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elsewhere for other possible donor tissues if necessary. Larger donor
sites can be achieved with tissue expanders if needed.
FLAP FAILURE AND SURVIVAL FACTORS
Flap failure usually stems from poor flap design. This often occurs in
the preoperative stage when the surgeon has not truly given enough
consideration to all the factors discussed above. Etiology of flap failure
can be attributed to either intrinsic or extrinsic factors; the extrinsic
factors are often a result of surgeon error. Common extrinsic factors
that are avoidable are excessive skin traction, inadequate flap size,
twisting or kinking of the flap pedicle, excessive compression and
inappropriate design of the flap within traumatized or radiated tissue.
Some extrinsic factors are not completely within the surgeon’s control,
such as arteriosclerosis of the vessels, hypotension, anastomotic
thrombosis, infection and hematoma. The only intrinsic factor known
to cause flap failure is lack of adequate nutrient blood flow, whether
due to venous or arterial insufficiency.
As much of the flap failure may be due to surgical misadventure,
there are steps that can be taken to increase the survivability of the
flap. Besides following sound surgical principles in the design of the
flap and the preparation of the recipient site, the principle of the delay
phenomenon, as discussed earlier, greatly enhances the flap survival.
There are two theories as to how the delay phenomenon increases the
survival of the flap. The first theory is that the delay conditions the
tissues to ischemia and permits the flap tissue to improve its survival
rate with less nutrient blood flow than is generally needed. The second
theory assumes that the delay actually improves or increases the vas­
cularity as seen with the choke vessels. Both may actually play a role
in the survivability of the flap. There have been attempts to reproduce
the effects of the delay phenomenon without surgical intervention by
producing a hypoxic environment by which the tissue may respond.
One method is exposure of the patient and the tissues to intermittent
hypoxic exposure followed by normoxic environment up to 4 weeks
before the surgery. This is similar to training methods utilized by some
high level athletes for improved competitive performance when at
high altitudes. Another method is by employing a suture at the periph­
ery of a flap to diminish blood flow and thereby the oxygen level in
the area preoperatively. In both methods, there was an increase seen
in flap perfusion and PO2 levels as well as overall flap survivability.
Some surgeons may also employ pharmacologic agents, such as
vasodilators, to increase the blood flow to the flap, but this is not
standardized in the medical community. Heparin has not been found
to affect the overall survivability of a flap, however high dose aspirin
has been shown to be effective in animal models by modulating
inflammatory response at the graft site and improving flap circulation
by direct vasodilatation. The human equivalent dose required however,
would be too great and therefore is not recommended. Another pos­
sible pharmacologic agent is the beta adrenergic stimulator, isoxsu­
prine. Isoxsuprine causes dilatation and increase in capillary cutaneous
blood flow with few side-effects.
If a complication does occur, the survival rate of the flap may
depend on intervening in a timely manner. This requires close moni­
toring of the flap to assess its status. Clinical observation is still the
best method of assessing the viability of a flap. A pale flap will indicate
arterial insufficiency and a blue flap will indicate failure of venous
outflow and venous congestion. Either of these will lead to loss of the
flap if intervention is not instituted. Dermal bleeding and capillary
refill in conjunction with one’s clinical observation and judgement
will usually suffice in determining the flap viability. There are objective
tests that can also be utilized to help evaluate the flap, such as fluo­
rescein dye to evaluate capillary diffusion, spectrophotometry, Doppler
use of the choke vessels of the bordering angiosomes in order to
enhance the survivability of the flap. The choke vessels, as stated earlier,
are usually closed between the angiosomes, unless there is a drop in
pressure gradient, and then the choke vessels will open between the
bordering angiosome and the ischemic angiosome (Fig. 14.8). If the
drop in pressure gradient and ischemia is very sudden, the choke vessels
will begin to open and sufficiently supply the ischemic angiosome after
a delay of ≥4 days. This is known as the delay phenomenon and is very
useful in developing the flap. If the area has been under prolonged
vascular compromise, then the choke vessels of the boundary angio­
somes may already be open and supplying the ischemic angiosome.
In the design of a flap, the length to width ratio was formerly con­
sidered of paramount importance to assure adequate blood flow to
the flap. Now with the understanding of the angiosome and the choke
vessels’ ability to expand the artery’s territory, it has become less criti­
cal in the overall design.
The delay phenomenon allows the surgeon to increase the surviv­
ability of a flap by creating the flap, but not performing the transfer
of the flap for 7 days or so. This allows the choke vessels to respond
to the sudden drop in the pressure gradient caused by the surgical
insult by opening up between the angiosomes and increasing the
blood supply to the flap. That is not to say that no thought needs to
be given to the width of the flap. The width does become important
when it becomes so narrow that there is an increased chance that the
pedicle will not have a large enough vessel present to feed it.
The goal of any flap reconstruction is to cover the defect or recipient
site with tissue of similar quality and appearance with the least
amount of risk and trauma to the tissues, but with the greatest pos­
sibility of success. This requires the surgeon to evaluate the tissues at
the recipient and donor site, to determine compatibility or to look
Figure 14.8  Response of choke vessels to ischemia of nearby angiosome.
(A) Artery A has the potential to directly supply blood to the adjacent
area fed by artery 1, via the open choke vessels between them, should
artery 1 lose its blood supply. (B) The vessel 1 has been tied off. In the
next 72 h, the choke vessels connecting the angiosome 1 to angiosome
2 on opposite sides have opened up. The flap has been delayed so that
artery B’s blood flow can now support the region once fed by artery 1
and has the potential to also supply the angiosome fed by artery 2.
(C) The reach of artery C has been further extended because artery 2 has
been tied off and an additional 72 h have passed. This sequential delay
(tying off artery 1 and then artery 2) allows artery C to carry the areas
fed by artery 1, artery 2 and artery 3, because the choke vessels between
them have had time to open.
(Adapted from: Taylor, G.I., Corlett, R.J., Caddy, C.M., et al., 1992. An anatomic
review of the delay phenomenon: II. Clinical application. Plast Reconstr Surg 89,
408–416.)
A
B
C
1
2
3
1
2
3
1
2
3

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ultrasound, laser Doppler and transcutaneous oxygen tension. Trans­
cutaneous oxygen tension is one of the earliest and least invasive
methods of detection of flap ischemia.
CONCLUSION
The skin flap requires extensive comprehensive surgical planning to
execute successfully with the best possible outcome for the patient.
All possible options, from the simple to the complex, should be
considered prior to performing the flap. A thorough knowledge of the
anatomy and the vascular anatomy is critical to the implementation
of the skin flap. Even with a broad knowledge base, a surgeon should
still have a back-up plan available to avoid the inevitable situation of
a flap not performing as expected. If the flap appears compromised at
the time of elevation, it should not be used. Expect the unexpected
with the performance of a flap that is unique to every situation and
every patient. This will allow the surgeon to be prepared for the capri­
cious nature of skin flaps and to still provide the patient with a suc­
cessful outcome.
FURTHER READING
Anderson, T.A., Yu, V., Hom, D.B., et al., 2010.
Interstitial delivery of vascular endothelial
growth factor to skin flaps. Arch Facial Plast
Surg 12 (5), 326–331.
Attinger, C.E., 2000. Plastic surgery techniques
for foot and ankle surgery. In: Myerson, M.
(Ed.), Foot and Ankle Disorders. WB
Saunders, Philadelphia, pp. 585–644.
Attinger, C.E., Cooper, P., Blume, P., 2001. The
safest surgical incisions and amputations
applying the angiosome principles and
using the Doppler to assess the arterial–
arterial connections of the foot and ankle.
Foot Ankle Clin 6, 745–799.
Attinger, C.E., Cooper, P., Blume, P., 1997.
Vascular anatomy of the foot and ankle.
Op Tech Plast Reconstr Surg 4,
183–198.
Bravo, F.G., Schwarze, H.P., 2009. Free-style
local perforator flaps: concept and
classification system. J Plast Reconstr
Aesthet Surg 62 (5), 602–608.
Calligari, P.R., Taylor, G.I., Caddy, D.M., et al.,
1992. An anatomic review of the delay
phenomenon: I. Experimental studies.
Plast Reconstr Surg 89, 397–407.
Christensen, J.C., Dockery, G.L., 1986. Flap
classification and survival factors: current
concepts. Clin Podiatr Med Surg 3,
579–588.
Ciresi, K.F., Mathes, S.J., 1993. The
classification of flaps. Ortho Clin North
America 24 (3), 383–391.
Clemens, M.W., Attinger, C.E., 2010.
Angiosomes and wound care in the
diabetic foot. Foot Ankle Clin 15 (3),
439–464.
Cormack, G.C., Lamberty, B.G.H., 1994. The
arterial anatomy of skin flaps, second ed.
Churchill Livingstone, London.
Dockery, G.L., Christensen, J.C., 1986.
Principles and descriptions of design of
skin flaps for use on the lower extremity.
Clin Podiatr Med Surg 3, 563–577.
Donegan, J.O., 1980. The assessment and
enhancement of skin flap viability. Head
Neck Surg 2, 470–475.
Ducic, I., Brown, B.J., Rao, S.S., 2011. Lower
extremity free flap reconstruction outcomes
using venous coupler. Microsurgery 31 (5),
360–364.
Finseth, F., Adelberg, M.G., 1979. Experimental
work with isoxuprine for prevention of skin
flap necrosis and for treatment of the
failing flap. Plast Reconstr Surg 63, 94–100.
Hidalgo, D.A., Shaw, W.W., 1986. Anatomic
basis of plantar flap design. Plast Reconstr
Surg 78, 627–636.
Hoopes, J.E., 1976. Pedicle flaps: an overview.
In: Krizek, J., Hoopes, J.E. (Eds.),
Symposium on Basic Sciences in Plastic
Surgery. CV Mosby, St Louis, pp. 241–259.
Ismavel, R., Samuel, S., Boopalan, P.R., et al,
2011. A simple solution for wound coverage
by skin stretching. J Orthop Trauma 25 (3),
127–132.
Kerrigan, C.L., 1983. Skin flap failure:
pathophysiology. Plast Reconstr Surg 72,
766–767.
Lecours, C., Saint-Cyr, M., Wong, C., et al.,
2010. Freestyle pedicle perforator flaps:
clinical results and vascular anatomy. Plast
Reconstr Surg 126 (5), 1589–1603.
Milch, H.S., Schubert, S.Y., Hammond, S.,
et al., 2010. Enhancement of ischemic
wound healing by inducement of local
angiogenesis. Laryngoscope 120 (9),
1744–1748.
Morris, S.F., Taylor, G.I., 1995. The time
sequence of the delay phenomenon:
when is a surgical delay effective? An
experimental study. Plast Reconstr Surg 95,
526–533.
Odland, R.M., Kim, P., Nadler, D., et al., 1995.
Nonsurgical delay of skin flaps: effect of
a suture delay technique on blood flow
and survival. Laryngoscope 105 (5 Pt 1),
523–528.
Roukis, T.S., 2000. The Doppler probe
for planning septofasciocutaneous
advancement flaps on the plantar aspect of
the foot: Anatomical study and clinical
applications. J Foot Ankle Surg 39,
270–290.
Schlaudraff, K.U., Pepper, M.S., Tkatchouk,
E.N., et al., 2008. Hypoxic preconditioning
increases skin oxygenation and viability but
does not alter VEGF expression or vascular
density. High Alt Med Biol 9, 76–88.
Shalom, A., Friedman, T., Westreich, M., 2008.
Effect of aspirin and heparin on random
skin flap survival in rats. Dermatol Surg 34,
785–790.
Sonmez, E., Bayram, F.C., Safak, T., 2011.
A new flap prefabrication model:
prefabricated neural-island flap. Ann Plast
Surg 66 (4), 364–369.
Stannard, J.P., Signanamala, N., Volgas, D.A.,
2010. Fix and flap in the era of vacuum
suction devices: what do we know in terms
of evidence based medicine? Injury 41 (8),
780–786.
Taylor, G.I., Corlett, R.J., Caddy, C.M., et al.,
1992. An anatomic review of the delay
phenomenon: II. Clinical applications.
Plast Reconstr Surg 89, 408–416.
Taylor, G.I., Doyle, M., McCarten, G., 1990.
The Doppler probe for planning flaps:
anatomical study and clinical applications.
Br J Plast Surg 43, 1–16.
Taylor, G.I., Pan, W.R., 1998. Angiosomes
of the leg: anatomic study and clinical
applications. Plast Reconstr Surg 102,
599–616.
Wallace, C.G., Kao, H.K., Jeng, S.F., et al., 2009.
Free-style flaps: a further step forward for
perforator flap surgery. Plast Reconstr Surg
124 (6), 19–26.
Weng, R., Li, Q., Li, H., et al., 2010. Mimic
hypoxia improves angiogenesis in
ischaemic random flaps. J Plast Reconstr
Aesthet Surg 63 (12), 2152–2159.

