Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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Chapter 15  Hemostasis
bleeder. A figure-of-eight suture or a square stitch around the
bleeding site is effective. Compressing the skin proximal to
the area of hemorrhage will temporarily reduce bleeding suf-
ficiently for suture intervention.
Excisions of vascular lesions (e.g. hemangiomas, port-wine
stains) are inherently difficult. There may be diffuse bleeding,
which limits visibility. A useful technique to control such
bleeding is a double imbricating suture.37 This method, which
consists of two modified vertical purse string sutures, is
applied peripheral to the area of excision. The tension is
adjusted by pulling on either ends of the suture, which con-
stricts the central area of surgery and permits controlled
hemostasis (see Fig. 15.7).
 OPTIMIZING OUTCOMES
Hypertension and anxiety
Optimizing medical issues and anxiolysis before surgery are
helpful strategies to decrease the risk of bleeding. Uncon-
trolled hypertension elevates intravascular pressure, which
aggravates surgical bleeding. Patients with untreated hyper-
tension should be stabilized before surgery, especially if
systolic pressures exceed 180  mm  Hg. Sustained systolic
hypertension above 180 mm Hg is dangerous and may lead
to myocardial infarction or stroke as well as bleeding. For
many patients already on treatment, hypertension on the day
of surgery is often situational and anxiety related. Calming
music, soft and reassuring voices, and distraction are all useful
methods to calm and relax patients. Medications, however,
have a role if more rapid and effective anxiolysis is required.
In patients with anxiety accompanied by situational hyper-
tension, clonidine 0.1 mg orally is especially effective. Cloni-
dine provides antihypertensive, sedative, and anxiolytic
effects.38 Its antihypertensive effect is prolonged (12 hours),
which is an advantage in the immediate postoperative period
when the risk of bleeding is greatest with hypertension.
Further, clonidine reduces analgesic needs after surgery and
lowers tachycardia through its α2 agonist effects.39 Clonidine
should be given 60 minutes before surgery. It should be
avoided in patients with a preoperative systolic pressure
less than 100 mm Hg or pulse rate less than 60/minute. If
hypertension is absent, however, but anxiolysis is still signifi-
cant, then oral midazolam (Versed) 5–10  mg will provide
rapid anxiolysis within 20 minutes and has no hemodynamic
benefits.40 More important than its rapid onset, however,
is its short half-life of 2 hours, which is an advantage in
elderly patients. Initial doses of both clonidine (0.1 mg) and
midazolam (5  mg) should be low in the elderly to avoid
excess sedation.
Anatomic location and hemostasis
Experienced surgeons will anticipate sites that are prone to
greater bleeding and prepare appropriately. Hemorrhage
during cutaneous surgery usually involves random vessels,
although named arteries may be transected in the head and
neck and fingers or toes. Hemostasis in periorbital procedures
must be meticulous and complete. The consequences of
orbital hemorrhage are disastrous. The dorsal nasal artery,
inferior and superior labial arteries, angular artery (and nasal
branches), and superficial temporal artery are most vulnera-
ble to injury in cutaneous reconstruction. Familiarity with
when electrosurgery is subsequently applied. Ideally, only the
vessel should be secured or at least the minimum tissue nec-
essary. This may be accomplished by using two forceps, where
the first clamps the general area to arrest bleeding, and the
second localizes the bleeding vessel to be electrocoagulated.
Suture ligation
Hemorrhage from vessels of all sizes may be arrested with
appropriate suture techniques. Vessels greater than 2 mm in
diameter should generally be ligated because other methods
of hemostasis are not as secure. If a vessel is transected, then
each end may be clamped and ligated individually. Curved
mosquito clamps (Halsted clamps) are preferred for securing
larger vessels. As in electrosurgery, only the minimum of
tissue should be clamped and ligated. Sutures that will be
buried should be absorbable (i.e. polyglactin 910 (Vicryl,
Ethicon, Inc, Johnson & Johnson Co, Somerville, NJ)).
Different suture techniques are available for hemostasis
(Figs 15.6–15.10). One of the most difficult situations in
hemostasis is a bleeding vessel that is not visible. This may
occur when a blood vessel spasms with injury and retracts
behind the wound edge. It may also occur when punch biop-
sies are performed in highly vascular areas (scalp) and bleed-
ing develops deep to the wound. For either situation, more
undermining may reveal the retracted vessel for ligation or
electrocoagulation. If further undermining is not possible,
then ligation is necessary without identifying the offending
Horizontal mattress suture
Figure 15.6  Horizontal mattress suture. As an epidermal suture,
the horizontal mattress is useful for non-specific epidermal
oozing along the wound edge.

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Part 2  Essential Surgical Skills
osteum) and below the nasalis muscles on the nose (above
perichondrium) is almost bloodless because the vascular
planes are not violated.
Procedural hemostasis
With most planned procedures, appropriate precautions will
reduce the bleeding risk. For example, out-of-town patients
undergoing a complex procedure may be asked to stay locally
overnight to permit rapid intervention if needed. For all
layered closures, the closure of dead spaces is essential for
hemostasis to prevent hematoma formation. Certain proce-
dures in dermatologic surgery are especially prone to bleed-
ing. Interpolation flaps for reconstruction tend to bleed at the
these arteries and their paths will assist the surgeon in hemo­
stasis. Arterial circulation is usually not compromised on the
head and neck because there is extensive arborization of
vessels and collateral supply. On the digits, however, extreme
vigilance is necessary to preserve the two sole arteries (palmar
or plantar digital arteries) to each finger or toe. The scalp is
extensively vascularized above the galea. Numerous arterial
perforators from the posterior auricular artery supply the
anterior auricular surface. On both the scalp and ear, even
minor punch biopsies may result in significant bleeding and
should be anticipated. Finally, incisions involving muscles
may result in profuse bleeding.
Appropriate undermining can greatly reduce surgical bleed-
ing. Undermining below the galea on the scalp (above peri-
A
B
C
Purse string or imbrication suture
Figure 15.7  Double purse
string or imbrication suture.
A 3-0 Prolene (Ethicon, Inc,
Johnson & Johnson Co,
Somerville, NJ) suture with
PS-2 needle is most useful
for this technique. (A) First
purse string is placed
around the central lesion,
with both ends of the suture
terminating on one side of
the lesion. (B) Second purse
string is begun on the
opposite end of the first
suture and placed around
the central lesion. (C)
Hemostasis is achieved as
both purse string ends are
cinched tight, tamponading
the vessels peripheral to the
centrally excised lesion.

235
Chapter 15  Hemostasis
X-suture
Figure 15.8  X-suture – as the hair graft ellipse is excised, an
assistant places a running locked suture behind the removed
graft, securing hemostasis.
A
B
Square or U-suture
Figure 15.9  Square or U-suture – this is similar to the
horizontal mattress suture, but can be placed deep with an
absorbable suture.
A
B
Figure-of-eight suture
Figure 15.10  Figure-of-eight suture – this technique may
secure hemostasis either as a surface (non-absorbable) or as a
deep (absorbable) suture. The figure-of-eight criss-cross
configuration tamponades the underlying bleeding vessel.
proximal pedicle. Bleeding may be delayed for several hours
if epinephrine has been used with local anesthesia. The
surgeon may either avoid using epinephrine or monitor the
patients for several hours after flap closure. The author
prefers monitoring because meticulous technique is difficult
without the vasoconstrictive benefits of epinephrine. Hair
transplantation is also an inherently vascular procedure. The
occipital arteries and its branches are invariably severed
during donor harvesting. Tumescent anesthesia, directed
compression, and the X-suture described in Figure 15.8 will
optimize hemostasis in hair transplantation. Finally, plantar
wart destruction is particularly prone to bleeding. Intrave-
nous regional anesthesia with its tourniquet compression is
ideal for this procedure, creating a relatively bloodless field.
 POSTOPERATIVE CARE
Patients must have detailed instructions on activity restric-
tions and wound care in the postoperative period (Box 15.1).
Hemostasis may be compromised if patients are excessively
active after surgery. The risk of postoperative bleeding is
greatest in the first 48 hours, and especially within the first
several hours. Acute bleeding occurs either with trauma or
with rebound vasodilatation when the effect of epinephrine
dissipates. Cold packs, elevation, and rest are important in
this initial period. Cold packs will stimulate vasoconstriction
and reduce swelling. Elevation and rest will reduce dependent
blood flow and risk of bleeding.
The purpose of wound care is to minimize bleeding,
promote wound healing, and prevent infection. There are as

