows a patient with an incomplete cleft
palate who underwent double opposing Z-plasty palato­
plasty (Furlow palatoplasty) repair. This technique was
first described by Furlow in 198616 and has been widely
used for repair of the soft palate and reconstruction of
the levator sling. In patients with cleft palate deformity,
the soft tissue musculature may be hypoplastic and has
abnormal orientation and insertion into the posterior
hard palate. Capitalizing on Z-plasty principles, the
Furlow palatoplasty technique allows transverse reorien­
tation of the musculature for reconstruction of the levator
sling. In addition, this allows lengthening of the palate in
cases of velopharyngeal insufficiency associated with sub­
mucous cleft palate.
Two opposing Z-plasties were designed on the soft
palate as mirror images of each other. Although the eleva­
tion of flaps may vary on the basis of the dominant hand
of the surgeon, the palatal musculature is always elevated
as part of the posteriorly based myomucosal flap (with
the oral or nasal mucosa attached). In this case, the left
posteriorly based oral flap was elevated as a myomucosal
flap, and the right anteriorly based oral flap was elevated
with mucosa only. After elevation of the two oral side
flaps, the nasal flaps were incised and elevated. The two
myomucosal flaps were transposed posteriorly; the two
mucosal flaps were transposed anteriorly. The immediate
postoperative result is shown in Figure 14-28B.
REFERENCES
1. Borges AF. Z-plasty. In: Borges AF, editor. Elective incisions and
scar revision. Boston: Little Brown; 1973.
2. Davis WE, Renner GJ. Z-plasty. In: Thomas JR, Holt GR, editors.
Scar revision. St. Louis: Mosby–Year Book; 1989.
3. Berger P. Autoplastie par dédoublement de la palmure et échange
de lambeaux. In: Berger P, Banzat S, editors. Chirurgie ortho­
pédique. Paris: G Steinheil; 1904.
4. Fricke JC. Bildung neuer Augenlider (Blepharoplastik): nach Zer­
störung und dadurch hervorgebrachten Auswärtswendungen der­
selben. Hamburg: Perthes & Basse; 1829.
5. Horner WE. Clinical report on the surgical department of the
Philadelphia Hospital. Am J Med Sci 1837;21:99.
6. Serre M. Traité sur l’art de restaurer les difformités de la face: selon
la méthode par déplacement, ou méthode française. Montpellier,
France: L Castel; 1842.
7. Denonvilliers CP. Blepharoplasie. Bull Soc Chir 1856;7:213.
8. McCarthy JG. Introduction to plastic surgery. In: McCarthy JG,
editor. Plastic surgery, vol 1, General principles. Philadelphia: WB
Saunders; 1990.
9. Limberg AA. Design of local flaps. In: Gibson T, editor. Modern
trends in plastic surgery. London: Butterworth; 1966.
10. Jankauskas A, Cohen IK, Grabb WC. Basic technique of plastic
surgery. In: Grabb WC, Aston SJ, editors. Plastic surgery. Boston:
Little Brown; 1991.
11. Davis JS, Kitlowsky EA. The theory and practical use of the
Z-incision for the relief of scar constriction. Ann Surg 1939;109:
1001.
12. Furnas DW, Fischer GW. The Z-plasty: biomechanics and math­
ematics. Br J Plast Surg 1971;24:144.
13. Converse JM, Smith B. Naso-orbital fractures and traumatic defor­
mities of the medial canthus. Plast Reconstr Surg 1966;38:156.
14. Walike J, Larrabee WF. Repair of the cleft earlobe. Laryngoscope
1985;95:876.
15. Frodel JL. Z-plasty. Facial Plast Surg Clin North Am 1998;6:149.
16. Furlow LT. Cleft palate repair by double opposing Z-plasty. Plastic
Reconstr Surg 1986;78:6.