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CHAPTER CONTENTS
V–Y-plasty
151
Y–V-plasty
152
V–Y–S-plasty
152
Single V–Y fasciocutaneous island flap
157
Extended V–Y island flap
160
Double V–Y island flap
161
Oblique sigmoid island flap
161
Conclusion
161
V–Y-PLASTY
The V–Y tissue advancement procedure is a useful surgical technique
for dealing with lower extremity scars, contracture of the skin (espe­
cially at the lesser digits), and other functional defects of the skin on
the feet. To advance the tissue in this procedure successfully, a detailed
plan must be developed and well executed. It is important to be
mindful of the underlying neurovascular anatomy of the specific skin
or tissue being treated. Careful planning at the beginning of the pro­
cedure will reduce many of the potential complications found with
skin flaps and skin-advancement surgery in general.
In the basic classification scheme, there are two primary methods
to categorize skin flaps: (1) the type of blood supply to the flap or
(2) the shape and movement of the flap. Understanding the method
by which blood supply is delivered to a unique flap is as essential to
its survival as is the design and placement of the flap. Examples of
skin flap types based on blood supply would include axial flaps,
random flaps or island flaps. The second method of categorizing
skin flaps according to mobilization or movement of the flap is also
very beneficial. Local flaps can be further divided into two classifica­
tions: those that revolve around a fixed point to reach the defect
(rotational flap), and those that are advanced to cover a defect
(advancement flap). The V–Y advancement flap falls into this last
group with the primary motion in a straight line from the donor site
to the recipient site with no rotary motion or lateral movement taking
place (Fig. 15.1). In this type of flap, the primary movement is so
prominent that it may not be obvious that the secondary movement
may well be equal to or at times greater than the primary movement
(Fig. 15.2).
The foremost benefit of the V–Y advancement flap is that it requires
few operative stages to perform, there is perfect match of skin color
and texture, hair growth in the area is not disturbed to any great extent
and thickness of the flap is consistent with adjacent skin tissue. It is
valuable in the forefoot for contracture of tissue associated with ham­
mertoes and scars or contracture in the region of the metatarsophalan­
geal joints. On the dorsum of the foot a single, narrow Wilson V–Y
procedure can be carried out for contracted digits, especially on the
fifth toe (Fig. 15.3). This is most useful when there is only mild
contracture and the extensor digitorum longus tendon to the fifth
toe is taut. When there is greater contracture of the toe or when there
has been previous surgery in the area, a wider V–Y-plasty is required
(Figs 15.4–15.6).
The V–Y-plasty only allows about a 20% increase in the distance
from the tip as it moves to its new location. This is frequently not
sufficient for greater degrees of contracture and other procedures,
such as the Z-plasty, are more suitable in this situation. The outcome
of the V–Y technique will be directly related to how the tissue is
handled and to preoperative preparation. The purpose is to advance
tissue with as little dissection as possible and without unnecessary
tension on the resultant skin flap. Minimal dissection will reduce
the potential for devascularization of the tissue, particularly at the tip
of the flap.
The outline of the incision should be mapped on the skin with a
marking pen prior to surgery with the line of contracture marked
through the middle of the V shape (Fig. 15.7). The first incision is
started with the tip of the scalpel blade, usually a No. 15, at the
apex of the V and is carried toward the base with the belly of the
blade where the incision is then completed with the tip of the blade
again (Fig. 15.8). The second incision is performed in a similar fashion
to complete the V (Fig. 15.9). The V-plasty is designed with the apex
of the triangle proximal when the incision is used for metatar­
sophalangeal contracture. The incisions are carried into the subcutane­
ous layer and undermining is performed in a blunt manner with
careful freeing of the surrounding tissues. While holding the flap,
pick-ups or skin hooks should hold the subcutaneous layer gently
©2012 Elsevier Ltd.
V–Y- and Y–V-plasty
G. Dock Dockery
Chapter
15

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Figure 15.1  Standard V–Y advancement flap. The skin incision is made
as a V and then moved forward, thereby lessening contracture or tension
directly in line with the skin. Direct closure of the tip creates a Y-shaped
suture line.
A
B
Figure 15.2  V–Y-plasty demonstration on pig foot. (A) The initial incision
is planned over the joint with the base as wide as the tissue to be
moved. (B) The flap tissue is carefully undermined minimally at the base
and it is apparent how much motion has occurred. (C) The final suture
closure will yield a Y appearance.
C
instead of grasping or clamping the dermis or epidermal layer with
forceps. A skin hook can be placed in the incision at the apex of the
V with gentle proximal pressure to assist in retraction while undermin­
ing (Fig. 15.10).
Complete soft tissue releases, tendon and capsule, are typically
necessary when dealing with contracted toes and can be performed
through the same incision. Care must be taken to protect the underly­
ing neurovascular structures during this dissection. When the under­
mining technique is complete, the V is transformed into a Y-shaped
incision (Fig. 15.11). Tissue is advanced as the digit is held in a cor­
rected attitude. There should be no tension on the surrounding deep
tissue, skin or flap at this time. The bottom of the Y incision is closed
first (Fig. 15.12), followed by the apex of the flap, which is closed with
a simple apical suture (also called a three-point suture or Gillies
corner stitch) or partially buried horizontal suture at the apex of the
V (Figs 15.13, 15.14). The remaining incision is closed with additional
interrupted non-absorbable sutures (Fig. 15.15). The skin edges are
carefully closed in an even manner with equal bites of tissue on each
side of the incision to properly evert the skin edges. When performed
correctly, it is easy to see the release of tension and the level of appro­
priate closure. Even though it would appear that turning the V around,
with the base proximal over the metatarsophalangeal joints, would
improve the potential blood supply to the flap, it is not recommended,
as a significant amount of flap motion is lost with this maneuver (Fig.
15.16). Since this flap only provides a small amount of actual move­
ment when performed properly, the loss of additional motion would
make it less worthwhile to perform.
Y–V-PLASTY
A related type of advancement flap is the Y–V flap. Essentially, this
flap is the opposite of the V–Y flap by increasing tension in line with
the Y–V and releasing tension perpendicular to the flap (Fig. 15.17).
The procedure is usually performed as a series of multiple Y–V inci­
sions (Fig. 15.18). These flaps are done in a series to release a con­
tracture over the dorsum of the forefoot, in areas of burn scar
contracture or in contracted digits (Fig. 15.19).
The incisions of the Y–V-plasty are carried deep into the subcutane­
ous tissue layer with gentle undermining of the surrounding tissue.
The subcutaneous tip of the flap should be gently held in position
with a skin hook with care taken not to damage the skin layer of the
tip. When the contracture is released, the Y incisions are closed with
simple interrupted sutures at the base to release tension on the apex.
The closure is comparable with that of a Z-plasty flap.
V–Y–S-PLASTY
This skin plasty combines the V–Y-plasty technique with the
rotation flaps of the S-plasty described in Chapter 12. This combi­
nation maximizes tissue conservation and reduces the need for
undermining the wound edges. Circular defects lend themselves to

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this procedure and it is effective in areas on the extremities where the
skin is taut.
Once the lesion has been outlined with a skin marker, an ellipse or
fusiform drawing in the typical 3-to-1 pattern further encompasses the
circular mark. The long axis of this marking lies parallel to the maximal
skin tension lines, along the relaxed skin tension lines or skin folds.
The circular defect is excised leaving two triangular sections on either
side of the defect. An intact side of one of the triangles is incised along
its entire length and a back-cut is made along approximately 30–50%
of the remaining side. This produces a flap that hinges upon one
partially intact side. When creating the back-cut on each side, it is
Figure 15.3  Wilson V–Y-plasty. (A) When there is mild contracture of the skin and extensor digitorum longus tendon, the deformity of the fifth toe is
easily corrected manually. (B) A narrow Wilson V–Y-plasty is all that is usually necessary. (C) Final appearance following suture closure with release of
skin and tendon tightness. Note: the amount of correction that has been obtained.
A
B
C
Figure 15.4  V–Y-plasty. Drawing of typical V–Y incision with a wider
base over the fifth joint. The width of the base needs to cover the extent
of the contracted tissues since a narrower base does not allow sufficient
movement of the skin.
Figure 15.5  Standard V–Y-plasty. (A) With greater contracture of the
skin over the fifth toe there is more deformity present. (B) A wider and
longer V–Y-plasty is required to obtain correction of the toe.
A
B
important not to exceed cutting >50% of one side. Back-cuts that
exceed 50% greatly increase the risks of vascular compromise to the
flap and enhance possible flap necrosis. This is even more of a pos­
sibility in skin that is under significant tension. In these cases, more
widespread undermining may be needed.

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Figure 15.6  Standard V–Y-plasty. (A) In cases of previous scar formation
and contracture, the deformity is less flexible. (B) Once again, a wider
and longer V–Y-plasty is needed to reduce the moderate contracture
present.
A
B
Figure 15.7  V–Y-plasty. The V shape has been drawn on the skin over
the center line of contracture (dotted line).
A
B
Figure 15.8  V–Y-plasty. (A) The initial incision starts with the tip of the
surgical blade. (B) The incision is continued with the belly of the surgical
blade. (C) The incision is completed with the tip of the blade.
C

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| 15 |
Figure 15.9  V–Y-plasty. The second incision is completed in a similar
fashion.
Figure 15.10  V–Y-plasty. (A) A skin hook is used to hold the flap as it is
being developed. (B) The flap is totally developed and can now be
repositioned.
A
B
Figure 15.11  V–Y-plasty. The V flap is allowed to advance to its new
position. Additional tendon or capsular lengthening may be performed at
this stage.
Figure 15.12  V–Y-plasty. The bottom of the Y is closed with interrupted
non-absorbable sutures.
Figure 15.13  V–Y-plasty. Drawing of the placement of an apical stitch
(or three-way suture) to secure the flap tip.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
A
B
Figure 15.14  V–Y-plasty. (A) The apical suture (Gillies corner stitch)
is brought through the skin just proximal to the apex and into the
subcutaneous layer of the distal tip of the flap. (B) The suture is then
brought from the underlying tip to the opposite side of the incision, even
with the entry point on the other side. (C) The apical stitch is then tied
to allow the flap to lie in place without strangulation.
C
Figure 15.15  V–Y-plasty. The remaining arms of the Y are now closed
with interrupted sutures.
Figure 15.16  V–Y-plasty. The V-incision has been placed improperly
with the base proximal. Very little motion will occur with this incision
placement, which essentially defeats its purpose.
Figure 15.17  Y–V-plasty. Drawing showing the process that releases
tension at right angles to the Y–V, and the skin tissue gained is
dependent on the angle of the triangle and the distance advanced.

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Once the first flap is made the second triangle is then transformed
into a flap in a similar manner, but the relative positions of the inci­
sions are reversed. The two triangles are then rotated towards each
other and sutured into place. A small amount of undermining may
be performed beyond the flaps in order to close them, but this is
usually not necessary. The small remaining defects are then closed in
the V–Y technique with minimal displacement of adjacent tissues. The
resultant closed incision resembles a US dollar sign ($); hence, the
slang term ‘dollar plasty’ (Fig. 15.20).
Figure 15.18  Multiple Y–V-plasty. Drawing of a series of Y–V incisions
used to release lateral contracture. The continuous line will lengthen as
the conversion from a Y to V occurs.
Figure 15.19  A short Y–V-plasty may be placed on a contracted digit to
obtain release of skin tension and allow lengthening to occur.
Figure 15.20  V–Y–S-plasty or dollar plasty. (A) Preoperative markings for
lesion with classical fusiform excision. (B) Creation of flaps after excision
of lesion. A combination of the V–Y-plasty and rotation flap is performed.
(C) Flaps sutured in place. The medial and lateral tips may be closed with
apical sutures or simple interrupted stitches.
A
B
C
SINGLE V–Y FASCIOCUTANEOUS
ISLAND FLAP
With the fundamental procedures of the basic V–Y incision under­
stood, more complex problems can be addressed. Large defects can
be closed with the utilization of triangular island flaps based on a
subcutaneous pedicle (Fig. 15.21). Island flaps utilize the concept of
tissue advancement and once sutured into place, this flap looks like a
triangular flap (Figs 15.22, 15.23).
The V–Y subcutaneous (fasciocutaneous) island flap is used in areas
where blood supply is plentiful, a full-thickness skin defect is present,
and where the standard V–Y skin plasty is insufficient to close the
defect. If the adjacent circulation is of concern, then one may use a
hand-held 5-MHz Doppler probe to identify the septofasciocutaneous
perforators with the proposed V–Y fasciocutaneous flap. The triangu­
lar flap is made 1.5–2 times as long as the defect in the direction of
the advancement and with the base of the triangle equal to the per­
pendicular diameter of the defect (Fig. 15.24).
Careful undermining is the key to maximizing the movement of
this advancement flap. The distal end of the flap is undermined in the
subcutaneous layer and this should be minimal. The undermining of
the proximal end of the flap is made to the level of the deep fascia,
Figure 15.21  Single V–Y island flap. (A) The lesion has
been excised and the flap is undermined as little as
necessary at the distal end. (B) As the flap is moved
into the defect, the subcutaneous and fascial tissues
are minimally undermined at the pedicle. The
surrounding skin is widely undermined until final
approximation is obtained.
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 15.22  Single V–Y island flap. Schematic of design of V–Y island
flap. The triangular flap is made 1.5–2 times as long as the diameter of
the defect. The pedicle is advanced into the defect, leaving the deep
structures intact. Final appearance of V–Y island flap when advanced and
sutured in place.
Figure 15.23  Single V–Y island flap. (A) Circular
defect created on pig’s foot specimen. (B) Lesion
is excised. (C) V-island flap is created below
defect and advanced into opening. (D) V-island
flap is sutured into place closing the defect.
A
B
C
D

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Figure 15.24  (A) Intraoperative photograph demonstrating the proper level of dissection deep to
the plantar fascia as evidenced by the loosely packed adipose tissue (blue arrow), compared with
the densely adherent adipose tissue superficial to the plantar fascia (green arrow), which maintains
vascular supply and enhances flap mobility. (B) A full-thickness ulcer with extension into bone
shown with the flap incised, and (C) flap advanced to cover the 1.7 cm defect. (D) Flap shown at
72 h and (E) 2 years postoperative. Note the excellent cosmesis and ability to withstand repeated
weight-bearing after using ‘like tissue to replace like tissue’.
(Courtesy of Dr Thomas S. Roukis.)
A
B
C
D
E

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 15.25  Extended V–Y island flap. Two smaller flaps, extending off
from the distal aspect of the V-shaped flap and on either side of the
defect, are created. As the V-shaped flap is advanced, the smaller flaps
are rotated into the defect, which requires less advancement of the main
V-shaped flap. Final appearance at closure.
Figure 15.26  Double V–Y island flap. Drawing of two V-island flaps are
created on either side of the defect. The flaps are advanced toward the
center of the defect. Final appearance at closure. The defect or excision
area may be square, rectangular or circular in nature.
A
B
Figure 15.27  Double V–Y island flap for closure of oval defect. (A) The
V-island flaps are drawn on either side of the defect. (B) The defect is
excised. (C) The flaps are advanced towards each other and sutured
into place.
C
creating an unfolding of the arc of the skin flap. Skin hooks are used
to apply gentle traction as the flap is drawn into the defect. Dissection
of the pedicle is done by cutting the tissue to the fascia and then, with
the utilization of scissors, spreading the subcutaneous tissue initially
to loosen it while preserving blood vessels. In some cases, it may be
advisable to use operating loupes for visualization of the vessels while
the undermining technique is being performed. The flap is initially
held in position with 5–0 absorbable sutures at the level of the sub­
cutaneous layer. The leading edge of the flap is sutured to the far edge
of the defect and at the V–Y junction. The incision is subsequently
closed with simple interrupted non-absorbable sutures or skin staples.
A large plantar skin defect may be closed with this technique if the
local tissues are pliable.
EXTENDED V–Y ISLAND FLAP
A variation of the V–Y island flap, the extended V–Y island flap, can
be used for larger defects and in areas with less tissue mobility (Fig.
15.25). As with the regular V–Y island flap, the long axis of this flap
is also in the direction of the lines of maximum extensibility (LME)
and the length remains 1.5–2 times the diameter of the defect. The
width of the extended V–Y flap is greater than the width of the defect
due to the presence of the extension of the flap on one or both sides
of the defect. If the extension is just on one side of the defect, then
the length of the extension is equivalent to the width of the defect. If,
however, the extension is made on both sides of the defect, then the
length of the extensions is equal to half the width of the defect. As
the flap is advanced, the extensions are hinged down into the distal