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Part 2  Essential Surgical Skills
restrictions and provide wound protection. For procedures on
the extremities, a compression stocking (20–30 mmHg) pro-
vides added support to the primary wound dressing. Stock-
ings are especially helpful for patients with venous insufficiency
to decrease wound swelling.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 The risk of bleeding is highest in the first 48 hours after
surgery, especially within the immediate postoperative
period.
 A new onset of painful swelling within a previously stable and
asymptomatic wound is an expanding hematoma until proven
otherwise.
 Expanding hematomas require intervention and are medical
emergencies in periorbital and cervical locations.
 Evacuation of a hematoma is not always necessary, especially
if it is small, stable, and not compromising tissue viability.
 Intervention may require wound exploration, irrigation,
aspiration, and/or drain placement.
 Bromelain may be given orally to expedite hematoma
resolution.
Box 15.1  Postoperative patient instructions
for hemostasis
Bleeding
Bleeding after surgery rarely occurs, but if it does, it usually
occurs during the first 48 hours after surgery. Following the
activity restrictions below will help minimize your risk of
bleeding. If you have any bleeding, please follow these
instructions:
1. Lie down, elevate the area if possible, and apply firm
pressure to the site for at least 15 minutes. If a bulky dressing
has been placed over the wound, it should be removed.
2. Direct, firm pressure should be applied for 15 minutes
to the gauze or towel on top of the wound. Do not stop
applying pressure until 15 minutes have passed.
3. If bleeding continues after 15 minutes, remove the pad,
change it to a clean one, and hold pressure for an additional
15 minutes.
4. If the bleeding has not stopped after three applications of
pressure, please call the contact number on your wound care
instruction sheet.
Activities after surgery
 Decrease your overall physical activity, especially physical
activity that pulls or stretches your wound and physical
activity that will increase your heart rate. Avoid any activity
that may traumatize your surgical site.
 Do not drink alcoholic beverages for 2 days after surgery.
Alcoholic beverages dilate your blood vessels and may
increase your risk of bleeding.
 Lifting – avoid lifting anything greater than 10 lb (45 kg) and
do not bend down to lift if the surgical site is above the waist.
 Facial surgery – avoid bending down below your waist.
Elevate your head with one or two extra pillows when
sleeping or lying down.
 Hand, feet, arm, or leg surgery – elevate the area as much as
possible above your waist when you are resting.
 Lip surgery – eat soft foods. Keep your lip well lubricated with
petrolatum ointment (Vaseline petrolatum, Aquaphor, or
bacitracin).
When to call your physician
Contact your physician if you notice any of the following:
 Bleeding not controlled by direct pressure.
 Pain that increases each day or is not relieved by over-the-
counter medications.
 Rapid or increasing swelling within the wound.
 Reopening of the wound at any time.
 Increased redness, warmth, or pain around the wound.
many variations of wound dressings as there are dressing
materials. To minimize bleeding, however, all dressings
should provide effective compression. A compressive dressing
not only provides pressure to close vessels but also immobi-
lizes the wound and prevents external trauma. Dressings on
the digits (fingers and toes) must be modified. Pressure
ischemia or necrosis is a complication with excessive and
circumferential compression. By using an elastic mesh such
as Surgitube (Western Medical Ltd, Tenafly, NJ), SurgiGrip
(Western Medical Ltd), or Surgilast (Western Medical Ltd),
dressings may be kept in place without excess constriction.
A splint, sling, or brace for the extremities and digits may
also be useful. These devices remind patients of activity
Despite all precautions, bleeding complications will occur if
enough surgeries are performed. Bleeding emergencies are
rare in cutaneous surgery. Dermatologic surgeons rarely pen-
etrate the deep fascia to injure larger arteries. However,
protective layers in the neck of elderly patients may be thin
or atrophied and more caution is warranted during incision
and undermining. With a large arterial bleed, the same prin-
ciples of intervention apply. Immediate compression, identi-
fication of the vessel, and clamping will prevent further
exsanguination. The patient should be transferred as soon as
stable to a more appropriate setting where surgical explora-
tion may be performed if needed.
A more likely scenario for dermatologic surgeons is an
expanding hematoma. This is often because of continued
bleeding within a closed wound, especially when there is a
dead space. For small bleeding vessels, the hematoma expan-
sion may eventually tamponade the open vessel(s), which
prevents further bleeding. However, if there is continued
bleeding, the hematoma will progressively enlarge and cause
compression injury to adjacent tissues. Wound necrosis,
dehiscence, and infection are all potential sequelae of hemato-
mas. Nowhere is this more dangerous than in the periorbital
and cervical regions. An expanding hematoma in the orbit,
for instance, will quickly result in blindness without treat-
ment. Intervention requires performing a lateral canthotomy
(the lateral canthal tendon is divided into a superior and
inferior tendon) and cantholysis (the inferior canthal tendon
is severed from its periosteal attachment) of the affected eye,
which immediately relieves orbital pressure. In the neck, an
expanding hematoma may compromise the airway if the
wound is not explored and ligated. Intubation for airway
protection may be necessary as hemostatic efforts are initi-
ated. Anticoagulated patients undergoing procedures such
as cervicofacial liposuction or rhytidectomy and platysmal
plication are at risk. Patients must know emergency phone
numbers and be aware of dangerous signs and symptoms. A