339
C H A P T E R 1 5 
SKIN AND COMPOSITE GRAFTS
Brian S. Jewett
SKIN ANATOMY AND PHYSIOLOGY
The epidermis, the most superficial layer of skin, consists
of keratinizing stratified squamous epithelium. The pre­
dominant cell type is the keratinocyte, making up 80%
of the cells. Layers of the epidermis include the basal cell,
prickle cell, granular cell, and keratin layers; the overall
thickness of human skin varies from 0.075 to 0.15 mm.
The epidermis is thin at birth, becomes thicker during
early adulthood, and thins during the fifth to sixth decades
of life.
The epidermis is attached to the dermis by a basement
membrane zone that extends from the epidermis to pilo­
sebaceous units and sweat ducts located in the dermis.
Each pilosebaceous unit contains sebaceous glands, a hair
shaft and follicle with associated arrector pili muscle, and
a sensory end organ. Epithelialization of partial-thickness
skin wounds occurs from wound edges and the basement
membrane zone around the hair follicles, sebaceous
glands, and sweat ducts.1
The dermis consists of a fibrous connective tissue
matrix made up of collagen, elastic tissue, and ground
substance. Dispersed throughout the dermis are epider­
mal appendages, blood vessels, nerves, and cells. The
most common cell in the dermis is the fibroblast. Fibro­
blasts have a synthesis role in wound healing, producing
collagen, elastin, and ground substance. Fibroblasts
behave like contractile cells during wound maturation.
The dermis is divided into a thin papillary and a
thicker reticular dermis. The overall thickness of the
dermis is variable, depending on its location. Eyelid skin
has the thinnest dermis, measuring less than 1 mm thick.
Dermal thickness measures 1.5 mm on the temple,
2.5 mm on the scalp, and more than 4 mm on the back.
The dermis is thin at birth, increases in thickness
until the fourth or fifth decade, and then decreases with
further aging. On average, men have a thicker dermis
than women do.1
Cutaneous blood flow is directed toward the more
metabolically active epidermis through dermal papillae,
hair papillae, and adnexal structures. Two vascular plex­
uses connected by communicating vessels are present in
the reticular dermis. A deep plexus lies at the junction of
dermis and fat; the superficial plexus gives rise to a rich
capillary loop system in the superficial dermal papillae.
This system provides nutrients to the epidermis through
diffusion.2
SKIN GRAFTS
On occasion, superficial facial defects are best addressed
by repair with a skin or composite graft. Very young
patients with tight facial skin presenting with large cuta­
neous defects are appropriate candidates for reconstruc­
tion with a full-thickness skin graft. Use of a skin graft is
usually reserved for those cases that cannot reasonably be
reconstructed with a local flap because of the size of the
defect. The skin graft obviates the need for additional
scars on the face or the use of a distant or microsurgical
flap. Unfortunately, full-thickness skin grafts used in such
cases frequently have a “patch” appearance, with discrep­
ancies of color and texture between native and grafted
skin (Fig. 15-1). Color and texture discrepancies between
facial skin and skin grafts may also be a problem in elderly
patients (Fig. 15-2). However, because of the tendency
for elderly patients to have thin skin, grafts used to repair
facial defects are more likely to display a better color and
textural match with native facial skin than when similar
grafts are used in younger patients (Fig. 15-3). Postopera­
tive dermabrasion assists in minimizing color and texture
discrepancies between skin grafts and facial skin.
Skin grafting involves removal of skin from one loca­
tion and placement at a separate site. Skin grafts can be
harvested in several different forms, including full thick­
ness, split thickness, and composite. Regardless of the
type of skin graft, graft viability depends on several
factors: vascularity of the recipient site, microcirculation
on the surface of the recipient site, vascularity of donor
graft tissue, contact between graft and recipient site,
and whether the patient suffers from certain systemic
illnesses.
Contact between the skin graft and recipient site is
essential. A bolster dressing is helpful to prevent fluid
collections beneath the graft postoperatively (Fig. 15-4).
Bolsters also prevent shearing forces from disrupting
vascular connections between graft and wound bed.