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Figure 15.28  Oblique sigmoid island flap. Drawing for a round or oval
lesion. Two small triangles are excised from opposite sides of the defect
creating a short fusiform shape. The sigmoid flap is created in a similar
fashion as other island flaps with the underlying tissues left intact. It is
then transferred into the center of the defect and closed.
aspect of the defect, as two small transpositional flaps meeting together
in the middle.
DOUBLE V–Y ISLAND FLAP
In a situation where the defect is too large to close with a single
advancement V–Y island flap or the lesion is >2 cm, a second subcu­
taneous island flap can be created on the opposite side (Fig. 15.26).
This double flap is designed in the same fashion as the single V-island
flap. Each flap is elevated in the same manner and advanced toward
the center of the defect. The transverse tension on the two flaps is
decreased by undermining and by closing the V-portion of the incision
first. This technique is suitable for closure of large circular or oval
defects as well (Fig. 15.27).
OBLIQUE SIGMOID ISLAND FLAP
This flap is a variation of the V–Y island flap and is suitable for closure
of round, oval or fusiform defects. In round and oval lesions, two
small triangles are excised from opposing sides of the defect with their
apices pointed along the relaxed skin tension lines (RSTL) (Fig.
15.28). The sigmoid shape (meaning, curved in two ways like the
letter S) is designed so that the width of the flap is equal to the diam­
eter of the defect and the length is twice as long as the defect. The flap
is designed so that it is shifted about half the distance to the center
of the defect in the lower right quadrant. Once the flap is developed
it is elevated and advanced with an intact pedicle into the defect and
sutured. This flap is very effective from a cosmetic point of view fol­
lowing excision of small lesions on the lower extremities.
CONCLUSION
The quality and usefulness of the V–Y, Y–V and their variant flaps must
be judged on the final cosmetic and functional results over other com­
monly used repairs. The V–Y and Y–V flaps are best suited in areas
where minimal lengthening or shortening of local tissues are required.
The island pedicle flaps are most useful in areas where good tissue
match of color and texture is needed and in areas where the geometri­
cal shape of the final closure is desirable. When selected and applied
properly, these repairs do not require additional revision or other
procedures to obtain a good end-result and generally exhibit fewer
complications than more technically difficult advancement flaps.
FURTHER READING
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advancement flap for defects of the lateral
nasal supratip. Arch Dermatol 139,
1039–1042.
Argamaso, R.V., 1974. V-Y-S-plasty for closure
of a round defect. Plast Reconstr Surg 53,
99–101.
Bharathi, R.R., Jerome, J.T., Kalson, N.S.,
et al., 2009. V-Y advancement flap
coverage of toe-tip injuries. J Foot Ankle
Surg 48 (3), 368–371.
Chan, S.T.S., 1988. A technique of
undermining of V-Y subcutaneous island
flap to maximize advancement. Br J Plast
Surg 41, 62–63.
Cigna, E., Fioramonti, P., Fino, P., et al, 2011.
Foot Ankle Surg 17 (1), 13–16.
Colen, L.B., Replogle, S.L., Mathes, S.J., 1988.
The V-Y plantar flap for reconstruction
of the forefoot. Plast Reconstr Surg 81,
220–227.
Cooper, M.A., 1990. The multiple Y-V plasty
in linear burn scar contracture release. Br J
Plast Surg 43, 145–149.
Dockery, G.L., 1992. Principles of forefoot
plastic surgery. In: Butterworth, R., Dockery,
G.L. (Eds.), Color Atlas and Text of Forefoot
Surgery. Mosby-Year Book, St Louis,
pp. 7–34.
Dockery, G.L., Christensen, J.C., 1986.
Principles and descriptions of design of
skin flaps for use on the lower extremity.
Clin Podiatr Med Surg 3, 563–577.
Eedy, D.J., Breathnach, S.M., Walker, D.P.,
1996. Surgical dermatology. Blackwell
Science, Oxford, pp. 213–247.
Gumus, N., 2010. Difficulties with running V-Y
plasty in releasing burn scar contracture.
Ulus Trauma Acil Cerrahi Derg 16 (5),
407–412.
Gusman, D., 1995. Wound closure and special
suture techniques. J Am Podiatr Med Assoc
85, 2–10.
Koyama, H., Fujimori, R., 1982. V-W plasty.
Ann Plast Surg 9, 216–220.
Kuwada, G.T., 1995. Plantar incisional
approaches. Current perspectives. J Am
Podiatr Med Assoc 85, 15–21.
Lai, C.S., Lin, S.D., Tsai, C.C., et al., 1995.
Running Y-V plasty for burn scar
contracture. Burns 21, 458–462.
Macpherson, N., Lee, S., 2010. Effect of
different suture techniques on tension
dispersion in cutaneous wounds: A pilot
study. Australas J Dermatol 51 (4),
263–267.
Maruyama, Y., Iwahira, Y., Ebihara, H., 1990.
V-Y advancement flaps in the reconstruction
of skin defects of the posterior heel and
ankle. Plast Reconstr Surg 85, 759–764.
Neelakandan, B., 1996. Double Y-V plasty for
postsurgical anal stricture. Br J Surg 83,
1599.
Nilson, R.Z., Dockery, G.L., 1995. V-Y plasty
and its variants. J Am Podiatr Med Assoc
85, 22–35.
Olbrisch, R.R., 1991. Running Y-V plasty. Ann
Plast Surg 26, 52–56.
Ono, I., Gunji, H., Sato, M., et al., 1993. Use
of the oblique island flap in excision of
small facial tumors. Plast Reconstr Surg 91,
1245–1251.
Paragas, L.K., Attinger, C., Blume, P.A., 2000.
Local flaps. Clin Podiatr Med Surg 17,
267–318.
Parker, J.A., Searles, J.M., 1997. Local flaps for
forefoot and midfoot reconstruction. Op
Tech Plast Reconstr Surg 4, 148–156.
Paton, R.W., 1990. V-Y plasty for correction
of varus fifth toe. J Pediatr Orthop 10,
248–249.

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Peker, F., Celebiler, O., 2003. Y-V advancement
with Z-plasty: an effective combined model
for the release of post-burn flexion
contractures of the fingers. Burns 29,
479–482.
Rader, A., Barry, T., 2008. The cone flap: A
fasciocutaneous flap option for plantar heel
ulcers. Clin Podiatr Med Surg 25 (1),
123–126.
Roukis, T.S., 2000. The Doppler probe
for planning septofasciocutaneous
advancement flaps on the plantar aspect
of the foot: anatomical study and clinical
applications. J Foot Ankle Surg 39 (5),
270–290.
Roukis, T.S., Schweinberger, M.H., Schade, V.L.,
2010. V-Y fasciocutaneous advancement flap
coverage of soft tissue defects of the foot in
the patient at high risk. J Foot Ankle Surg
49 (1), 71–74.
Salon, A., Pouliquen, J.C., 1999.
Reconstruction of the great toe in a child
using the Y-V pedicle elongation technique
for a medial plantar flap. Br J Plast Surg 52,
146–148.
Shaw, D.T., Li, C.S., 1979. Multiple Y-V plasty.
Ann Plast Surg 2 (5), 436–440.
Sheridan, A.T., Humzah, D., 2000. V-Y-S-plasty
closure of circular defects. Austral J
Dermatol 41, 260–261.
Suzuki, S., Matsuda, K., Nishimura, Y., 1996;
Proposal for a new comprehensive
classification of V-Y plasty and its
analogues: the pros and cons of inverted
versus ordinary Bürow’s triangle excision.
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Tan, O., Atik, B., Ergen, D., 2006. A new
method in the treatment of postburn scar
contractures: double opposing V-Y-Z plasty.
Burns 32 (4), 499–503.
Terashi, H., Kurata, S., Hashimoto, T., et al.,
1997. Extended V-Y flap: patient reports
and reconsideration. Ann Plast Surg 38,
147–150.
Whitaker, D.C., 1994. Random-pattern flaps.
In: Wheeland, R.G. (Ed.), Cutaneous
Surgery. WB Saunders, Philadelphia,
pp. 329–352.
Wilson, J.N., 1953. V-Y correction for varus
deformity of the fifth toe. Br J Surg 41,
133–135.
Yaremchuk, M.J., 1989. Flap reconstruction
of the foot. In: Yaremchuk, M.J., Burgess,
A.R., Brumback, R.J., (Eds.), Lower
Extremity Salvage and Reconstruction.
Elsevier, New York, pp. 181–190.
Yildirim, C., Senturk, S., Keklikci, K., et al.,
2011. Correction of syndactyly using a
dorsal separated V-Y advancement flap and
a volar triangular flap in adults. Ann Plast
Surg 67 (4), 357–363.
Zgonis, T., Stapleton, J.J., Roukis, T.S., 2007.
Advanced plastic surgery techniques
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547–568.

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CHAPTER CONTENTS
Single Z skin plasty
163
Planning the Z-plasty
165
Variations of the Z skin plasty
167
Extension of limbs or central arm
167
Asymmetrical Z-plasty flaps
167
Long central-arm Z-plasty flap
167
Curved-arm Z-plasty
167
Lazy-S Z-plasty
167
Planimetric Z-plasty
170
Extended planimetric Z-plasty
170
Oblique continuous planimetric Z-plasty
170
Multiple Z-plasty
171
Double opposing Z-plasty
171
Double opposing semicircular flap
172
Four-flap Z-plasty
173
Double-Z rhomboid flap
173
W skin plasty
174
Geometric broken-line closure (GBLC)
174
Postoperative care
174
Conclusion
175
SINGLE Z SKIN PLASTY
The Z-plasty is one of the more useful techniques for tissue rearrange­
ment and it is commonly used to redirect tension along an area of
taut skin or scar contracture. The basic principle of the Z-plasty lies in
the transference of available tissue to the central axis of the previous
scar or contracture to lengthen it and relieve the tension (Fig. 16.1).
The standard or stereometric Z-skin plasty has one central incision
and two lateral incisions that are generally equal in length to the
central incision. An imaginary line connecting the two lateral limbs
becomes the new central arm upon transference of the triangular flaps
(Fig. 16.2). Transposition of the flaps results in lengthening along the
longitudinal axis and an equal amount of shortening along the trans­
verse axis (Fig. 16.3).
Another way to look at this concept is to consider that the two
triangles together have the shape of a parallelogram with its shorter
diagonal in the line of the contracture and its longer diagonal perpen­
dicular to it. The two diagonals can be referred to as the contractural
diagonal and the transverse diagonal, respectively (Fig. 16.4). It is
important to remember that the common limb, or central arm, of the
Z is placed along the line of contracture. It is under significant tension
and, because of this, the ends of the incision tend to spring apart as
the tissue along the line is released when the flaps are raised. This has
the effect of changing the shape of the parallelogram and causes the
triangular flaps to become transposed, the contractural diagonal to
lengthen and the transverse diagonal to shorten (Fig. 16.5).
The changes in length are such that the length of the contractural
diagonal after transposition equals that of the transverse diagonal
before transposition. The contractural diagonal length has been
achieved at the expense of the transverse diagonal, which has short­
ened as much as the contractural diagonal has lengthened. In other
words, the skin has been brought in from the sides with a tightening
effect, causing shortening of the transverse diagonal, which allows
lengthening of the skin along the contractural diagonal.
The percentage of lengthening achieved with the Z-skin plasty is
based on both the angle of the triangles and the length of the central
arm. Theoretical increase in length is achieved with the increase in the
angle of the triangles. The theoretical increases are as follows: a 25%
increase in length with 30°; a 50% increase in length with 45°; a 75%
increase in length with 60° and, finally, a 100% increase in length
with 75° (Fig. 16.6).
The actual length achieved is somewhat less because of individual
skin properties, such as extensibility and elasticity. The most com­
monly used angle of the lateral limbs is 60°. A 75° angle results in
too great a lateral tension on the rotated flaps and can result in failure.
Also, marked tissue distortion is noted at this angle. Additionally, a
30° angle gives too small an increase in length and not enough release
of tension, yielding no significant benefit to altering the scar or achiev­
ing length. It also has been shown that the lengthening achieved is
based upon the length of the central arm. A short central arm with a
©2012 Elsevier Ltd.
Z and W skin plasty
G. Dock Dockery
Chapter
16

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 16.1  The standard or stereometric Z-plasty. A schematic representation of the several stages of the Z-plasty from design to final closure.
Figure 16.2  A standard Z-plasty with 60° angles and limbs of equal
length. An imaginary line connecting the two lateral limbs becomes the
new central arm on transposition of the triangular flaps.
Figure 16.3  Transposition of flaps results in lengthening along the
longitudinal axis and an equal amount of shortening along the transverse
axis. An overall increase in length is achieved when the two flaps are
transposed.
Figure 16.4  The diagonals of the Z-plasty, showing how the contractural
diagonal lengthens and the transverse diagonal shortens, respectively.
Transverse
Diagonal
Contractural
Diagonal
Transverse
Diagonal
Contractural
Diagonal
Figure 16.5  Stages of the Z-plasty. (A) The central arm is placed along
the line of contracture. (B) The flaps are released allowing them to spring
apart. (C) The contracture is released and the parallelogram shape
changes. (D) The flaps are transposed easily due to the change in shape
of the parallelogram.
A
B
C
D
Figure 16.6  The percentage increase of length, which results from the
use of different angle sizes. With an angle of 30°, there is a theoretical
increase of 25% in length, with 45° a 50% increase, while an angle of
60° allows an increase of 75%.
Angle size
Increase in length
30o
25%
45o
50%
60o
75%