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Chapter 15  Hemostasis
Bromelain should be given cautiously to patients who have
coagulation disorders or severe liver and renal disease.
 SUMMARY
Successful hemostasis requires careful forethought through-
out the perioperative period. Patients must be properly eval-
uated preoperatively, prepared appropriately intraoperatively,
and followed carefully postoperatively. Advances in the
understanding of physiologic hemostasis have resulted in
better interventions for surgical bleeding. Most patients may
continue their anticoagulation with dermatologic surgery. A
wide array of hemostatic agents and techniques is available
to locally manage perioperative bleeding. Pre-emptive strate-
gies of reducing hypertension and anxiety and optimizing
hemostatic anesthesia are helpful adjuncts. Bleeding compli-
cations, however, must be quickly recognized and managed
to avoid patient morbidity and poor surgical outcome.
 REFERENCES
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system and implications for new therapeutic options with recombinant
Factor VIIa. Curr Med Chem 2003;10:797–811.
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Willebrand’s disease I. Phenotypic variation within families. Blood 1979;
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4. DeLoughery T. Hemostasis and thrombosis. Georgetown, TX: Landes
Bioscience; 1999.
5. Peterson SR, Joseph AK. Inherited bleeding disorders in dermatologic
surgery. Dermatol Surg 2001;27:885–889.
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7. Billingsley EM, Maloney ME. Intraoperative and postoperative bleeding
problems in patients taking warfarin, aspirin, and nonsteroidal anti-
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381–383.
8. Shalom A, Wong L. Outcome of aspirin use during excision of cutaneous
lesions. Ann Plast Surg 2003;50:296–298.
9. Stables G, Lawrence CM. Management of patients taking anticoagulant,
aspirin, non-steroidal anti-inflammatory, and other anti-platelet drugs
undergoing dermatologic surgery. Clin Exp Dermatol 2002;27:432–
435.
10. Kovich O, Otley CC. Thrombotic complications related to discontinua-
tion of warfarin and aspirin therapy perioperatively for cutaneous opera-
tion. J Am Acad Dermatol 2003;48:233–237.
11. Kearon C, Hirsh J. Current concepts: management of anticoagulation
before and after elective surgery. New Engl J Med 1997;336:1506–
1511.
12. Otley CC. Continuation of medically necessary aspirin and warfarin
during cutaneous surgery. Mayo Clin Proc 2003;78:1392–1396.
13. Denkler K. A comprehensive review of epinephrine in the finger; to do
or not to do. Plast Reconstr Surg 2001;108:114–124.
14. Willhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine
in digital blocks: myth or truth? Plast Reconstr Surg 2001:107:393–
397.
15. Reuben SS, Steiberg RB, Lurie SD, et al. Intravenous regional anesthesia
using lidocaine and clonidine. Anesthesiology 1999;91:654–658.
16. Blaheta HJ, Vollert B, Xuder D, et al. Intravenous regional anesthesia
(Bier’s block) for botulinum toxin therapy of palmar hyperhidrosis is safe
and effective. Dermatol Surg 2002;28:666–672.
17. Grice SC, Morell RC, Balestrieri FJ, et al. Intravenous regional anesthe-
sia: evaluation and prevention of leakage under the tourniquet. Anesthe-
siology 1986;65:316–320.
18. Tucker GT, Boas RA. Pharmacokinetic aspects of intravenous regional
anesthesia. Anesthesiology 1971;34:538–549.
19. Alcalay J, Goldberg LH. Intraoperative nasal ala stabilization using the
Foley catheter. J Dermatol Surg Oncol 1991;17:957–958.
20. Smith IM, Austin OM, Knight SL. A simple and fail safe method for
digital tourniquet. J Hand Surg [Br] 2002;27:363–364.
new onset of painful swelling within a previously stable and
asymptomatic wound is an expanding hematoma until proven
otherwise.
Hematoma evolution
The management of a stable hematoma depends on its stage,
size, and associated symptoms. Hematomas evolve through
four stages as outlined below.
First stage – early development
This occurs within hours, with active hemorrhage and early
blood accumulation. Clinically, the wound is swollen, warm,
and fluctuant. Regardless of size, intervention is recom-
mended to prevent progression. Suture removal and opening
of part or the entire wound may be necessary to identify the
bleeding areas. Most often, several bleeding foci are encoun-
tered rather than one offending vessel. Suction is useful to
increase visibility. Following hemostasis with electrosurgery
or ligation, the wound should be examined, irrigated with
normal saline, and re-examined for more bleeding. If the
wound is not contaminated, then all layers should be resu-
tured. A drain may be considered if the risk of rebleeding is
high or if complete hemostasis was not possible. Drains
should be removed within 24 hours to minimize the risk of
infection. For diffuse oozing, not responsive to electrosurgery
or ligation, fibrin sealants or thrombin hemostats should be
strongly considered.
Second stage – gelatinous phase
Hematomas quickly become gelatinous with physiologic clot-
ting. The wound becomes more spongy than fluctuant and
there may be a purplish hue. If a gelatinous hematoma is
small, asymptomatic, and not threatening tissue viability,
then observation is appropriate. Otherwise, evacuation is nec-
essary and is similar to intervention in the first stage.
Third stage – organization
Within several days, the hematoma becomes organized into
a rubbery, adhesive clot and the wound feels solidly firm. The
adhesive clot is more difficult to remove completely at this
stage and deferring intervention until the fourth stage may be
best.
Fourth stage – liquefaction
After 7–10 days, the organized hematoma begins to liquefy
with fibrinolysis and is eventually resorbed. The wound again
feels fluctuant. Resorption of the hematoma may require
months, depending on the hematoma’s size. Intervention at
this stage is simpler and does not require wound opening. The
liquefied clot may be aspirated with a 16- or 18-gauge
needle.41 After the first stage, the decision whether or not to
resuture the wound is subjective. If active infection is present
or if the risk is high, then second intention healing with anti-
biotics is recommended with possible scar revision in the
future. Bromelain (Ananase, Delta Labs; Traumanase,
Aventis) is an oral concentrate of proteolytic enzymes derived
from the pineapple plant, Ananas sativus. It inhibits plasma
exudation and has anti-inflammatory and fibrinolytic effects.
Bromelain may be given to expedite hematoma resolution at
a dose of 500 mg three to four times daily until resolution.42

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33. Apfelberg DB, Maser MR, Lash H, et al. Sapphire tip technology for YAG
laser excisions in plastic surgery. Plast Reconstr Surg 1989;84:273–279.
34. Khouri S, Lodha R, Nouri K. Electrosurgery. In: Khouri S, Nouri K, eds.
Techniques in dermatologic surgery. Philadelphia: Mosby Elsevier 2003;
81–83.
35. Edlich RF, Reddy VR. 5th Annual David R Boyd, MD Lecture: Revolu-
tionary advances in wound repair in emergency medicine during the last
three decades. A view toward the new millennium. J Emerg Med 2001;
20:167–193.
36. Nichter LS, Goldstein LJ, Bush AM, et al. A simple method for pre-
venting misplaced electrocauterization. Plast Reconstr Surg 1987;80:
307.
37. Harahap M, Siregar AS. Method of minimizing hemorrhage in excising
hemangiomas. J Dermatol Surg Oncol 1989;15:1077–1080.
38. Klein J. Ancillary pharmacology. In: Klein J, ed. Tumescent liposuction.
St Louis: Mosby 2000; 196–209.
39. Beer GM, Spicher I, Seifert B, et al. Oral premedication for operations
on the face under local anesthesia: a placebo-controlled double blind trial.
Plast Reconstr Surg 2001;108:637–643.
40. Otley CC, Nguyen TH, Phillips PK. Anxiolysis with oral midazolam in
pediatric patients undergoing dermatologic surgical procedures. J Am
Acad Dermatol 2001;45:105–108.
41. Salasche SJ. Acute surgical complications: cause, prevention, and treat-
ment. J Am Acad Dermatol 1986;15:1163–1185.
42. Petry JJ. Surgically significant nutritional supplements. Plast Reconstr
Surg 1996;97:233–240.
21. Tucker S, Harris PC. The unforgettable finger tourniquet. Injury 2002;
33:76–77.
22. Salasche SJ. Surgery. In: Scher R, Daniel CR, eds. Nails: therapy, diag-
nosis, surgery, 2nd edn. Philadelphia: WB Saunders 1997; 326–349.
23. Wakai A, Winter DC, Street JT, et al. Pneumatic tourniquets in extrem-
ity surgery. J Am Acad Orthop Surg 2001;9:345–351.
24. Larson P. Topical hemostatic agents for dermatologic surgery. J Dermatol
Surg Oncol 1988;14:623–632.
25. Micromedex Healthcare series.
26. Sweetman SC. Martindale: the complete drug reference. London: Phar-
maceutical Press; 2002.
27. Casdorph DL. Topical aminocaproic acid in hemophiliac patients under-
going dental extraction. DICP 1990;24:160–161.
28. Product information. Urgent QR™.
29. Bonadio WA, Wagner VR. Adrenaline–cocaine gel topical anesthetic for
dermal laceration repair in children. Ann Emerg Med 1994;23:1435–
1438.
30. Vibe P, Pless J. A new method of skin graft adhesion. Scand J Plast
Reconstr Surg 1983;17:263.
31. Currie LJ, Sharpe JR, Martin R. The use of fibrin glue in skin grafts and
tissue-engineered skin replacements: a review. Plast Reconstr Surg
2001;108:1713–1726.
32. Dover JS, Arndt KA, Geronemus RG, et al. Continuous and pulsed
carbon dioxide laser surgery. In: Dover JS, Arndt KA, Geronemus RG,
Alora MB, eds. Illustrated cutaneous and aesthetic laser surgery, 2nd edn.
Stamford, CT: Appleton & Lange 2000; 23–80.