Systemic illnesses that may compromise graft survival
include collagen vascular diseases, hematologic disorders,
diabetes, nutritional deficiencies, and hypoxemia.3 Use of
tobacco products is also detrimental to the survival of
skin grafts.
Recipient site conditions that are not favorable to skin
graft survival include irradiated tissue; scar; exposed
bone, cartilage, or tendon; and bleeding wounds. Grafts
placed over avascular defects smaller than 1 cm2 may
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340
SECTION I  FUNDAMENTALS
For deeper wounds, skin grafting may be delayed until
granulation tissue has filled the wound bed (2-3 weeks).
Any epithelium on the surface of the granulation tissue
is removed before grafting, and the tissue is crosshatched
so that myofibrils are released. Granulating wounds nor­
mally contain bacteria. Bacterial counts greater than 105
organisms per gram of tissue often lead to graft loss.4
When delayed grafting is planned, the patient is pre­
scribed a 10-day course of an antistaphylococcal antibi­
otic to begin 3 days before skin grafting. When necessary,
wound culture specimens are obtained to direct antibiotic
selection.
DEFECT PREPARATION
Facial defects occasionally involve multiple facial aes­
thetic regions. In considering reconstructive options, it is
helpful to mark the division between different regions so
that defects involving multiple regions can be repaired
with separate methods. Following this principle enables
the placement of scars along boundary lines. This in turn
helps preserve the natural contours of the face.
survive by nutritional support through the wound edges;
however, grafting over larger avascular wounds is unlikely
to succeed.3 Skin graft survival on bone is enhanced if a
thin layer of bone is removed with a diamond fraise bur
until punctuate bleeding is achieved. On the skull, holes
can be made in the outer bone table to allow communica­
tion with the inner diploë. Large areas of exposed bone,
cartilage, or tendon may require coverage with a muscle
or fascial flap before grafting. Another technique that has
proved successful in skin grafting auricular cartilage
devoid of perichondrium is to create windows through
the cartilage, exposing perichondrium and subcutaneous
tissue on the opposing surface of the ear. The windows
are made as large as possible through the cartilage in
areas that can be resected without jeopardizing the struc­
tural integrity of the ear. The windows provide a port for
vascular ingrowth to revascularize the graft (Fig. 15-5).
Only very thin full-thickness skin grafts should be used
for covering auricular cartilage so that the graft will not
obscure the complex and delicate topography of the car­
tilage. Thin skin grafts are more likely to survive com­
pared with thick full-thickness skin grafts, given the
limited contact with a vascular source for nourishment.
FIGURE 15-1  ■  A, A 4.5 × 4.2-cm skin defect after micrographic excision of basal cell carcinoma in a 34-year-old woman. B, C, Repair
with full-thickness skin graft from supraclavicular fossa. D, E, Postoperative views at 11 months. No adjunctive procedures per­
formed. Graft has poor color and textural match with facial skin. (Courtesy Shan R. Baker, MD.)
A
B
C
D
E

15  SKIN AND COMPOSITE GRAFTS
341
FIGURE 15-2  ■  A, A 5 × 4-cm melanoma in situ. Suture line marks planned excision. B, Melanoma excised. Resulting wound partially
closed primarily. Remaining wound covered with 3.5 × 4-cm full-thickness skin graft. C, D, Postoperative views at 1 year. Z-plasties
performed at superior border of graft. (Courtesy Shan R. Baker, MD.)
A
B
C
D

342
SECTION I  FUNDAMENTALS
FIGURE 15-3  ■  A, B, Lentigo maligna of cheek outlined by linear incisions from attempts to obtain tumor-free margins before complete
resection (square technique; see Chapter 8). Resected area (7 × 6 cm) was reconstructed with full-thickness skin graft harvested from
supraclavicular fossa. C, D, Postoperative views at 10 months. Skin graft provided an excellent color and textural match with native
facial skin. No adjunctive procedures performed. (Courtesy Shan R. Baker, MD.)
A
B
C
D