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scar. Because thickened scars show notable improvement just by repo­
sitioning the scar to the RSTLs, the present scar is usually not excised.
Excision of the existing scar can lead to less lengthening with more
tension on closure, leading to further poor scar formation.
In planning the construction of the lateral arms, it may be difficult
to decide where they should be placed. One method to help deter­
mine the placement is to draw an equilateral triangle on each side of
the contracture and from the resulting parallelogram to select the
more suitable of the two sets of limbs. One set may have no particular
advantage over the other, in which case either may be used. Considera­
tion should be given to the placement of the lateral limbs as close to
the RSTLs as possible and avoidance of any vital anatomical structures.
The final consideration of the placement of the lateral limbs is to
assure adequate incoming blood supply to the base of the rotated
flaps.
Subsequently, using an accurate measuring device, the planned
lateral limbs are drawn (Fig. 16.9). The first consideration is the
amount of lateral movement available in the surrounding skin. If
extremely taut, it is better to choose a slightly lower angle, such as 45°
and a longer central arm to gain length without resulting in too much
tension. However, the optimal angle allowing the greatest increase in
length and release of tension is 60° and the length of the lateral limbs
should also be equal in length to the central arm.
After the Z skin plasty is accurately drawn out on the skin, the flaps
may be incised. Several important rules need to be adhered to at this
time to prevent loss of the Z-plasty flaps as the result of hematoma,
inadequate release of tension, seroma, or poor cosmetic results with
depressed or elevated scar formation. The procedure itself is normally
performed without the use of a tourniquet or local injections of epine­
phrine, so that adequate hemostasis can be achieved at the time the
flaps are created. Vessels that cannot be saved are either cauterized or
ligated as needed to obtain hemostasis.
Generally, the depth of the flaps should be full-thickness, including
some or all of the subcutaneous fat. In highly lipomatous areas, only
some of the subcutaneous fat may be included in the flaps, but the
amount must be consistent throughout the flap to provide the same
thickness of flap in all areas. Otherwise, the Z-plasty may have areas
of depression or elevation resulting in a less than acceptable cosmetic
appearance. One of the most crucial aspects of performing the Z-plasty
correctly is the amount and location of the undermining of the flaps.
The lateral motion and the transposition of the two flaps are achieved
by undermining all areas around the skin contracture or previous
scar, although very minimally at the actual bases of the triangular
60° lateral limb angle will have less increase in length than a longer
central arm with the same angle.
The success of the Z skin plasty is based on more than just the length
and angles of the central arm and lateral arms. The orientation of the
lateral limbs has much to do with the tension that will now be placed
on the newly formed scar. The newly transposed lateral limbs will lie
parallel to the old ones and be oriented on opposite sides of the new
central arm (Fig. 16.7). Therefore, it is crucial to align the original
lateral arms as close as possible to the relaxed skin tension lines
(RSTLs).
PLANNING THE Z-PLASTY
The planning of the Z-plasty is regarded as one of the most important
aspects of the procedure. A decision must be made on the size, site
and directions of the individual flaps to be created. The Z-plasty
should be accurately and meticulously marked out on the skin with
a sterile skin scribe or marking pen prior to the actual incision. This
should be regarded as a formal procedure and the design drawing
should be done each time a Z-plasty is performed.
Initially, the line of contracture of the skin or the present scar is
identified. The central arm is drawn in the same direction as the con­
tracture or the existing scar (Fig. 16.8). Usually, the existing scar is
merely incised with the central arm. This is dependent on both the
anticipated tension on the new scar and the appearance of the original
Figure 16.7  The newly transposed lateral limbs of the Z-plasty will lie
parallel to the old ones and be oriented on opposite sides of the new
central arm. This helps to orient scar tissue in a new plane. Alignment of
the original lateral limbs close to the relaxed skin tension lines is
important.
Figure 16.8  The central arm of the Z-plasty is placed in the same
direction as the contracture or in the existing scar line.
Figure 16.9  Using an accurate measuring device, the lateral limbs of the
Z-plasty are drawn. In this case, an instrument is used with a 60° angle
to draw the arms of Z.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
flaps (Fig. 16.10). This will allow adequate gain of lateral motion
without compromising the blood supply to the pedicle of the flaps.
As soon as the triangular flaps are transposed, the color of the flaps
should be examined. If the flaps are pale, there may still be too great
a tension on the rotated flaps and further undermining may be neces­
sary around the perimeter. The transposed flaps should lie easily in
their new position without much traction on the apices. The flaps
should be held gently in place with the use of subcutaneously placed
skin hooks or sutures, instead of forceps, at the flap apex to prevent
any crushing of the most fragile portion of the tip of the flaps
(Fig. 16.11).
Now that the flaps are in position, the Z-plasty is sutured in the
following order. The first simple suture is placed at the midpoint of
the new central arm, called the crucial stitch, which is important in
reducing the tension on the remaining closure. Next, sutures are
placed at the midpoint of the side arms followed by the base of the
flaps to hold the position and relieve some of the tension being
applied to the apex by the skin hooks (Fig. 16.12). Now the single
apex closure can be performed with either an apical stitch (a partially
buried horizontal mattress) or a single corner stitch (a simple inter­
rupted suture) (Fig. 16.13). The author prefers the horizontal suture
technique for small or delicate flap tips and the single interrupted
suture technique for wider and healthier flap tips. The most vital
aspect of the apical suture technique is the equidistance of the suture
on either side of the apex. It is also important to remember that the
more often the needle has to be passed through the skin at the apex,
the more chance of necrosis of the flap tip. The risks of tip necrosis
can also be decreased by securing the limbs in their new position with
skin tapes or Steri-Strips rather than suture.
After the apical (or single apex) stitches or skin tapes are in place,
the remaining stitches are then inserted along the flap edges, going
from the outer skin into the flaps to decrease the pressure applied to
the flap as much as possible. Simple interrupted suturing technique
with 5–0 or 6–0 non-absorbable suture is usually used for closure.
Once the transposed flaps are in place and the suturing completed, a
sterile dressing is applied with a non-adherent dressing and either fluff
4 × 4 gauze sponges or 14-inch sterile felt or thick roller gauze. The
gauze or felt is used to add mild-to-moderate compression and to help
prevent seroma or hematoma formation under the transferred flaps.
Figure 16.10  Accurate undermining of the flaps of the Z-plasty is
essential. Transposition of the flaps is accomplished by undermining all
areas in the region of the skin contracture or previous scar. The shaded
areas of the bases of the flaps should have minimal or no undermining
to avoid compromise of the blood supply.
Figure 16.11  Slight tension should be all that is required to rearrange
the transposed flaps. (A) The Z-plasty has been undermined completely.
(B) The flap may be handled with a subcutaneous skin hook.
(C) Additionally, the flap may be transposed using a subcutaneous
suture, rather than forceps, to prevent crushing of the tip.
A
B
C

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VARIATIONS OF THE Z SKIN PLASTY
Several variations on the standard Z-plasty technique can be advanta­
geously employed in select circumstances to provide better results in
scar revision. As described earlier, the standard Z-plasty has a central
arm, equal lateral limbs and two equal-angled flaps. There are occa­
sions when it may be necessary to deviate from the standard Z-plasty
by varying one or more of the design features.
Extension of limbs or central arm
One simple variation of the Z-plasty is that one or more of the arms
can be extended to allow surgery to an adjacent area. For example, in
a patient with excessive skin contracture over the fifth metatar­
sophalangeal joint with an overlapping fifth toe and secondary painful
heloma durum, the surgical procedure could include a Z-plasty
skin flap with an extended limb to reduce the skin contracture and
provide good surgical exposure to allow for additional procedures
such as tenotomy, capsulotomy and an arthroplasty of the fifth digit
(Fig. 16.14).
Asymmetrical Z-plasty flaps
Occasionally, in a restricted area with minimal space available to
perform the skin plasty, an asymmetrical design may be employed. In
this case, a Z-plasty is performed with unequal angular flaps (Fig.
16.15). Lengthening is comparable with an average of two symmetric
flap angles of similar sizes. In other words, the lengthening is calcu­
lated as an average of the two angles of the flap.
Long central-arm Z-plasty flap
Another modification that is commonly used deals with the length of
the lateral limbs and the central arm. Although normally equal in
length, there are occasions when the central arm may be longer. Since
the central arm is made within the existing scar or line of tension,
contracture within this area is more than within the site of the lateral
limbs. To compensate for this inequality in contracture, the central
arm is occasionally made up to 22% longer than the lateral limbs
(Fig. 16.16).
Curved-arm Z-plasty
An additional deviation in design technique uses curved arms that
provide slightly broader flaps when transposed. When adjacent skin
has decreased vascularity caused by scarring, there is always a risk that
the flaps will not survive the transfer. To decrease this possibility, the
width of the flaps near their tips can be enhanced by curving
the limbs of the Z-plasty incision (Fig. 16.17). By curving the arms of
the Z flaps, the surgeon can include extra tissue in the flap base and
this may augment flap vascularity (Fig. 16.18). The flaps should be
fully elevated, probably slightly beyond their bases, allowing for ease
of rotation. If planning has been accurate, little or no trimming will
be required and the completed transfer will appear very similar to a
standard Z-plasty procedure.
Lazy-S Z-plasty
A modification of the standard single Z-plasty was designed by
Nagasao et al. (2007), to create three curvilinear lines (lazy-S inci­
sions), instead of the traditional straight lines of the Z-plasty (Fig.
16.19). The lazy-S Z-plasty is also referred to as the ‘Beak’ plasty. In
Figure 16.12  The crucial stitch is the first suture, which is placed at the
midsection of the new central arm. Other sutures are placed at the base
of the flaps and center of side arms to hold the position and relieve
tension at the apex.
Figure 16.13  (A) The corner stitch may be either a partially buried
horizontal mattress suture (apical stitch) or a single corner stitch (simple
interrupted suture). (B) Closure with crucial stitch, midsection sutures in
each arm and apical stitches in place.
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 16.14  (A) The Z-plasty is drawn with the central arm aligned with the contracture of the skin and tendon. (B) In the contracted and displaced
position, it is difficult to see where to place the central arm. (C) Once the Z-flap, capsulotomy and tenotomy are completed, the central incision can be
extended onto the fifth toe for the arthroplasty procedure. Transposition of the flaps then follows. (D) Final closure of flaps and incision on fifth toe
with excellent correction.
A
B
C
D
Figure 16.15  (A) Asymmetrical Z-plasty with unequal angular flaps (75° and 60° angles). This is important in areas of limited space or when
placement helps with surgical exposure of underlying structures. (B) Final closure gives good visual appearance.
A
B

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A
B
Figure 16.16  Long central arm Z-plasty. (A) In heavily scarred areas or
severe skin contraction, it may be necessary to make the central arm
incision longer than the lateral limbs. The central arm incision may be up
to 22% longer than the adjacent lateral incisions. (B) Long central arm
incision over fifth metatarsophalangeal joint. (C) Final closure with good
position and skin lengthening.
C
Figure 16.17  Curved-arm Z-plasty. Comparison of the standard flap with
the modified shape of the Z-plasty flap to give maximum vascular
capacity. This flap is broader at the tip and the flaps are cut as thick as
possible.
Figure 16.18  Curved-arm Z-plasty. (A) Using slightly curved arms
provides a broader flap. (B) Once transferred the completed Z-plasty
appears similar to a standard flap.
A
B
Figure 16.19  Lazy-S Z-plasty. Each arm of the flap forms a lazy S shape.
Top row shows the conventional Z-plasty design, appearance after
transfer and potential postoperative change of the scar. The lateral arms
form a steep angle against the relaxed skin tension line and may become
hypertrophic over time. Lower row shows the Lazy-S Z-plasty design with
its appearance after transfer and potentially less hypertrophic scarring
after final healing.
(Redrawn from Nagasao, et al. 2007.)
A
A
B
B
A
B
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
lateral arm (Fig. 16.22). This design is estimated to have 28% greater
efficacy and its other benefits include plane adjustment to the body
surface, removal of scarred skin and shorter scars. The planimetric
Z-plasty would best be suited for larger flat surfaces, such as over the
dorsum of the foot or on the posterior calf area, where surface irregu­
larities would be obvious after standard Z-plasty. The disadvantage of
this variation may be an increase in tension perpendicular to the long
axis of the scar.
Extended planimetric Z-plasty
When the scar to be removed is wider or longer and the skin tension
in the transverse direction is less, more tissue can be excised by length­
ening the central arm of the planimetric Z-plasty (Fig. 16.23). The
width of the excision is determined by checking that both parallel
sides can easily be pulled together by the tissue forceps. It is reason­
able to prepare the triangular flaps with slightly sharper angles than
the estimation and to trim the excess tissue after transferring the flaps.
Oblique continuous planimetric Z-plasty
In cases where the scar is even wider and long, a modification of the
extended variation, called the oblique continuous planimetric Z-plasty,
can be applied to excise even more tissue (Fig. 16.24). Several plani­
metric Z-plasties can be linked obliquely and their implementation
Figure 16.20  Lazy-S Z-plasty. Demonstration (pig foot) of the technique
with end result of transfer, without full closure. (A) Each of the straight-
line arms in a conventional Z-plasty is modified to a lazy-S curved line.
(B) The flaps are transposed as in standard Z-plasty.
A
B
the conventional Z-plasty, a pair of equilateral triangular flaps is
created and the lateral arms form a 60° angle against the RSTL at the
completion of the procedure. These lateral arms form a steep angle
against the RSTL and may become hypertrophic over time. To prevent
this from occurring, the incisions may be created in the shape of a
lazy S rather than the conventional straight incision. The shape of each
lazy-S curve must be identical for all arms produced in one Z-plasty.
Once the design is complete, the two flaps are raised, rotated and
sutured into place. Since the curved scar tends to become less
hypertrophic than a straight scar, this modification should reduce the
potential for hypertrophic scarring of the lateral arms of the Z-plasty
(Fig. 16.20).
Planimetric Z-plasty
This variation helps to reduce cones and depressions produced by the
standard Z-plasty. The planimetric design makes use of a greatly short­
ened central arm to lateral arm ratio and removal of triangles of skin
before transposition of the flaps (Fig. 16.21). The planimetric design
is distinguished by a vertical angle of 75°. The longer lateral arm is
twice as long as the shorter lateral arm and four times as long as the
shorter central arm. The longer central arm is as long as the longer
Figure 16.21  The planimetric Z-plasty. This variation uses a greatly
shortened central arm to lateral arm ratio and removal of triangles of
skin before transposition of the flaps.
Figure 16.22  Planimetric ratio design. The longer lateral arm (a) is twice
as long as the shorter lateral arm (b) and four times as long as the
shorter central arm (c). The longer central arm (d) is as long as the longer
lateral arm (a). The vertical angle between the shorter lateral arm and the
shorter central arm is 75°.
a
b
c
d