239
16
Ellipse, Ellipse Variations, and
Dog-ear Repairs
Samuel E Book MD FAAD, Sumaira Z Aasi MD, and David J Leffell MD
Summary box
 The best results in ellipse excision are achieved by:
n designing the simplest repair that will achieve optimal
cosmesis
n avoiding unnecessary flaps or grafts
n undermining only as needed.
 The repair type is selected according to patient characteristics
and clinical circumstance, including:
n consideration of the patient’s age, health, and level of
activity
n consideration of second intention healing if cosmetic
outcome is likely to be superior to reconstructive repair.
 An understanding of cosmetic units of the face and skin
characteristics of the anatomic location are important in
elliptical excision.
 There are a number of variations on the ellipse and when to
apply them depends on the circumstances.
 Even the best-planned ellipse may result in standing cones
(dog-ears); there are several techniques to repair these.
 INTRODUCTION
The increasing practice of skin surgery by dermatologists has
introduced a philosophy of reconstruction that reflects an
understanding of the biology of the skin. From less invasive
skin biopsy to complex local reconstruction, office-based
surgery as advanced by dermatologists under local anesthesia
has led to refinements and improvements in a range of
common procedures. Chief among the surgical procedures
performed on skin is the ellipse, or fusiform excision. It is
used for the therapeutic removal of benign and malignant
lesions and is critical to the proper diagnosis of pigmented
lesions and inflammatory diseases of the skin. The elliptical
excision comprises all the fundamental elements of more
advanced procedures such as local flaps, skin grafts, and cos-
metic procedures. Those elements which must be learned
thoroughly, understood instinctively, and practiced continu-
ally include a knowledge of local anatomy, skin type, cosmetic
units, incision technique, tissue handling, suture selection and
placement, and wound management. All of these essentials
are the bedrock of more advanced procedures. Learn the
ellipse and perform it flawlessly and all else will follow. The
goal of the elliptical excision, as with all other repairs, is a
cosmetically excellent result; the scar should be hairline in
thickness and well concealed within natural contours.
 PREOPERATIVE PREPARATION
History
In skin surgery, as in most endeavors which are not by their
very nature spontaneous, thorough preparation is paramount.
Every skin lesion is associated with a patient, and that patient
needs a complete and directed medical history as a prerequi-
site to excellent care and an optimal result (see Chapter 5).
Most of the medical history can be obtained on the day of
surgery. Two exceptions are information about an artificial
heart valve or another condition that may require antibiotic
prophylaxis,1 and whether the patient has a pacemaker or an
implantable cardioverter–defibrillator (ICD). While the issue
of antibiotic prophylaxis remains controversial, the American
Heart Association currently recommends prophylaxis only
for contaminated skin wounds or those that have been open
for more than 2 hours. The risk of bacteremia leading to
endocarditis from a clean skin biopsy or similar minor proce-
dure is extremely low and prophylaxis is not currently recom-
mended (see Chapter 6). Confirmation should be sought
from the cardiologist to ascertain whether the patient has a
pacemaker or an ICD. Most newer pacemakers have filters
that block extraneous electrical current, permitting the
routine use of short bursts of electrocautery, but ICDs can
adversely be affected by any electrical impulses. The options
for these patients include disabling the ICD temporarily,
using heat cautery, or using bipolar forceps to confine the
current to a very small local area (see Chapter 9).2
Evaluation
Once the history has been satisfactorily obtained and clearly
documented, evaluation of the individual who presents for
facial excision should be done under proper lighting, with the
patient in a sitting position.
First, any landmarks, cosmetic units, and relaxed skin
tension lines that can be used to help camouflage the scar are
identified. Examination and planning are not passive activities:
inspection, palpation, and gentle manipulation are necessary
to confirm relaxed skin tension lines and to determine the

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Part 2  Essential Surgical Skills
In our experience, scarring is the outcome of greatest
concern to most patients. It is important to be explicit about
the fact that there will be a scar and that it is the natural
consequence of healing. We explain that scarring is actually
the end result of the amazing ability of the body to heal. And
we explain that the issue is not whether there will be a scar
– there will most definitely be one. The issue is whether it
will be noticeable. Explained in these terms, we are comfort-
able that the patient is best prepared for the healing process
that will ensue.
As part of the informed consent procedure, we provide
a hand-held mirror so that the patient can see the extent
of the lesion and probable length of the scar that we outline.
It is important to explain the concept of dog-ears and that
in order to correct such ‘darts’ (a term well-understood
by people who sew), the scar may be lengthened. No one
likes surprises in this situation, which is why it is valuable
to give an explicit description of what the surgeon will be
doing and why it is good medicine. The informed consent
discussion and written consent should include references
to the risk of bleeding, infection, recurrence of the lesion,
damage to pertinent nerves, and an unsatisfactory cosmetic
result. Other treatment options should also be described,
at least verbally. Finally, offer to answer any remaining
questions and have the patient sign the informed consent.
In the case of an adverse outcome, the patient might claim
that they did not understand what they were signing, but a
proper and detailed discussion can prove such a claim to
be false.
Anesthesia
Introducing the local anesthesia is often a source of great
anxiety for the patient. There are many techniques to mini-
mize the fear induced by the ‘needle’ and ‘injection.’ Before
proceeding with this step, which often requires patience and
much skill, the lesion must be carefully marked and the exci-
sion outlined with respect to the evaluation already per-
formed. Mark important landmarks, such as the vermilion
border, which might be distorted by the introduction of the
local anesthetic. The most popular markers are gentian violet
and indelible felt-tipped markers. The latter offer the advan-
tages that they are slow to dry out and do not spill. Gentian
violet markers have a limited and unpredictable life span. Dry
markers are ineffective. In addition, gentian violet may
‘tattoo’ if not cleaned off before closing the wound.
The method used to inject the anesthesia will be remem-
bered by the patient more than anything else the surgeon or
surgical assistants do. The patient will recall whether the
procedure was gentle or not, whether it was very painful or
minimally so, and whether it was done with compassion.
Most patients fear needles, and fear accounts for a great
proportion of perceived pain. With an enhanced anesthetizing
procedure, the patient will do well throughout the rest of the
operation. Follow these simple guidelines:
• If lidocaine with epinephrine is used as the anesthetic,
buffer it with 8.4% sodium bicarbonate to reduce the
acidity and minimize the burning and stinging sensation
caused by the injection; mixing one part of 8.4% sodium
bicarbonate with ten parts of lidocaine with epinephrine
will raise the pH to above the neutral range.3
• Use a 2.5-cm 30-gauge needle to permit wide
distribution of the anesthetic.
impact of a particular repair on adjacent structures. The
patient can be asked to ‘show’ their teeth, in preference to
being asked to ‘smile,’ as most patients are anxious, and not
naturally disposed to cheerfulness when a surgeon looms over
them, poised to incise. Observe the patient making specific
facial expressions to accentuate the natural facial lines. Pursing
the lips and raising the brow are two important maneuvers for
studying the lip area and forehead and brow region.
The importance of understanding facial cosmetic units
cannot be emphasized strongly enough (see Figs 1.4–1.7). A
longer scar limited to one cosmetic unit will be less notice-
able than a shorter one that crosses the border between two
units. It is important to recognize potential functional prob-
lems, such as the risk of ectropion, elevation or depression
of the lip, or collapse of the nasal ala. Often the extent of
potential ectropion can be estimated by asking the patient to
look upward. This exaggerates the pull on the lower lid as the
globe rotates upward. If the proposed repair lacks sufficient
laxity under these circumstances, it is likely that an ectropion
will result, even if it initially seems the wound is small enough
to repair otherwise.
Although relaxed skin tension lines are useful guidelines,
variations in skin laxity, previous surgery, and skin texture
may often suggest alternative preferred ways to align the scar.
If the optimal direction for the ellipse is unclear, it may be
helpful to excise the lesion as a simple circle, undermine as
needed, and then observe which direction, independent of
relaxed skin tension lines or cosmetic units, will provide for
the most cosmetically elegant repair. Often, excision of the
redundant cones of excess skin will be performed in a way
that achieves a well-concealed scar.
Informed consent
Once the surgeon decides on the nature of the excision to be
performed, and understands its impact, the risks and benefits
of the procedure must be discussed in detail with the patient.
First, give a clear description of the diagnosis and the need
for the procedure. For cosmetic procedures it should be
emphasized that the procedure is not medically indicated; in
this circumstance, the risks are especially germane because
they are affected by the benefit that accrues to the patient.
The greater the medical need, the more risk the reasonable
person would assume. The inverse is true for cosmetic pro-
cedures. Next, simple terms should be used to explain exactly
what will happen during surgery and what can be expected
during the postoperative period. The use of medical jargon
should be avoided. Remember that while the surgeon gives
informed consent many times a day and the process may feel
routine, for the patient it is all new information. Therefore
care must be taken to avoid words that are likely to frighten
or confuse, and all discussions should be direct but compas-
sionate. An instinctive assessment of the patient’s level of
comprehension should be made. Do not quote an endless
stream of statistics – they generally are only meaningful to
options traders, actuaries, and gamblers. If the risk of infec-
tion is 1%, explain that in your experience ‘only one out of a
hundred’ patients is likely to get an infection, but add that
this can usually be treated easily with antibiotics. Spend a
few minutes discussing the issue of ‘scarring.’ This issue is of
great concern to patients, often because of an unrealistic
expectation of the final aesthetic result and familiarity with
others who have had suboptimal skin surgery.

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Chapter 16  Ellipse, Ellipse Variations, and Dog-ear Repairs
that are well demarcated should be excised with a minimum
margin of 4 mm if the Mohs micrographic surgery technique
is not used.9 It is generally considered that severely atypical
nevi and melanoma in situ require a 5-mm margin from the
discernible edge of the pigmented process.10 Margins for inva-
sive melanoma are based on the Breslow level of invasion. For
optimal closure, all excisions must be extended into the sub-
cutis or else approximation of wound edges will be impeded.
After the surgical site has been marked, anesthetized, and
prepped and draped, the surgeon’s technique becomes para-
mount. The incision must be directed, smooth, and confident.
In our experience, novice skin surgeons tend to make short,
ragged incisions along the length of the ellipse when in fact
a smooth incision angled at approximately 10° to the outside
of the wound is required (Fig. 16.2). The point of the blade
makes the initial cut at the apex, then quickly the sharper
belly is used to move along the arc. Traction of the surround-
ing area is critical and if no assistants are available the surgeon
must learn how to use the non-dominant hand, or must rest
the fifth finger of the dominant hand on adjacent skin to apply
mild tension on the surgical site. The incision should be
carried down to subcutis on the first pass. On the back, where
the dermis is very thick, this is not always possible although
use of a #10 blade can facilitate a smooth percutaneous inci-
sion. The specimen can be marked with a suture for orienta-
tion either while the specimen is still in situ (to avoid errors),
or after it has been completely removed. Using a toothed
forceps, grasp the specimen at one of the apices and gently
elevate it. Then dissect in an even plane, using a scalpel for
sharp dissection, or scissors for blunt dissection. If properly
executed, there should be a fusiform defect with smooth,
even walls and base.
Bleeding is normal, especially in more vascular areas such
as the scalp and face. Meticulous hemostasis should be
achieved. Do not underestimate the effectiveness of direct
pressure. Holding firm pressure over the area with gauze even
• Gently pinch the area to be injected, taking advantage
of the gate theory of pain, and inject slowly because
some pain is associated with tissue expansion caused by
the solution.4
• Do not perform multiple needle sticks through the
epidermis – introduce the needle only once, using a
fan-like method to distribute the anesthetic throughout
the surgical field, injecting slowly while the needle is
advanced around the lesion.
• If the lesion is large and multiple needle sticks are
unavoidable, be sure that the second injection is in an
area that is already numb (a ring block is especially
helpful for very large excisions because it limits the
amount of anesthetic used and decreases the risk of
toxicity).
• Remember basic skin anatomy and target the dermal
neural plexus for maximally efficient anesthesia.
• In anatomic areas of concern, such as the temple, the
surgeon may want to add anesthetic solution to swell or
tumesce the area to protect underlying structures.
Prepping and draping
After the patient is anesthetized, the surgical area should be
prepped with antiseptic and draped. This is a critical step,
but it should be noted that the risk of serious infection in
skin surgery is quite low and that the level of antisepsis used
for general surgical cases is not achieved in the office setting
nor, apparently, is it required. However, every effort should
be made to prepare the surgical site in an appropriate fashion.
Popular prepping agents include povidone-iodine, chlorhexi-
dine, and pHisoDerm (Chattem, Inc, Chattanooga, TN).
Povidone-iodine can cause contact allergies5 and chlorhexi-
dine can cause keratitis with prolonged contact.6 Ototoxicity
has been reported from chlorhexidine gaining access to the
middle ear.7
The surgical site should be cleansed in an outward-spreading
spiral, which begins from the center of the planned surgery.
The cleansing agent should remain on the skin for the requi-
site period of time necessary for full effectiveness.
 TECHNICAL ASPECTS
Elliptical excision
The classic simple excision is most commonly known as the
ellipse or fusiform excision. The procedure is based on a
design that bears a length:width ratio of 3 : 1 or 4 : 1 with the
apical angles ranging from 30° to 75° (Fig. 16.1).8 This design
is intended to eliminate any redundancies or dog-ear forma-
tion at the apices as the circular defect is transformed into a
linear closure. The final result of such an excision should be
a long thin scar which conforms to anatomic contours. As
mentioned earlier, the excision should be designed to take
advantage of anatomic ‘hiding places.’ Rhytides, relaxed skin
tension lines, and borders of cosmetic units can all be used
to advantage. In most instances, excision along the relaxed
skin tension lines is advantageous (a notable exception is the
forehead where a mid-forehead excision perpendicular to the
relaxed skin tension lines – a vertical excision – may offer a
superior result).
When designing the ellipse, the size of the lesion, including
the margins of normal skin necessary for appropriate removal,
must be considered. Basal cell and squamous cell carcinomas
Lesion
Fusiform excision line
Maximal skin tension line
Margin
30˚
An ellipse or fusiform excision line
Figure 16.1  An ellipse or fusiform excision with a length:width
ratio of 3 : 1 or 4 : 1 and 30° to 75° angles at the apices.
(Modified with permission from Leffell DJ, Brown M. Manual of
skin surgery. New York: Wiley-Liss 1997; 154. Copyright ©
John Wiley & Sons.)