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of scarring in a particular pattern or design may influence the recon­
struction and make skew flaps preferable (Fig. 16.27), but the use of
parallel arms allows the flaps to rotate uniformly in transposition.
This also prevents the occurrence of a broad-tipped flap with its
narrow base, common with the skew pattern, which is undesirable
from a vascular point of view. The irregular pattern of the continu­
ous skew construction inevitably results in this broad-tipped flap
(Fig. 16.28).
Double opposing Z-plasty
In this variation, two Z-plasties are joined at the ends of the central
arms, with the side arms mirror images of each other; unlike the
continuous multiple Z-plasties with parallel lateral arms (Fig. 16.29).
This is sometimes referred to as the five-flap Z-plasty due to the
appearance of the final closure. This technique is very similar to the
continuous skew multiple Z-plasty described in Figure 16.28. A
reduction in closure tension can be achieved by decreasing the medial
arm angle. However, this will also narrow the medial flap pedicles.
produces planimetric elongation of an oblique contracture in the
longitudinal direction.
The implementation of traditional Z-plasties produces stereometric
elongation. They are very effective when carried out on web spaces or
across contracted joints. In contrast, when they are carried out on a
large flat surface, they produce a bulging effect and are, therefore, less
effective than planimetric Z-plasties in preventing this bulging. Even
though this bulging effect is partially decreased by tension forces, skin
elasticity and the changes in skin tension following the release of skin
contractures, the bulging effect appears particularly prominent in
inelastic skin. With the planimetric Z-plasty techniques the elongation
of scar contracture is less, but the planimetric efficacy is greater than
with the stereometric Z-plasty. This effect is important in large hyper­
trophic scar formation, especially those with mild contracture.
Multiple Z-plasty
When a single large stereometric or planimetric Z-plasty cannot be
employed for any reason, the alternative may be to use a multiple
Z-plasty. The line of the contracture is then regarded as a series of
contracted segments and on each, a small Z is constructed creating a
line of separate Zs, ranging from two to many more (Fig. 16.25). In
most cases, it is probably better to perform this technique by produc­
ing a continuous multiple Z-plasty, where the Zs, instead of being
individual, form a continuous series. This gives the appearance of a
single long line of multiple Z lateral arms along the line of contracture
(Fig. 16.26). Another variation is a continuous Z pattern without
concern for the central arm within the contracture line. The presence
Figure 16.23  Extended planimetric Z-plasty. When the scar is wider or
longer and the tension in transverse plane is less, more tissue can be
excised by extending the central arm of the planimetric Z-plasty.
Figure 16.24  Oblique continuous planimetric Z-plasty. Several planimetric
Z-plasties can be connected obliquely.
Figure 16. 25  Parallel multiple Z-plasty. Several small Z-plasties can be
made along the line of contracture instead of a large single Z-plasty.
Figure 16.26  Continuous parallel multiple Z-plasty. Instead of being
individual, the Zs are connected along the line of contracture.

172
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Use of the continuous Z-plasty should be considered before choosing
the double opposing Z-plasty for web scar revision.
Double opposing semicircular flap
In this modification of the double opposing Z-plasty used to close a
circular defect, two semicircular flaps are prepared from opposite sides
of a circular defect that will allow closure without additional healthy
tissue excised from the defect itself or the raised flaps (Fig. 16.30).
There are two possible sites for the preparation of the double oppos­
ing semicircular flaps to place them parallel to the relaxed skin tension
lines, but the choice that would be preferred is the one that will not
interfere with or distort the adjacent anatomical landmarks. This tech­
nique provides successful closure of circular defects and is best used
with defects ranging from 2 to 5 cm in diameter (Fig. 16.31). The
benefits of this procedure are that it does not require excision of
normal adjacent skin to convert a circular defect into a rhomboid,
square or ellipse shape or excise dog-ears or make Bürow’s triangles.
This flap design fits accurately into the concavity of a circular defect
and the length of the final suture line is not greater than three times
the diameter of the original circular defect. The flaps transposed, as in
a Z-plasty, result in a zig-zag or W-shaped scar that may minimize later
scar contracture. Three of the five arms of the final suture lines are
parallel to relaxed skin tension lines, making the closure easy and
resulting in a healed scar that is easily hidden in the natural skin
creases. There is no tendency for the development of a trap-door
deformity that is produced by the contracting forces in semicircular
scars because the resultant scar is not semicircular in design.
Figure 16.27  Interrupted skew multiple Z-plasty.
Figure 16.28  Continuous skew multiple Z-plasty. Arrows show the
broad-tipped flaps that result.
Figure 16.29  Double opposing Z-plasty. (A) Two Z-plasties are joined at
the ends of the central arms, which are parallel to the relaxed skin
tension lines. (B) The flaps are incised and undermined. (C) The flaps are
transposed in a similar fashion as a regular Z-plasty.
A
B
C
Figure 16.30  Design of the double opposing semicircular flap procedure.
(A,B) show the initial design of the flap; (C,D) show the final design of
the flap. The ‘A–t’ distance is not incised; (E,F) show final suture lines of
the flap. Three of five segments of the suture lines are parallel to the
related skin tension lines and to each other.
(Redrawn from Keser et al. 1998.)
A
Line 1
A
B
h
t
AB=AC
RSTL
Line 2
Line 2’
B
C
Line 2’
C
A
B’
A’
B
D
t
t’
CD=Bt
C
C’
D’
D
A
x
x’
B
B’ A’
E
A
x
x’
B
B’
A’
F

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Four-flap Z-plasty
The four-, five- and six-flap Z-plasty variations are primarily used for
revision of web scars, especially those found on the foot web spaces.
The design is based on 90°–90° angles, which are then bisected result­
ing in four 45° angle flaps (Fig. 16.32). These flaps are subsequently
transposed so that they lie in alternating fashion, in between each
other and then sewn into place. The main advantage of this flap is
greater lengthening than is possible with the standard 60° Z-plasty.
The use of this four-flap variation also reduces tension compared with
the standard Z-plasty.
Double-Z rhomboid flap
The design of the double-Z rhomboid flap incorporates two 60°
Z-plasties generated on opposite sides of a standard 60°/120° equi­
lateral parallelogram rhomboid defect (Fig. 16.33). The amount of
tissue required to close the defect is provided by borrowing equal
amounts from each of the opposite sides of the defect. Closure of the
original rhombic defect is affected by elevation and transposition of
the four Z-plasty flaps, which are transposed in a similar fashion as
a standard Z-plasty, resulting in an incision shaped like two Zs
Figure 16.31  Double opposing semicircular flap. The two pairs of flaps
are elevated with sufficient undermining and then transposed.
A
B
Figure 16.32  Four-flap Z-plasty. (A) A 90° Z-plasty is designed first and
then bisected at the dotted lines, which results in four 45° angled flaps.
(B) The incision is deepened and the flaps are elevated. (C) The final
closure.
1
1
1
2
2
2
3
3
3
4
4
4
A
B
C
Figure 16.34  Alternate method for double-Z rhomboid flap. Once a
rhombic defect has been created by excising the lesion, there are two
potential methods of creating the double-Z rhomboid flap, which will
allow closure with minimum tension. The dotted line represents the
relaxed skin tension line (RSTL). The final line of closure must have three
of the five segments of the double Z-plasty parallel with the RSTL.
(Compare with Fig. 16.33.)
Figure 16.33  The double-Z rhomboid flap. This technique incorporates
two 60° Z-plasties on opposite sides of an equilateral parallelogram
rhomboid defect. The dotted line represents the relaxed skin tension
lines. (Compare with Fig. 16.30.)
end-to-end. However, once the defect has been excised with adequate
margins to form a rhombic shape, there are two potential sets of
double-Z rhomboid flaps that may be utilized (Fig. 16.34). The
double-Z rhomboid flap is more reliable, more easily executed and
cosmetically superior to other rhomboid flaps. The double-Z rhom­
boid flap is superior in situations in which the defect is in proximity
to moveable anatomic landmarks or over small joints, making this
procedure quite useful on the toes, fifth metatarsal head region, as
well as on a variety of scar conditions, plantar forefoot lesions and
rearfoot conditions.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
GEOMETRIC BROKEN-LINE CLOSURE (GBLC)
This is a modification of the W-plasty. The GBLC is a scar-excision
technique that involves disruption of the linearity of a scar. The tech­
nique is a series of random, irregular, geometric shapes cut from one
side of a wound or linear scar and interdigitated with the mirror image
of this pattern on the opposite side (Fig. 16.38). All shapes should be
between 3–7 mm in any dimension for improved camouflage. Designs
<3 mm tend to be too small to close and those >7 mm tend to be too
visible individually to produce a camouflage result. The GBLC is well-
suited for long, unbroken scars that cross resting skin tension lines.
Since the eye is naturally drawn to straight lines, the irregularly irregu­
lar pattern camouflages the new scar to an observer (Fig. 16.39).
Subcuticular sutures help to prevent suture track scars. This technique
does not affect the overall length of a scar like the Z-plasty. As with
the W-plasty, wide undermining is essential for a tension-free closure.
POSTOPERATIVE CARE
Postoperatively, for all of these procedures, the patient is encouraged
to keep the extremity elevated as much as possible during the first
week. The patient is also discouraged from moving the surgical site or
W SKIN PLASTY
The geometric basis for the standard W-plasty is a bilateral advance­
ment flap with angulated leading edges. Similar to the Z-plasty and
its variants, the W-plasty can also be used to break up a scar and
disperse the tension across contracture lines. When used in scar revi­
sion, the scar tissue is excised with multiple juxtaposed triangles,
which then results in a zigzag pattern of closure. Generally, the closed
incision appears to be two adjoining Ws (Fig. 16.35).
The accurate creation of the W-plasty requires an exact determina­
tion of the corresponding limbs, angles of the cuts, number of units
and subunits and orientation of the design. In most cases, the orienta­
tion and length of the W-plasty is determined by the original scar
tissue that it encompasses. Lateral tissue advancement provides
modest lengthening of the original scar line through a Y–V movement
and produces a leveling effect that is very helpful in depressed scars.
In the standard W-plasty, the angles are designed to create a series of
60° cuts into both sides of the incision, so that they will accurately
match and fit together in a tongue-in-groove manner. Whenever pos­
sible, the bisection of the tip angles should be at right angles to the
long axis of the scar. Undermining of the skin edges is completed
slightly beyond the base of the flaps as needed to reduce constriction
and allow closure with the least amount of tension.
Suture closure may be similar to that employed for the V–Y incision
or the running Z-plasty. If there is tension on the incision site, a simple
way of closing the W-plasty is with a continuous subcuticular absorb­
able suture placed halfway between the apex and the base of each
individual triangle. Final closure is then made with multiple simple
interrupted sutures. For rapidity and ease, a continuous running
suture technique can be performed sequentially with closure of all tips
on one side of the incision to its corresponding notch on the opposite
side. However, this technique does not allow staged removal of the
sutures, as is possible with multiple simple interrupted sutures.
A large or very long running W-plasty may result in the formation
of dog-ear deformities at the ends of the incision, which may be
excised with a simple fusiform procedure at the pole. Another option,
as in this case, is a modification of the W-plasty ends in which the
size of the triangles are decreased at both ends of the W-plasty (Fig.
16.36). This will not only reduce the formation of dog-ear deformities,
but will allow the incision to blend better with the RSTLs.
Alternatively, other methods may be used at the ends of the running
W-plasty to avoid dog-ears or obtain greater extension of the closure.
The two main choices would be the M-plasty (see Ch. 12) or the
Z-plasty (Fig. 16.37). The M-plasty makes use of the inner peak created
within the excision after the two triangles are excised, which facilitates
a Y–V advancement of the central tissue. On the other hand, the
Z-plasty is used in areas where greater lengthening is needed.
Figure 16.35  W-plasty. Two zigzag designs are made on either side of
the scar to be excised full-length. The corresponding tips are then closed
into the center of the base of an opposite triangle as they are advanced
toward each other. The closed incision appears to be two adjoining Ws.
Figure 16.36  Prevention of dog-ear deformity. At the ends of the
running W-plasty the size of the triangles should be reduced to prevent
dog-ear deformity.
Figure 16.37  Either an M-plasty or a Z-plasty may be performed at the
end of the running W-plasty to avoid dog-ears or obtain greater
extension of the closure, respectively.

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Figure 16.38  Geometric broken-line closure (GBLC). This is a scar-
excision technique that involves disruption of the linearity of a scar.
RSTL, relaxed skin tension line.
RSTL
Geometric broken-line closure
Incision
Scar removed
Closure
Figure 16.39  Geometric broken-line closure. (A) Multiple irregular,
geometric shapes are cut from one side and the mirror image is designed
on the opposite side, creating an irregularly irregular pattern to help
camouflage a linear scar. (B) Final appearing of GBLC.
A
B
from removing the overlying dressings until further instructed by the
surgeon to do so. On the first dressing change at 5–7 days, the inci­
sions are examined and the viability of the flaps is assessed. This is
followed by the reapplication of a sterile dressing and mild compres­
sion dressings.
Figure 16.40  Postoperatively, the flap tips may appear dark or covered
with eschar. It is important that the tip not be disturbed at this time and
the doctor and patient are discouraged from removing the dried blood
or eschar.
At 10–14 days postoperatively, the dressings are removed in a sterile
manner again and if there are no signs of hematoma or wound dehis­
cence, the sutures may be removed from non-weight-bearing sites. For
areas over joints or plantar weight-bearing regions, every other stitch,
other than the apical stitches, are removed from the flaps at this visit.
At 18–21 days, all sutures are removed from the flaps. On occasion,
the apices of the flaps may appear dark or necrotic and covered with
a dark eschar (Fig. 16.40). It is imperative that during the early stages
of the revascularization of the flaps, these areas are not disturbed. The
patient, nurse and doctor are all discouraged from trying to remove
the dark eschar. The apices will usually survive and revascularize, if
left intact.
CONCLUSION
The most common complication of the Z- and W-plasty is necrosis of
the tip of the flaps and it can be extensive if there has been much
previous scarring of the skin. Precautions to avoid necrosis can be
taken at all steps of the procedure. It is important to provide the flaps
with the maximum vascular capacity, avoid tension on the flaps,
prevent injury to the tips from instrumentation and perform meticu­
lous hemostasis throughout the procedure. Even though hemostasis
is consequently imperative, the use of epinephrine is to be strictly
avoided in the area of skin flaps. Much of this precautionary effort
may be achieved by designing the flaps broad at the tip (rather than
very narrow), by avoiding scarring across the base of the flaps by using
minimal undermining and by cutting the flaps as thick as possible.
When the surgical site has been selected properly and the procedure
designed and performed as outlined the tension on the transposed
flaps will be minimal.
The Z-plasty, along with its variants and W-plasty are the most com­
monly used techniques in contracture and scar revisions and for pre­
vention of skin contracture. This is because of their ability to redirect
the skin more parallel to the RSTLs and to relieve tension along con­
tracted tissue. In scar revisions, the resulting scar, although larger than
the original scar, is usually less pigmented, less hypertrophied and less
elevated. Lengthening the skin also releases the surrounding con­
tracted structures, making for a more functional result. In many cases,
these skin plasty procedures are usually more pleasing to the patient
and the surgeon than conventional straight incisional approaches for
the same condition.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
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Shockley, W.W., 2011. Scar revision techniques:
z-plasty, w-plasty, and geometric broken
line closure. Facial Plast Surg Clin North
Am 19 (3), 455–463.
Stanec, Z., Delimar, D., Stanec, S., 1999.
Tensioning and securing of W-plasty. Eur J
Plast Surg 22 (5), 286–288.
Suzuki, S., Um, S.C., Kim, B.M., et al., 1998.
Versatility of modified planimetric
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363–369.
Swanson, N.A., Tromovitch, T.A., Stegman, S.J.,
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CHAPTER CONTENTS
Advancement flaps
177
Types of advancement flaps
177
Single advancement flap
177
Pantographic expansion flap
179
Double advancement flap
179
Rotational flaps
180
Classic rotation flap
181
Satterfield–Jolly rotation flap
181
Catanzariti–Wehman rotation flap
181
Single-lobed rotation flap
183
Double-lobed rotation flap
183
Conclusion
189
A graft is a piece of detached skin which is dead when
you put it on and may come to life later. A flap is a
partly attached piece of skin which is alive when you
put it on and may die later.
Sir Harold Gillies 1920 (Plastic Surgery of the Face: based on selected
cases of war injuries of the face including burns.)
ADVANCEMENT FLAPS
The benefit of the advancement flap is that the general final appear­
ance is frequently better than that associated with a free graft, as there
is usually a superior skin match to the neighboring tissue. The draw­
back is that if an advancement flap is not properly designed, then
ischemia, hematoma formation or infection may give rise to flap
failure. Flap failure is more common in patients who smoke, have
diabetes mellitus, are on anticoagulation therapy or have autoimmune
deficiencies (see Ch. 30).
Advancement flaps are among the most common flaps used to
eliminate simple lesions. The movement of this flap is directly forward,
with sliding, stretching and pushing of the tissue, and ultimately
covering of the defect without any lateral or rotational movement
noted. The flap tissue stretches over the defect and the incision is
closed by unequal side closure. Undermining is necessary and is
carried out at the level of the subcutaneous fat, known as the subder­
mal plane. However, care must be taken to avoid extensive undermin­
ing, which may lead to flap failure. On the whole, advancement flaps
are predictable when planned correctly. Even so, these flaps have only
moderate coverage potential and, therefore, have limited utility. In
most cases, the surgeon can manipulate the adjacent tissue preopera­
tively and determine the ability of the tissue to move sufficiently in
this manner. Very rarely do such flaps give more movement than is
apparent during the preoperative assessment of the skin.
Types of advancement flaps
There are numerous flaps that are technically listed as advancement
flaps. They include the single advancement flap, pantographic expan­
sion flap, double advancement flaps, some of the excisional tech­
niques (see crescentic ellipse and T-plasties, Ch. 12), and the V–Y and
V–Y advancement island flaps (see Ch. 15). The single and double
advancement flaps utilize movement that is the same on its inferior
and superior dimensions. The tissue immediately adjacent to the flap
moves very little (secondary motion) when compared with the flap
itself (primary motion).
Single advancement flap
The single advancement flap is the easiest flap to envision (Fig. 17.1).
The lesion is excised leaving a circular, oval or rectangular defect. Two
incisions are made, extending away from the defect, creating a flap
with its distal edge adjacent to the defect. The width of the flap should
be adequate to allow for random blood supply and the length should
be sufficient to provide mobility for the flap to advance. The flap is
then undermined within the subcutaneous level and advanced into
the defect, while minimizing tension. The motion of this flap is
directly forward, covering the defect without any lateral or rotational
movement. The primary movement is so predominant that it may not
be evident that the secondary movement may be equal to, or at times
©2012 Elsevier Ltd.
Advancement and rotational flaps
G. Dock Dockery
Chapter
17

178
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
greater than, the primary movement. When the forward advancement
flap produces dog-ears or puckers at the proximal base of the flap,
they may be excised. These corner excisions are termed Bürow’s trian­
gles (or wedges) and they are cut out large enough to remove any
excess tissue (Fig. 17.2). They also aid directly in relieving some of the
tension on the flap itself. In inelastic tissue, the wedge excisions may
have to be large; however, in supple skin, they may be small or, in
most cases, unnecessary. This advancement flap is useful when existing
skin lines run parallel to the incisions of the flap. Sutures are placed
obliquely along the edge of the flap to offset some of the tension
towards the tip, with the corners also secured by simple sutures to
reduce tension at the tip.
A
B
Figure 17.1  Basic single advancement flap. (A) Drawing showing how
this flap can be used for a round, oval or rectangular shaped defect.
(B,C) Demonstration of single advancement flap for oval lesion.
C
A
B1
B2
Figure 17.2  Basic single advancement flap. (A) Drawing of how Bürow’s
triangles or wedges decrease tension on the ends of advancement flaps.
(B1–B3) Demonstration of Burow’s triangles.
B3

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made so that the flaps advance along the lines of maximum extension.
In most cases, the two flaps are of the same width, however, they do
not need to be the same length. If the flap is planned with no greater
than a 3 : 1 length : width ratio, then the flap has excellent survival rate.
In areas of less extensibility the ratio should be closer to 2 : 1 for
optimum results.
As with the single advancement flap, the dual flaps are undermined
within the subcutaneous level and both are advanced to meet midway
within the defect. The major movement is along the direction of
advancement of the flaps and there is usually very little noticeable
secondary motion. Dog-ears may form at the bases of the flaps.
Bürow’s triangles may be performed in the same manner as described
This flap works well with lesion excision of ≥1 cm diameter on the
side of the foot, the plantar aspect of the foot and the posterior heel
(Fig. 17.3). On the plantar foot, the flap base should be medial or
lateral, in order to avoid venous congestion. On the posterior heel
region, this same orientation allows for the majority of the scars to be
in the relaxed skin tension lines. The key to the success of this flap,
and to evaluating whether this flap is appropriate or not, lies in the
capacity to see not only the defect but the resultant scar and where
the dog-ears will lie.
Pantographic expansion flap
The pantographic expansion flap, a modification of the single advance­
ment flap, aids in relieving tension on the graft without the need for
Bürow’s triangle excisions (Fig. 17.4). The flap is slightly widened at
the base to account for the back-cuts that are placed into the flap to
allow for additional movement. As a rule, this flap is not recom­
mended, because of the potential to jeopardize the vascularity of the
flap with the back-cut incisions.
Double advancement flap
If a single advancement flap does not furnish enough laxity to close
the defect, then a second flap from the opposite side can be fashioned
(Fig. 17.5). This is frequently referred to as an H-plasty or O–H flap
due to its general appearance. In this procedure, the incisions are
Figure 17.3  Single advancement flap used to remove a thickened and painful scar from the medial side of the first metatarsophalangeal joint.
(A) Design of flap with small Bürow’s wedges. (B) Excision of painful scar with undermining of the flap. (C) Advancement of flap, suture closure and
Steri-Strips. (D) 6 months postoperative.
(Courtesy of David Tollafield.)
A
B
C
D
Figure 17.4  Pantographic expansion flap. This modified design is
widened at the base and a back-cut is placed on both ends to allow for
movement without tension on the flap.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
the medial and lateral aspect of the heel, the posterior Achilles tendon
region, and the medial and lateral malleolar area.
ROTATIONAL FLAPS
Many flaps that are classified as rotation flaps are actually combina­
tions of rotation and advancement flaps. These are sometimes called
transpositional flaps, which will be discussed in the next chapter. Pure
rotation flaps and rotation flaps combined with advancement flaps
are very useful in closing cutaneous defects in certain anatomical loca­
tions such as the plantar foot. Rotation flaps can be either axial or
earlier to reduce the redundancy and they should be positioned so
that the width of the flap base is not compromised.
The major problem with this double advancement flap design is the
potential for disruption of the blood supply to the flaps. Since the
majority of the advancement flaps are of the random pattern blood
supply, failure to plan for proper movement may result in additional
tension across the distal end of the flap, resulting in failure. It is rare
that advancement flaps on the lower extremity has to be designed for
primary movement only. The areas that require primary movement
only are those in which the defects are on fixed structures that cannot
be moved or distorted, such as over the digits or the nail base. Areas
that can provide secondary movement are those in which the skin is
inelastic but mobile (or mobilized by careful undermining), including
Figure 17.5  Double advancement flap. (A) Drawing of adjoining flaps that are created on either side of the defect and advanced toward each other
to close the opening. (B–E) The lesion is marked and the double advancement flaps are drawn out. The lesion is then excised and the flaps are
mobilized and transferred. Final suture closure shows good apposition of flaps.
A
B
C
D
E

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triangular wedge of skin is then excised to encompass the plantar
lesion so that the base is formed by the initial transverse incision. The
apex of the excised tissue is proximal. Essentially, this long wedge
excision is similar to a long fusiform excision with the benefit of
adjacent tissue being transferred via the rotation flap. The undermin­
ing of the flap is minimized and increased as needed to allow move­
ment of the flap. Closure by this method is somewhat easier than with
a fusiform excision alone, but slightly more intricate. Bürow’s triangles
are usually needed at the end of the transverse incision to reduce
tension along the closure site. This ultimately provides a non-weight-
bearing scar that heals very well.
Catanzariti–Wehman rotation flap
A very similar approach using a modified rotation flap was described
by Catanzariti and Wehman in 1988. However, in their procedure, the
placement of the rotation flap was distinctly different (Fig. 17.11).
They describe the wedge as being much smaller and the incision along
the arc as much longer. This does provide for complete closure without
random pattern, depending upon the plane of dissection and angio­
some involved. These flaps provide redistribution and redirection of
tension from the primary defect to the donor site. On the plantar foot
the flaps can be elevated from the non-weight-bearing areas to the
weight-bearing areas.
Rotation flaps are those flaps that revolve around a fixed point and
subsequently move through a semicircle or arc. The rotational flaps
include the classic rotation flap, the Satterfield–Jolly rotation flap, the
single-lobed rotation flap and the double-lobed rotation flap. Each of
these flaps has a design benefit that allows them to be selected for
specific situations on the lower extremities.
Classic rotation flap
The archetypal rotation flap consists of a triangle or two radians or
wedges from a portion of a circle (Fig. 17.6). Rotation occurs about a
pivot point and can be visualized as degrees of movement or degrees
of rotation within a circle. It may be difficult to apply this concept of
triangular defect closure with a rotation flap in the clinical situation,
without some modifications. When a circular defect is converted to a
triangular wedge, there may be a dramatic increase in the size of the
defect created to accommodate the rotation flap.
In the advancement flap, all tissue must come from direct move­
ment of the flap to cover the defect. On the other hand, in the rotation
flap, there is more than one option available for additional tissue
movement. If the rotation flap does not cover the entire defect it may
be designed larger or the length of the curved incision may be extended
to free more tissue. Additionally, if even more movement is needed,
a back-cut may be employed to the arc of the flap. The rotation flap
used to close a circular defect is usually a combination of both primary
and secondary movements (Fig. 17.7). The primary movement is
the rotation and advancement of the flap itself over the defect and the
line of the greatest tension extends from the pivot point toward the
defect site (Fig. 17.8). This distal tension point is the area of greatest
vascular compromise. The secondary movement is the movement of
the adjacent or surrounding skin in the opposite direction of the flap
movement. The skin from the side of the defect opposite the flap
moves over the defect more than the flap itself moves over the defect.
This requires less rotation of the flap and creates less puckering at the
flap pedicle. When puckers occur they may be eliminated by cutting
a Bürow’s triangle at the end of the incision (Fig. 17.9).
Satterfield–Jolly rotation flap
This flap is a modification of the classic rotation flap, which is very
useful for excising wedge-shaped or irregular scars on the plantar ball
of the foot (Fig. 17.10). The transverse incision is made along the
plantar edge of the web sulcus following its natural curved arc. A long
Figure 17.6  Classic rotation flap. Rotation flap used to close a triangular
defect.
Degrees of
rotation
Defect
Flap
incision
Figure 17.7  Movement of tissue in a rotation flap. All three movements
are shown in the illustration.
Primary
Secondary
Combined
Figure 17.8  Classic rotation flap. The line of greatest tension extends
from the pivot point toward the defect site.
Defect
Pivot point
Line of tension

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 17.9  Classic rotation flap. (A) Drawing showing the Bürow’s
triangle used to prevent dog-ear formation. (B–D) Rotation flap without
the use of Bürow’s triangle.
Bürow's triangle
A
B
C
D
Figure 17.10  Satterfield–Jolly rotation flap. The transverse incision is
made following the natural arc of the plantar ball from medial to lateral
along the margin of the digital sulcus. The lesion is excised with a
long narrow wedge and then closed so that the final scar is
non-weight-bearing.
Figure 17.11  Catanzariti–Wehman rotation flap. The wedge resection is
in a small triangular shape. The curved incision is brought down across
the plantar ball, trying to avoid the weight-bearing surfaces as much as
possible.