242
Part 2  Essential Surgical Skills
cautery enhances outcomes and minimizes bleeding compli-
cations, it should always be used judiciously.
It is a widely held belief that undermining the surrounding
skin is required to close any wound. In fact, undermining is
only needed to the extent that it is necessary to minimize
tension on the wound. If the skin surrounding the surgical
site is intrinsically lax from photodamage or chronologic
aging, and the wound can be approximated without under-
mining, it is quite appropriate to do so. Moreover, in patients
receiving anticoagulants or platelet inhibitors, excess under-
mining increases the risk of bleeding and hematoma. In some
larger, deep defects, absorbable sutures can be placed in the
subcutis to decrease the tension and eliminate the need for
undermining.11
When undermining is required, it must be done carefully
and meticulously. Regardless of whether sharp or blunt tech-
niques are used, the surgeon must have in mind a clear under-
standing of the local anatomy: severing motor nerves or large
vessels because of poor technique is an adverse outcome. Use
of a skin hook is very helpful when undermining as it allows
lifting of the wound edge with minimal tissue damage. The
hook should be held perpendicular to the surface of the
for a few minutes will significantly decrease the amount of
oozing. When pressure alone is insufficient, the use of electric
or heat cautery should be employed. While heat cautery will
work in a wet field, electrocautery is only effective in a dry
field. Quickly dabbing the area with gauze or rolling a cotton-
tipped applicator over the area prior to cautery enhances
its effectiveness. Vacuum suction is often required to
obtain a clear field if there is moderate to severe bleeding.
To help decrease unnecessary tissue damage and char, pin-
point cautery is preferred. Remember the phrase ‘visualize
– then cauterize.’ The surgeon cannot treat what the surgeon
cannot see. Random cautery is ineffective and may be harmful
because it causes unnecessary thermal tissue damage. For
larger vessels, cautery may not suffice and the vessel should
be ligated with 4-0 or 3-0 absorbable suture. A hemostat can
be used to identify and isolate the bleeding end of the arte-
riole or artery prior to ligating.
Once hemostasis is achieved, repair of the defect can begin.
It is not unusual to have persistent wound-edge bleeding from
the dermal plexus, especially in individuals with ruddy skin.
It is not necessary to cauterize this tissue as the bleeding
will stop promptly once the wound is sutured closed. While
Incorrect
Incorrect
Correct
Wrong
Wrong
Incision
Figure 16.2  Incision. In
order to avoid a jagged
edge, use firm confident
strokes. Using the non-
dominant hand to provide
tension is also helpful.
(Modified with permission
from Leffell DJ, Brown M.
Manual of skin surgery. New
York: Wiley-Liss 1997; 156.
Copyright © John Wiley &
Sons.)

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Chapter 16  Ellipse, Ellipse Variations, and Dog-ear Repairs
are very helpful. An occasional vertical mattress stitch may
help in proper eversion (see Fig. 13.7) .
A running subcuticular suture placed in the subepidermal
plane is an alternative to the typical epidermal suture. Because
of the location of the suture, it can be left in for an extended
period of time. This approach is sometimes helpful when one
wants to maintain approximation of the epidermis during the
early healing period. Another advantage of this technique is
the ability to use a dry dressing by placing Steri-Strips (3M
Surgical Products) or similar tapes over the wound. This
minimizes wound care and is very much appreciated by
patients. It is not clear whether a running subcuticular suture
results in a better cosmetic result than other techniques for
epidermal closure. However, it is an option if one intends to
leave the epidermal suture in for more than the standard
period. While any monofilament suture can be used, those
with a low friction coefficient (e.g. polypropylene, polydiox-
anone) are easier to remove. While this technique requires
more effort and precision than a regular running suture, with
practice it can be performed quickly and accurately. There
are many ways to initiate and terminate the suture but one
effective approach is to tie a knot after leaving a small tail
and folding it back over the suture line so it can be taped in
place (see Fig. 13.13).
After the suturing is complete, ensure that there is no
active bleeding. This is best accomplished by firmly rolling a
cotton-tipped applicator along the suture line. There should
be only minimal oozing, which disappears with subsequent
rolls. If there is continued bleeding, apply firm pressure with
gauze for 5 minutes by the clock. Finally, if bleeding through
the incision persists, it must be opened and the wound bed
examined for any active sources of bleeding.
Crescent excision
There are variations to the standard ellipse that may provide
superior results, depending on location or specific situations.
The crescent excision, which takes advantage of sides of
unequal length, can result in a shorter curvilinear scar which
can be cosmetically superior to a longer straight scar. The
crescent repair is a versatile one that is often helpful on the
cheek and around the chin. When evaluating the patient in
the sitting position, note the natural rhytides. The arc of the
crescent will determine the final result, so orient the arc in
the direction of the natural lines (Fig. 16.3). These must be
closed by the rule of halves in order to avoid any redundan-
cies. Even with this approach, small redundancies at either
end of the wound may have to be removed. If so, direct the
final scars so they are well hidden.
M-Plasty
The M-plasty is a simple and effective method for reducing
the length of the scar when it otherwise would encroach on
neighboring functional or cosmetic structures. Instead of
extending the fusiform excision beyond its apex, as one
would normally do to excise the redundant cone of skin or
dog ear, an M-plasty can be designed to remove the excess
skin while allowing the limbs of the repair to be well con-
cealed (Fig. 16.4). The M-plasty can be designed prior to
the excision or, if indicated, during the completion of the
repair. When planning the excision, envision a typical ellipse
but draw an ‘M’ shape instead of the apical tip at approxi-
wound to permit maximal exposure of the wound bed. Some
prefer to use a forceps, but care must be taken to avoid crush-
ing the wound edge. If needed, undermine around the whole
ellipse, including the apices. Often, simply undermining at
the apices will obviate the need for excising small dog ears.
To evaluate the adequacy of the undermining, use two skin
hooks and bring the sides together. If they do not come
together easily, further undermining might be helpful. After
the undermining is complete, inspect the base of the wound
and the undersurface of the undermined tissue for bleeding.
Remember that when epinephrine is used as an anesthetic
ingredient, vessels can go into spasm, only to relax and bleed
2–3 hours after surgery. For this reason the surgeon must
identify and cauterize any vessels that might be at risk.
With the wound properly prepared, and hemostasis com-
plete, the layered closure can be initiated. This consists of
the use of absorbable deep sutures and a non-absorbable
superficial suture. There are variations with respect to how
the epidermis can be closed and some defer epidermal closure
completely if approximation of wound edges is otherwise
excellent.
If there is little tension on the wound, closure by halves is
the rule. The first suture is placed in the center of the wound.
Next, each half of the remaining defect is repaired in a similar
fashion. If there is tension on the wound, it might be benefi-
cial to simulate the ‘zipper’ effect: start suturing at the apex
and close the wound incrementally by placing a deep dermal
suture every 3  mm. This helps reduce the tension as the
repair advances down the defect. The buried dermal suture
is suggested by some to provide optimal wound eversion (see
Fig. 13.14).12 The buried suture, regardless of the technique
used, is the foundation of the repair and will have the great-
est impact on the final result. Precise placement is critical.
Remove improperly placed sutures and reposition as needed.
Once the buried sutures have been placed, proceed with
the superficial epidermal layer. The goal of this component
is epidermal approximation. In areas with no tension and
good subcutaneous approximation, these additional sutures
may not be needed. In such cases, adhesive tapes such as
Steri-Strips (3M Surgical Products, St Paul, MN) applied
with an adhesive such as Mastisol (Ferndale Labs, Ferndale,
MI) can be used. Alternatively, octylcyanoacrylate tissue
adhesive (Dermabond (Ethicon, Summerville, NJ)) is expen-
sive but popular. Glustich (Glustitch, Inc, Delta, BC, Canada)
is a similar medical adhesive and is much less expensive.
The typical epidermal sutures can range from 4-0 to 6-0
monofilament. On the lip, silk may be used. Where additional
hemostasis is not a concern, a running suture effectively
achieves rapid, excellent approximation (see Fig. 13.11).
Because tension is less predictable with this method, simple
interrupted sutures should be used if better approximation
or hemostasis is required (see Fig. 13.5). Similarly, if it
becomes necessary to open the wound to find the source of
postoperative bleeding or to place a drain, it will be possible
to open a few sutures and not have to remove an entire
running suture. All sutures should be snug, but not so tight
that they strangulate the tissue.
Running locking sutures, which provide additional hemo­
stasis, may be used on the ear or genitals where blood supply
is plentiful and unlikely to be compromised by the locking
suture (see Fig. 13.12). Finally, in areas where the skin natu-
rally inverts (e.g. forehead creases), vertical mattress sutures

244
Part 2  Essential Surgical Skills
A
B
C
D
E
Figure 16.3  (A) Circular defect on the cheek following removal of a basal cell carcinoma utilizing the Mohs method. (B) The patient
is asked to show his teeth to accentuate the natural lines of expression. (C–D) Crescent designed to result in a curvilinear line that
follows the natural relaxed skin tension lines. (E) The crescent repair permits a final scar that is well hidden within the natural lines of
facial expression. Note that the original circular wound is modified so that the sides of the repair have unequal lengths.
mately one-quarter of the length of the ellipse. When used
to remove a dog ear, the ‘M’ shape is formed by lifting the
excess tissue with a skin hook and making incisions with 45°
angles on both sides of the standing cone. Proceed by draping
the tissue over the incision lines and remove the redundant
triangles on each side. A tip stitch is helpful when performing
an M-plasty.
S-Plasty
Another variation of the ellipse is the S-plasty or Lazy-S
repair. This repair is used to achieve a superior cosmetic
result when working on convex surfaces such as the jaw and
extremities (Fig. 16.5). Although a standard fusiform will
heal well initially, as the scar contracts over time the repair
may become depressed or buckled. By elongating the scar
through the use of an S-plasty, where both sides of the ellipse
are designed in the shape of the letter ‘S,’ the contraction
will occur over a greater length, which will minimize buckling
of the scar. This is important to understand since all scars can
contract up to 30% in length over time.
Partial closure
When excising benign lesions, one should be careful to calcu-
late that a complete closure is possible so that the final cos-
metic result is superior to the appearance of the lesion itself.
With malignant tumors, the defect is determined by the
extent of the cancer. At times, the health of the patient, or
the patient’s wishes, suggests consideration of second inten-
tion healing. Although most wounds will heal well by second
intention, this process can often be facilitated by performing
a partial closure. One option is to begin the closure at the
apex where there is the least amount of tension and to
proceed to close like a zipper. When the wound edges can no
longer be approximated, the closure can be commenced at
the opposite apex, working towards the center of the wound.
Often, as the repair progresses, tissue creep will allow com-
plete closure at the center. A pulley stitch (3-0 monofila-
ment) left in place for approximately 20 minutes prior to
closure may also enhance complete approximation. Finally,
even if it is not possible to join the wound edges completely
at the center, satisfactory healing will usually occur at this
site by second intention healing (Fig. 16.6). The final scar will
usually take on the linear conformation of the sutured ends
of the wound.
Dog-ear repairs
Even the best-planned and designed ellipse may result in
redundancies at one or both ends. The dog-ear repair will
correct these imperfections, which can be quite noticeable

245
Chapter 16  Ellipse, Ellipse Variations, and Dog-ear Repairs
B
D
A
C
E
F
Figure 16.4  (A) Basal cell carcinoma on the chin. (B) Circular defect status after Mohs micrographic surgery. (C) M-plasty designed
to avoid crossing over into a new cosmetic unit. (D–E) A tip stitch may be used to complete the M. (F) Final result: shorter scar
remains within one cosmetic unit.

246
Part 2  Essential Surgical Skills
and distracting even when small. Skillful management of
standing cones of redundant skin, created by the transforma-
tion of a circular defect into a linear repair, will contribute
substantially toward a superior cosmetic result. The novice
surgeon is frequently fearful of excising excess ‘normal’ skin.
However one must remember that it is not the length of the
scar that is important but how noticeable it is when finally
healed. A long fine line with no protrusions is far superior to
a shorter scar with puckers. The removal of even a few mil-
limeters of excess will greatly improve the outcome. It is
helpful to explain this concept to the patient so there is less
surprise at what is inevitably a longer ‘scar’ than they might
have expected. Remind them that over time the scar will
become less noticeable. Repair of dog ears can be accom-
plished in several ways.
Most often the standing cone of excess tissue can be
removed in a linear fashion by extending the incision. To do
this, lift the apex of the cone with a skin hook or just gently
squeeze the excess between the thumb and index fingers of
the non-dominant hand. Using the scalpel, make a straight
incision from the apex through the center of the cone. There
should now be two individual triangles which, when incised
at their bases, will extend the original incision line linearly
(Fig. 16.7). An alternative to this method is excision of
another small ellipse at the point of redundancy.
In many instances, a curved line will be less conspicuous
than a linear one. This is especially true when dealing with
Lazy-S repair
Figure 16.5  The Lazy-S repair is designed by juxtaposing two
S-shaped incisions around the defect. By approximating the
center of each slightly offset S to the other, the final repair
becomes a smooth serpentine line which contracts over convex
surfaces with minimal buckling. (Reprinted with permission from
Leffell DJ, Brown M. Manual of skin surgery. New York:
Wiley-Liss; 1997. Copyright © John Wiley & Sons.)
A
B
C
D
Figure 16.6  (A) Large basal cell carcinoma on the parietal scalp. (B) Defect after Mohs micrographic surgery. (C) Pulley stitches act
as an intraoperative tissue expander. (D) Closing the wound from the apices and ‘zippering’ towards the center leaves only a small
wound to heal by second intention, thus reducing healing time.

247
Chapter 16  Ellipse, Ellipse Variations, and Dog-ear Repairs
excisions on the face where there are natural rhytides, smile
lines, and relaxed skin tension lines. The hockey-stick or
curved method of dog-ear repair allows the surgeon to take
advantage of these natural creases and create an optimal
outcome (Fig. 16.8). Once again, start by elevating the apex
of the excess tissue with a skin hook or forceps. Gently pull
the cone in the direction of the desired final incision. Start
from the end of the original excision and make a curved inci-
sion in the desired location. The remaining triangle of skin
can then be draped down over this curved incision line and
excised along the curved line. Remember that the first inci-
sion will determine the direction of the line. It may be helpful
to lightly score the tissue with the scalpel prior to making a
full-thickness cut. Some prefer to score with a scalpel and
then excise the dog ear with sharp scissors.
An L-shaped repair is similar to the curved repair, but
after lifting the cone at the apex, an incision is made at a 90°
angle to the original suture line, forming an ‘L’ shape. The
triangle is draped over the incision and removed at its base.
The T-shaped correction is the same, but is bilateral so as to
form a ‘T.’ In most instances, a curved repair gives a superior
result.
 POSTOPERATIVE CARE
When the closure is complete, a pressure dressing is placed
on the wound and postoperative instructions are given to the
patient. There are many bandage variations but they all gen-
erally consist of a triple antibiotic ointment layer, followed
by a non-adhesive layer (e.g. Telfa: (Kendall, Mansfield,
MA)), a pressure layer (gauze), and a semielastic surgical
tape. Alternatively, skin glue or paper adhesive strips may be
used in place of epidermal sutures or in conjunction with
absorbable epidermal sutures such as fast-absorbing gut
sutures. In these cases, daily wound care is not required.
Regardless of the dressing used, application of pressure to
the wound site in the first 24 hours is, in our experience,
beneficial. After removing the dressing, the wound should be
cleansed with tap water to gently remove any crust. We avoid
hydrogen peroxide despite its continued popularity as it has
been shown to be cytotoxic to cells in vitro and adds no
benefit to the healing process. Patients should be instructed
to pat dry and reapply a thin layer of ointment, a non-stick
gauze, and paper tape. Should there be a thick adherent crust,
a wet gauze should be placed on the wound for 5–10 minutes.
This will help loosen the crust and allow it to be removed
with minimal discomfort or damage. The patient may shower
after the first 24 hours but should be careful not to allow the
forceful stream of water to hit the wound directly. Advise
the patient that there may be swelling and bruising as well as
some oozing from the wound. This is especially true for exci-
sions in the periocular region.
These basic wound care instructions should be given both
orally and in writing. If a family member or friend will be
handling the care, be sure to review it with them. Potential
adverse events such as bleeding and infection, and steps to
take if they occur, should be thoroughly reviewed. Be sure to
provide a contact number so that the patient can bring up
any questions or concerns.
Sutures on the face and neck are generally removed in 5–7
days and those on the trunk and extremities can be removed
at 7 days if adequate buried sutures have been placed. Leaving
A
B
C
D
E
Dog-ear repair
Figure 16.7  In this dog-ear repair, the excess cone of skin is
incised so that the final scar is an extension of the linear
closure.