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| 17 |
The three single-lobe rotation flaps possess all of the advantages of
local or classic rotation flaps and permit the use of unusually large
flaps. The principle of these flaps ensures sufficient vascularization,
and the normal relationship between the length of the flap and its
breadth of 1 : 1 can generally be exceeded. The additional mobiliza­
tion of the skin around the defect as a part of the plasty leads to a
reduction in the overall size of the defect. The flap, consequently, can
be cut smaller than the defect site. This exploitation of the adjacent
skin reserves has the effect of reducing the size of the defect and leads
to a reduction in the extent of the resulting scars. The created flap
narrows to its point and the incisions in all three flaps are never made
parallel. The sides of the flap are not cut to the same length, thus
increasing the size of the flap base and its potential blood supply.
A further advantage of this type of flap over the conventional free
flap is the similarity of the tissues used. Subcutaneous tissue, and even
muscle situated under it, can be rotated with the skin. It has universal
applicability with reference to the size and location of the defect.
There is also a special resistance of the flap, resulting from the broad
base that helps to ensure a good blood supply. The principal advan­
tage is the avoidance of a secondary defect, which might need a
skin graft or additional incisions, creating the potential for more
scarring.
These flaps can be used to treat many different types of lesions in
a large variety of locations on the feet and legs. The single-lobe flap
for correction of circular defects is preferred for removing small digital
lesions such as fibrous scars, intractable keratoses or digital mucoid
cysts (Fig. 17.15). The plantar hallux also allows adequate tissue
mobility for a single-lobe flap (Fig. 17.16). In weight-bearing areas,
especially on the ball of the foot or plantar heel, the single-lobe flap
allows for complete removal of large lesions with excellent closure
and reduced scarring (Figs 17.17–17.19). This technique is also useful
on the lower leg for removal of premalignant or suspected lesions
where the final scar has more cosmetic importance (Fig. 17.20).
The single-lobe rotation flap has many uses in foot, ankle and
lower-leg surgery. The Schrudde flaps are the preferred variation of the
standard or classical rotation flap or other more complex flaps in most
situations. The technique allows excellent exposure to underlying
tissues, complete removal of most circular or oval lesions and com­
plete closure of the resultant defect. Complications have been rare
with this procedure. In a small number of cases, it may be difficult to
rotate the single-lobe flap. In those cases, the flap can be replaced in
its original position and sutured (Fig. 17.21) or the flap can be con­
verted to a double-lobed flap.
Double-lobed rotation flap
The bilobed flap is usually described as a rotation flap consisting of
two flaps with a 90° angle between flaps that share a common pedicle
(Fig. 17.22). This flap is designed to move more tissue over a larger
Figure 17.12  Single-lobed rotation flap. Schrudde Type-1 flap for circular
defects. The base of the flap is at a 90° angle from the defect.
Figure 17.13  Single-lobed rotation flap. Schrudde Type-2 flap for oval or
oblong defects. The base of the flap is at a 60° angle from the defect.
Figure 17.14  Single-lobe rotation flap. Schrudde Type-3 for limited tissue
or space areas.
the need for Bürow’s triangles, but their design places more of the
incision on the ball of the foot.
Ultimately, these procedures mobilize a great deal of tissue to cover
a relatively small percentage of the defect, but when selected properly,
both versions of this modified rotation flap have a place in foot
surgery. They are especially useful in the removal of hypertrophic scars
or triangular lesions on the plantar aspect of the foot.
Single-lobed rotation flap
A variation of the classic rotation flap, the single-lobed rotation flap,
or unilobe flap, is a combination of a transpositional flap and a rota­
tion flap (Fig. 17.12). The flap used to close the defect and the defect
itself are both cut to a round shape. This is referred to as a swing-slide
plasty, or a Schrudde Type-1 flap, useful in closing circular defects. The
flap can be created at any point on the round defect. The excision of
the defect is arranged so that a right angle (90° angle) is formed at
the base of the defect for the start of the flap. The flap base is placed
in a position that provides the best potential incoming blood supply.
This method prevents the skin from bulging at this right angle point
when the flap is rotated into place reducing the potential for a dog-ear
formation. The resultant primary and secondary skin movement
reduces the size of the formerly round defect so that the shape of the
closed defect corresponds more or less to that of the flap.
The flap designed for an oval or oblong defect is referred to as a
Schrudde Type-2 flap (Fig. 17.13). The excision of the defect is
arranged so that a 60° angle is formed at the base of the defect. In
this case, care must be taken to ensure that the movement of the skin
leads to a reduction in the length of the original defect when closing
the secondary defect.
The flap designed for semicircular defects, limited space areas or
whenever there is limited tissue available is referred to as a Schrudde
Type-3 flap (Fig. 17.14). This flap has an extremely large base that
preserves blood supply, but frequently results in tissue protrusion or
a dog-ear defect at the secondary defect closure site. This is the least
user-friendly flap of the three described.

184
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 17.15  Type-1 single-lobe rotation flap for correction of digital lesion. (A) Digital mucoid cyst is outlined with design of flap. (B) Lesion excised
and unilobe flap transferred into defect. (C) Final closure. (D) At 1-year follow-up.
A
B
C
D
A
B
Figure 17.16  Type-2 single-lobe rotation flap for correction of a painful plantar hallux lesion. (A) Oval lesion is marked and flap is drawn. (B) Lesion is
excised and flap is created.

Chapter
Advancement and rotational flaps
185
| 17 |
(C) Flap is rotated and sutured. (D) Final appearance at 3 months.
C
D
Figure 17.17  Type-1 single-lobe rotation flap for correction of large plantar lesion on ball of foot. (A) Giant keratoacanthoma is outlined and flap is
drawn. (B) Lesion is excised and flap is elevated. (C) Flap is rotated and sutured. The tension around flap will reduce within about 10 min due to skin
elasticity. (D) Final appearance of scar at 1 year.
A
B
C
D
Figure 17.16, Continued

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
A
B
C
D
Figure 17.18  Type-2 single-lobe rotation flap for correction of deep painful lesion on plantar weight-bearing heel. (A) Lesion is outlined and the flap is
drawn. (B) The lesion and subcutaneous mass is excised and flap is created. (C) Flap is rotated into defect and sutured. (D) Final closure. (E) Results at 4
weeks.
E

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| 17 |
D
Figure 17.19  Type-1 single-lobe flap on foot. (A) The lesion is outlined and the flap is drawn. (B) Intraoperative photograph during suture closure.
(C) 2 weeks postoperative. (D) Final appearance at 3 months.
(Courtesy of Dr Jeffrey C. Christensen.)
A
B
C
A
B
C
Figure 17.20  Type-1 single-lobe rotation flap on lower leg. (A) Pigmented lesion on lower leg. (B) Complete excision of lesion for dermatopathology
review. (C) Creation of single-lobe rotation flap.

188
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
(D) Flap rotated into defect and sutured. (E) Results at suture removal in 3 weeks.
D
E
Figure 17.21  Type-1 single-lobe rotation flap on lateral heel. (A) The lesion is outlined and the single-lobe flap is drawn. (B) The lesion is excised and
the flap is elevated. At that time it was found that the flap would not easily rotate. (C) The extra mobility secondary to the flap and additional
undermining allowed the flap to be replaced in its original location and the wound closed primarily. (D) Appearance at 3 months.
A
B
C
D
Figure 17.20, Continued

Chapter
Advancement and rotational flaps
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| 17 |
Figure 17.22  Double-lobed rotation flap. Classical presentation with the
two lobes at 90° angles to each other.
Figure 17.23  The 30° double-lobed rotation flap as described by Bouché
et al. (1995).
0°
Triangular skin wedge excision
30°
60°
Figure 17.24  The 45° double-lobed rotation flap.
0°
45°
90°
distance than may be possible with a single-lobe rotation flap. This is
important in areas where the skin is thicker or the skin mobility is
limited. Because two flaps are used with this technique, two adjoining
donor sites are created to close the defect. The first lobe rotates into
the defect, while the secondary lobe closes the primary donor site. On
the plantar aspect of the foot, the angles between the flaps should be
smaller than 90°. The angles between flaps may range from 30° to
90° in this area where the mobility of the tissues is less than on other
parts of the lower extremity. Modifications of the 90° angled flaps
include the 30° bilobed rotation flap (Fig. 17.23) and the 45° bilobed
rotation flap (Fig. 17.24).
In most cases, the primary lobe of the rotation flap is smaller than
the defect site (approximately 80% the defect size) while the second­
ary lobe is smaller than the primary lobe (again, approximately 80%
of the primary lobe size). A general rule of thumb is that the first lobe
is 75% of the width of the primary deficit size and the second lobe is
50% of the width of the primary deficit size.
Once the lesion has been excised and the flaps have been
designed and incised, the skin flaps are raised with careful undermin­
ing at the subcutaneous level, avoiding the flap pedicle. The flaps are
then mobilized using skin hooks and simultaneously rotated. The
primary lobe is placed into the original defect site and the secondary
lobe is placed into the primary flap deficit. If accurately executed, the
pieces should all fit nicely together. A dog-ear may form at the end
of the incision adjacent to the primary flap, but this is usually not
a problem. If the dog-ear is large, it may be excised and closed
primarily.
Closure takes place with the securing of the secondary lobe into
the primary donor site with a few key sutures and then placing
the primary flap into the original defect and securing with a few
well-placed sutures. The two apices are then secured and equally
spaced simple interrupted sutures are then placed around the incision
until it is completely closed (Figs 17.25–17.27). Suture removal is
staged, as with other types of flaps. Ordinarily, for plantar rotation
flaps, the sutures in the least tension areas are removed first at
2 weeks postoperatively. The remainder of the sutures can be
removed at 3 weeks. It is highly recommended that there be no
weight-bearing for the entire 3 weeks following plantar foot surgery
with skin flaps.
CONCLUSION
Advancement and rotational flaps are important techniques to master,
especially when dealing with plantar foot lesions not amenable to
simple excision techniques. As with other types of flaps on the plantar
aspect of the foot, the donor site should not be taken from over an
enlarged prominence or weight-bearing surface, which would make it
more vulnerable to pressure and repetitive trauma. It is important to
point out again that these procedures are advantageous as they avoid
the creation of secondary defects that need additional grafts or proce­
dures to close them.
It is essential to make the distinction between tissue movability
and tissue elasticity when taking into consideration tissue transfer,
with the hope of predictable excellent results. Tissue moveability
is either inherent, as on the back of the calf, or is produced by
undermining, back-cutting, or cutting out Bürow’s triangles. The
elasticity of skin is different everywhere on the body and is difficult
to accurately predict. Elastic tissue will gape open when cut, whereas
inelastic tissue will not. Lastly, elastic tissue will rotate with
minimal puckering, but inelastic tissue will form large dog-ears
when rotated.
Because of these considerations, it is important to pre-think the
dynamics of flap movement as soon as the decision has been made
to use a flap. Determining which type of flap to use and what needs
to be accomplished with that flap must be given much forethought.
If deliberation is given preoperatively to which flap will best allow
proper transfer of tissue and simultaneously give the best cosmetic
result, the task is generally simpler. By taking into consideration the
secondary movement of neighboring tissues, as well as the primary
movement of the flap, the amount of potential techniques and designs
are significantly expanded.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 17.25  The double-lobed rotation flap. (A) The lesion is outlined. (B) The bilobed flaps are drawn. (C) The flaps are rotated into place with a
skin hook. (D) Final suture closure.
A
B
C
D

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| 17 |
Figure 17.26  The double-lobed rotation flap. (A) An accurate mathematical diagram is drawn on the lesion with two 30° flaps. (B) The lesion is
excised and the flaps are elevated. (C) The flaps are rotated into the defects. (D) Final suture closure.
(Courtesy of Dr Richard T. Bouché.)
A
B
C
D

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 17.27  The double-lobed rotation flap. (A) Classic-design bilobed flap is drawn on plantar lateral aspect of foot. (B) The lesion is excised and the
flaps are elevated and rotated. (C) Final suture closure. (D) Appearance at 6 months.
(Courtesy of Dr Jeffrey C. Christensen.)
A
B
C
D

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| 17 |
FURTHER READING
Belczyk, R., Stapleton, J.J., Zgonis, T., 2009.
A case report of a double advancement
flap closure combined with an Ilizarov
technique for the chronic plantar forefoot
ulceration. Int J Low Extrem Wounds 8 (1),
31–36.
Binning, T., Miller, M., 1986. Approaches to
the management of soft tissue defects of
the malleolar region. Clin Podiatr Med Surg
3, 769–780.
Boggio, P., Gattoni, M., Zanetta, R., et al.,
1999. Bürow’s triangle advancement flaps
for excision of two closely approximated
skin lesions. Dermatol Surg 25, 622–625.
Bouché, R.T., Christensen, J.C., Hale, D.S.,
1995. Unilobed and bilobed skin flaps.
Detailed surgical technique for plantar
lesions. J Am Podiatr Med Assoc 85,
41–48.
Boyer, J.D., Zitelli, J.A., Brodland, D.G., 2001.
Undermining in cutaneous surgery.
Dermatol Surg 27, 75–78.
Buratti, R., 1986. Rotational pedicle grafting.
Clin Podiatr Med Surg 3, 249–251.
Catanzariti, A.R., Wehman, D., 1988.
Rotational skin flap for treatment of
hypertrophic plantar scars. J Foot Surg 27,
124–126.
Clark, J.M., Wang, T.D., 2001. Skin flaps,
design. eMedicine 10, 1–21.
Dockery, G.L., 1989. Skin grafting techniques.
In: Jay, R.M. (Ed.), Current Therapy in
Podiatric Surgery. BC Decker, Toronto,
pp. 1–17.
Dockery, G.L., 1995. Single lobed rotation
flaps. J Am Podiatr Med Assoc 85, 36–40.
Dockery, G.L., 1992. Principles of forefoot
plastic surgery. In: Butterworth, R.F.,
Dockery, G.L. (Eds.), Color atlas and
text of forefoot surgery. Mosby, Chicago,
pp. 1–34.
Dockery, G.L., 1994. Digital mucoid cysts:
Diagnosis and treatment. J Foot Ankle Surg
33, 326–333.
Dockery, G.L., Christensen, J.C., 1986.
Principles and descriptions of design of
skin flaps for use on the lower extremity.
Clin Podiatr Med Surg 3, 563–577.
Dzubow, L.M., 1985. The dynamics of dog-ear
formation and correction. J Dermatol Surg
Oncol 11, 722–728.
Ertas, N., Borman, H., 2011. Double opposing
rectangular advancement flap is an
alternative technique in the treatment of
wide linear postburn scar contractures.
Burns 37 (8), 1449–1457.
Fleetwood, J.R., Barrett, S.L., Day, S.V., 1987.
Skin flaps. The Bürow’s advancement flap
for closure of plantar defects. J Am Podiatr
Med Assoc 77, 246–248.
Gormley, D.E., 1985. A brief analysis of the
Bürow’s wedge/triangle principle. J
Dermatol Surg Oncol 11, 121–123.
Hoy, E.A., Schwartz, R.A., Granick, M.S., et al.,
2003. Closure of complicated wounds.
eMedicine 12, 1–13.
Julien, P.H., Marcinko, D.E., Gordon, S., 1988.
Reconstruction of soft tissue defects about
the great toe. J Foot Surg 27, 116–120.
Marcinko, D.E., 1988. Plastic surgery in
podiatry (simplified illustrated techniques).
J Foot Surg 27, 103–110.
McGregor, J.C., Soutar, D.S., 1981. A critical
assessment of the bilobed flap. Br J Plast
Surg 34, 197–205.
Mendelsohn, R.S., Miller, L., 1988. Soft tissue
coverage for defects on the plantar aspect of
the foot. J Foot Surg 27, 121–123.
Miller, S.J., 1986. The bilobed skin flap
rotation. Clin Podiatr Med Surg 3,
253–258.
Petrovici, V., Pless, H., 1978. The Schrudde
method of plastic surgery. Results after 15
years use of the method. Chirurg 49,
440–447.
Sanchez-Conejo-Mir, J., Buenos Montes, J.,
Moreno Gimenez, J.C., et al., 1985. The
bilobed flap in sole surgery. J Dermatol
Surg Oncol 11, 913–917.
Satterfield, V.K., Jolly, G.P., 1994. A new
method of excision of painful plantar
forefoot lesions using a rotational
advancement flap. J Foot Ankle Surg 33,
129–134.
Schrudde, J., Petrovici, V., 1981. The use of
slide-swing plasty in closing skin defects: a
clinical study based on 1308 cases. Plast
Reconstr Surg 67, 467–481.
Schrudde, J., Petrovici, V., 1981. Recontouring
the lower extremity after injuries. Z Plast
Chir 5 (4), 246–253.
Stegman, S.T., 1980. Principles of design
and the dynamics of movement of flaps.
J Dermatol Surg Oncol 6, 182–186.
Storm, T.R., Lee, M.S., 2001. Plastic and
reconstructive surgery. In: Banks, A.S.,
Downey, M.S., Martin, D.E., et al., (Eds.),
McGlamry’s Comprehensive Textbook
of Foot and Ankle Surgery. Lippincott
Williams & Wilkins, Philadelphia,
pp. 1487–1521.
Throckmorton, G.S., Williams, F.C., Potter, J.K.,
et al, 2010. The geometry of skin flap
rotation. J Oral Maxillofac Surg 68 (10),
2545–2548.
Warren, S.E., Snell, G.F., 1986. Complex
wound closure, excisional biopsy, and
use of simple flaps. Primary Care 13,
433–445.
Whitaker, D.C., 1994. Random-pattern flaps.
In: Wheeland, R.G. (Ed.), Cutaneous
surgery. WB Saunders, Philadelphia,
pp. 329–352.
Yetkin, H., Kanatli, U., Ozturk, A.M., et al.,
2003. Bilobed flaps for nonhealing ulcer
treatment. Foot Ankle Int 24, 685–689.
Young, K.A., Campbell, A.C., 1999. The
bilobed flap in treatment of mucous cysts
of the distal interphalangeal joint. J Hand
Surg 24, 238–240.
Zimany, A., 1953. The bilobed flap. Plast
Reconstr Surg 11, 424–434.
Zitelli, J.A., 1987. Bürow’s grafts. J Am Acad
Dermatol 17, 271–279.
Zivony, D., Siegle, R.J., 2002. Bürow’s wedge
advancement flaps for reconstruction of
adjacent surgical defects. Dermatol Surg 28,
1162–1164.

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CHAPTER CONTENTS
General concepts
195
Transposition flaps
195
Simple or classic transposition flap
196
Complex transpositional flaps
196
Rhombic flap
196
Limberg rhomboid flap
196
Dufourmentel flap
199
Webster flap
199
Double rhomboid flap
200
Triple rhomboid flap
200
Iida double transposition flap
201
Rhomboid flap with multiple Z-plasty
202
The ‘Reading Man’ transposition flap
203
Comparative procedures
204
Interpolation flaps
204
Conclusion
205
GENERAL CONCEPTS
The heterogeneous cutaneous anatomy contributes to the unique bio­
mechanical properties of skin. All of the structures of skin, including
the dermal collagen, elastin, subcutaneous fat, blood vessels and
nerves contribute to these properties. Unlike other materials, skin’s
stress–strain relationship varies with time. Skin is both viscoelastic
and anisotropic (meaning its stretchability is non-linear or it has the
property of being directionally dependent, as opposed to isotropy,
which implies identical properties in all directions). There are four
important concepts pertaining to flap physiology: stress, strain, creep
and stress relaxation. Stress refers to the force applied per cross-
sectional area. Strain refers to the change in length divided by the
original length of the given tissue to which a force is applied. Creep
refers to the increase in strain seen when skin is under constant stress.
This occurs over a matter of minutes and is due to an extrusion of
fluid from the dermis and a breakdown of the dermal framework.
Meanwhile, stress relaxation is the decrease in stress when skin is held
in tension at a constant strain for a given time. This occurs over a
matter of days to weeks and is due to an increase in skin cellularity
and the permanent stretching of skin components. The concept of
serial excision is based upon the fact that skin closed under tension
will display a certain amount of stress relaxation and creep over time.
This concept is very beneficial in flap creation.
TRANSPOSITION FLAPS
The transposition flaps are rectangular or square areas of skin and
subcutaneous tissue that are rotated around a pivot point into the
defect site. The donor site can be closed by a skin graft, direct suture
closure, or a secondary flap from adjacent skin. They are the most
complicated flaps for the surgeon to envision conceptually and they
demand more experience to perform competently. Transpositional
flaps make use of tissue that is separated from the defect by interven­
ing normal tissue (not a complete bridge of skin) that is transposed
over the normal tissue into the defect.
Transposition flaps are particularly useful when one wants to trans­
fer tension away from closure of the primary defect and into the repair
of the secondary defect. A trapdoor defect is prevalent with transposi­
tion flaps. The term trapdoor refers to a dome-like elevation of the
flap when it is compared with the surrounding tissue. A trapdoor
defect is best avoided by the performance of wide undermining
around the defect and the use of vertical mattress sutures in wound
closure. The ideas and understanding of tissue movement learned
from rotation flaps are important in the implementation of transpo­
sitional flaps.
One of the most essential factors and fundamental principles of flap
design is to close the secondary defect cosmetically as well as function­
ally. This goal is not accomplished if the secondary defect cannot be
entirely closed or must be grafted. It is necessary to note that most
surgery texts repeatedly show drawings or illustrations portraying a
©2012 Elsevier Ltd.
Transpositional flaps
G. Dock Dockery
Chapter
18

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Complex transpositional flaps
As the name implies, these flaps are much more complex in design
and function. They require sufficient donor tissue nearby so that the
flap can be cut, undermined, elevated, rotated, and then transposed
into the primary defect. The secondary defect that is formed, as well
as the intervening normal tissue, must be visualized concurrently with
the complete flap arrangement. The angles of most transposition flaps
vary from 30° to 120°. Of the various types of transposition flaps
described, none of them are applicable in all situations and the
surgeon must be able to determine the best variation for each proce­
dure independently.
Rhombic flap
An essential hypothesis of the transpositional flap is that the surgeon
has made a major decision in the flap design and has contemplated
how well it will work when choosing the angle at which the flap will
be fashioned and rotated into the defect. The standard transposition
flap at 90° is frequently referred to as a rhombic flap (Fig. 18.2). As
was discussed earlier, the surgeon must be able to visualize the
rhombic-shaped flap around an oval or circular defect in order to
mentally picture the end results (Fig. 18.3).
Limberg rhomboid flap
A rhombus is an oblique-angled equilateral parallelogram as described
above, which may be regarded as a fusiform shape with straight sides.
A rhomboid, on the other hand, is an oblique-angled parallelogram
with unequal adjacent sides. The 60–120° rhomboid transpositional
flap has gained wide acceptance and popularity as an excellent-shaped
flap for reconstruction of defects. This flap was designed for the closure
of a 60° rhomboid defect, with angles of 60° and 120° (Fig. 18.4).
Its use of adjacent tissue in transfer and rotation to avoid tension
makes this rhomboid flap the ideal local pedicle flap in many cases
on the lower extremity (Fig. 18.5). This is also a useful flap because
it can be rotated from any side over a defect and the broken-line scar
triangular-shaped defect along with a sharply angled transpositional
flap that closed the triangle. This depiction can only be successfully
conveyed to the clinical situation by converting the actual oval or
circular defects themselves into the triangular diagram. This is why it
is sometimes difficult for the surgeon to visualize the design needed
for a clinical case. Generally, as with other flaps, an exact measurement
of an angle is not necessary to produce a successful transpositional
flap. It is more important to evaluate whether there is enough tissue
that can be moved to close the defect while, at the same time, success­
fully closing the donor site.
Technically, by definition, the Z-plasty, the single-lobed and double-
lobed (bilobe) rotation flaps are sometimes referred to as transposi­
tion flaps. In this section, however, the transpositional flaps will
include the simple or classic transposition flap and the complex trans­
positional flaps. The complex transpositional flaps include the 90°
rhombic flap; the 60–120° rhomboid or Limberg flap; the Dufour­
mentel flap; the 30° or Webster flap; the double rhomboid or Cuono
flap and the Iida double transposition flap. Finally, the interpolation
flap, which often is included in the transposition flaps, will be briefly
discussed.
Simple or classic transposition flap
The simple or classic transpositional flap is usually thought of
as a square or rectangular-shaped flap that, when closed, covers the
original defect, leaving the secondary defect open (Fig. 18.1). The
primary motion allows the flap to be rotated about a pivot point
into the immediate adjacent defect area. This fact necessitates that
the end of the flap adjacent to the defect be selected to extend past
it. Then, as the flap is rotated, with the line of greatest tension at
the radius of the rotation arc, the advancing tip of the flap is suffi­
ciently long. The resultant secondary defect is then covered with
a split-thickness skin graft, direct closure of the wound or a second­
ary flap.
One of the most important uses of this type of transposition flap is
in covering defects located over exposed joints or bony prominences,
such as the malleoli and posterior calcaneus. Many classic transposi­
tion flaps performed in the past did not result in superior long-term
results. One reason was the appearance of the secondary skin graft
after maturation and the other reason was a trapdoor type of defect
of the flap as the scar matures. Both of these findings are unsightly
and may be functionally inferior to other flaps. In fact, many other
flaps in this text may be more suitable and may eliminate the need
for additional skin grafting or additional procedures.
Figure 18.1  Classic or simple transpositional flap. Primary movement
allows rotation at the pivot point to close the defect. The secondary
defect is often closed by a skin graft.
Primary defect
Secondary defect
Line of greatest
tension
Figure 18.2  Drawing of rhombic transpositional flap. The sides are of
equal length and the standard rhombic is at 90°. The diagonal cut is
extended an equal distance and a back-cut is made parallel to the side of
the rhombic.
Rotation°
90°
Defect
Figure 18.3  Clinical visualization of the rhombic flap around a circular
defect and the potential final resultant scar.

Chapter
Transpositional flaps
197
| 18 |
that results is cosmetically favorable. With experience, a rhomboid flap
can be designed and moved to cover circular, triangular or other
irregular defects. Both primary and secondary motion should occur
for maximum benefit with this flap. The primary motion is of the flap
itself moving toward the defect site and the secondary motion is of
the adjacent tissue around the defect moving toward the flap.
To minimize tension in the final closure, the original rhomboid
defect should be oriented so that its long diagonal is parallel with the
lines of maximal extensibility (LME) and follows the natural skin
creases, or relaxed skin tension lines (RSTL). In so orienting the flap,
tissue is taken from the LME, where it is plentiful, and transferred to
the defect. Every rhomboid defect has four potential closure flaps (Fig.
18.6). To determine which flap is optimal to close a particular defect,
the LMEs surrounding the defect must first be determined. The LMEs
are oriented perpendicular to the RSTLs. Two parallel lines are drawn
along the LMEs and adjacent to the defect. Two additional parallel
lines are drawn to create the 60° and 120° angles. The short diagonal
then is extended by the length of the sides of the rhombus. A cut is
made from each of the two extensions of the short diagonal back to
the lines along the LMEs and parallel to the sides of the rhombus.
Figure 18.4  Planning of Limberg rhomboid transposition flap. The
rhomboid defect is converted to one that has 60° and 120° angles. The
short diagonal (which bisects the 120° angles) is in line with the relaxed
skin tension lines.
C
LME
60°
120°
B
A
E'
D D'
E
C
B
D'
D F
E
E'
F
R
S
T
A
A
B
C
D
Figure 18.5  Rhomboid transposition flap. (A) Site of previous lesion excision on the ankle in need of additional border excision. (B) The rhomboid flap
is designed with potential random blood supply to flap in mind. (C) Deep and full excision of the lesion. (D) Transposition of the flap with care in not
damaging the skin.

198
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
E
F
G
Figure 18.6  The rhomboid transposition flap. Every rhomboid flap has
four potential closure flaps.
60°
120°
C
D
A
B
(E) Final appearance at closure. (F) Appearance
at time of suture removal. (G) Final appearance at 6 weeks.
(Courtesy of Dr Stephen Schroeder.)
Figure 18.5, Continued 
Thus, two flaps are created, and the surgeon must determine which
best matches the skin and conceals the scar. Choosing the correct flap
is done most easily if one simply visualizes the rhomboid shape
around the lesion and orients it so that the distal point of the base of
the flap is along the LME.
Difficulty in marking the rhomboid flap, owing to the inability to
visualize the relationship between the rhomboid drawn around the
lesion and the orientation of the adjacent flap, with the proposed line
of closure of the secondary defect, may be greatly reduced by using a
90° set square made of metal, which could easily be sterilized and
used in surgery. The 30° and 60° angles of the set square permit easy,
rapid and accurate marking of the flap.
The principles of design and placement of the rhomboid flap
include excising the lesion in the shape of a rhombus (as an equilat­
eral parallelogram with oblique sides). The flap should be designed
along whichever one of the four equilateral sides that is most conven­
ient or feasible at that anatomical site (Fig. 18.7). This transpositional
flap is commonly used in the reconstruction of lower leg/ankle lesions
and distal and plantar ulcerations of the foot (Fig. 18.8). Sufficient
undermining of the recipient sites allows closure of defects with donor
flaps that are slightly smaller than the defects themselves. Undermin­
ing the base of the flap should not be done and excising tissue from
the flap itself is not recommended because this may severely compro­
mise the blood supply to the flap. The donor site should be closed
first with anchoring sutures to take tension off the flap. The flap
should not be stretched because that may compromise the blood
supply as well. Dog-ears or pucker defects should be removed, but
away from the flap pedicle. As few sutures as possible should be used
along the base of the flap to avoid constriction of blood supply. Exces­
sive movement or pressure of the flap should be avoided after surgery
to prevent tissue death or formation of hematoma or seroma.
Because of the dynamics of the rhomboid transposition flap, there
are certain limitations to its usage and additional problems may
include excessive tension, anatomic landmark displacement and trap-
door deformity. Excessive tension may manifest along the line of
closure of the flap donor site and at one or both of the tips of the
advanced flap. Over one-half the total tension is located along the line
of closure of the donor site, with the remainder being distributed at
the tips of the advanced flap. Furthermore, since all of the tissue that
is required to resurface the rhomboid defect is borrowed from one
area and since the flap donor site is closed by advancement, the
potential for anatomic landmark displacement exists. Tension at both
tips of the advancement flap may result in blunting or rounding of