248
Part 2  Essential Surgical Skills
A
B
C
D
E
F
G
Figure 16.8  (A) Excess tissue after a linear closure of a wound on the medial cheek. (B) Using a skin hook or forceps, the apex is
pulled to one side and (C) a curved incision is made. (D) The tissue is then draped over the incision line, and (E) the redundancy is
removed along the curved cut edge of the incision. (F–G) Suturing is then completed.
 OPTIMIZING OUTCOMES
Optimizing outcomes
 Remember that a shorter scar is not necessarily a less
noticeable scar; the choice of technique should be based on
location, the patient’s needs, and their level of activity.
 If there is uncertainty about the proper orientation of the final
repair, first excise the lesion as a circle and observe the
actual relaxed skin tension lines.
 Consider second intention healing if the cosmetic result is
likely to be superior to reconstructive repair.
 Crescent excision takes advantage of sides of unequal length
and is helpful on the cheek or chin.
 M-plasty is a useful method when the scar would otherwise
encroach on neighboring functional or cosmetic structures.
 S-plasty achieves a superior cosmetic result on convex
surfaces such as the jaw and extremities.
sutures in too long will result in permanent suture marks
which are unsightly. When removing the sutures, it is best to
have the patient in a comfortable supine or prone position.
After carefully removing the sutures, apply a liquid adhesive
(e.g. Mastisol) and wound closure tapes (e.g. Steri-Strips
(3M Surgical Products)). The strips help keep the epidermal
edges approximated and occluded, allowing for additional
epidermal proliferation. The strips can be removed in 3–5
days and the patient may apply make-up at that point if
desired. Remind the patient that the final outcome of the
scar cannot be determined until a full year has elapsed.
Patients will very often ask about the use of vitamin E or
other products to enhance wound healing. There is no evi-
dence that vitamin E enhances the appearance of the final
scar or the ‘speed’ of healing but it is so ingrained in the
popular imagination that we do not strongly discourage it.
Massage and the application of polyurethane foam or silicone
patches may be beneficial in some patients in the early stages
of healing.

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Chapter 16  Ellipse, Ellipse Variations, and Dog-ear Repairs
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Extensive intraoperative bleeding increases the possibility of
postoperative bleeding; placement of a drain may help prevent
fluid collection and hematoma formation.
 Scrupulous use of sterile technique, careful tissue handling,
and closure without tension reduce the likelihood of infection.
 In the areas more prone to infection (intertriginous areas, the
extremities, and exposed cartilage), use acetic acid soaks
and/or antibiotic prophylaxis.
 If infection does occur, treat it empirically with antibiotics for
Staphylococcus aureus, the most likely cause of infection, but
if there is drainage, send a specimen for culture and modify
antibiotic choice accordingly.
 Advise patients preoperatively that at least some scarring will
occur, particularly where there is significant tension as on the
shoulders and upper back.
 Warn patients that incompletely dissolved sutures are not
uncommon and that they should return for prompt treatment if
this happens.
When surgeons operate frequently enough, they eventually
experience complications; that is the nature of the imperfect
discipline of medicine. With the elliptical excision and its
variants there are four major categories of complications:
bleeding, infection, dehiscence, and scarring. The importance
of clear and explicit communication with the patient both
preoperatively and postoperatively cannot be overstressed. If
the patient is clearly informed about the possibility of com-
plications, and how they can be managed, the impact of any
complication will be minimized. The surgeon should always
remain accessible to patients, so that problems or potential
problems can be heard at an early point when they might be
easier to resolve.
Intraoperative bleeding was discussed earlier, but if there
was extensive bleeding during the surgery one must anticipate
the possibility of postoperative bleeding as well. The place-
ment of a drain at the surgical site may help prevent the
collection of fluid and hematoma formation. The surgeon can
use either a Penrose drain or a gauze wick for this purpose.
If a drain was not placed and the wound continues to bleed
despite firm pressure for 15 minutes, or if there is an expand-
ing collection of blood beneath the suture line, surgical
intervention is necessary. The patient should be positioned
comfortably, prepped and draped. Local anesthetic may be
needed, but avoid using one containing epinephrine as it can
cause vasoconstriction and mask the source of the bleed.
Remove the sutures and open the wound. Clean out any col-
lection of blood and irrigate with saline. Carefully search for
any obvious arterial pumper that may be the cause. Most of
the time the source is less obvious and there is generalized
oozing. Be thorough in the search for the source of the bleed-
ing as it may be coming from beneath an undermined edge.
Use cautery and suture ligation to stop the bleeding. During
the first 24 hours, one can safely resuture the wound but it
may be preferable to leave it open to heal by second inten-
tion. After it has healed completely, a scar revision can be
performed. In either case the patient should be placed on
antibiotics to avoid infection.
When the bleeding is slower, a hematoma may develop over
a few days and only become apparent to the patient several
days later as an enlarging tender (or non-tender) mass. If the
hematoma is small and stable and there is no concern about
infection, observation is acceptable. Alternatively, draining
the hematoma will facilitate healing and avoid the develop-
ment of excess scar tissue. If any compromise of wound
healing is suspected, the surgeon must remove it. Although
an 18-gauge needle is usually sufficient to aspirate the
hematoma, opening the wound may be necessary. If the
wound is open at this point, it should be left to heal by second
intention.
Infection rates in office-based skin surgery range from 1 to
3%.13,14 While mild wound infections with erythema and
swelling are most common, abscess formation and even sys-
temic infection can occur. Immunocompromised patients
are obviously at greater risk but the operative technique and
anatomic location also play a role. Using sterile technique,
prepping the patient properly, careful handling of the tissue,
and closure without tension will all decrease the chance of
infection. Intertriginous areas such as the perineum and
axillae, as well as the lower extremities, are more susceptible
to infection.
Exposed cartilage, especially on the ear, is likewise at an
increased risk of infection, particularly Pseudomonas infec-
tion in diabetic patients.12 Thus, in such instances, acetic acid
soaks and/or prophylactic antipseudomonal antibiotics are
recommended. Although it may be difficult to distinguish
routine postoperative erythema and swelling from true infec-
tion, if the postoperative pain is increasing rather than
decreasing, and other classic signs of infection are present,
one must suspect infection and treat appropriately.
Most superficial skin wound infections are caused by Sta-
phylococcus aureus so empiric treatment with the appropriate
antibiotic is reasonable. If there is drainage, a specimen
should be sent for culture, and sensitivity and antibiotic cov-
erage modified if necessary once the culture results are
obtained. Any collection of fluid or abscess formation should
be drained and sutures should be removed. The wound should
be packed with iodoform gauze and changed daily until there
is no more drainage. Once again, the wound should be left
to heal by second intention and repaired in the future if
necessary.
There is no such thing as scarless surgery but there is such
a thing as an optimal scar. Never promise the patient that
there will be no scar. In fact it is best to be explicit
about the fact that there will be a scar but that every effort
will be taken to make it minimally noticeable. The patient
must understand that a scar is unavoidable and that in
many instances the final outcome is not in the hands of the
surgeon, but is subject to the impact of genetics and anatomic
location.
Hypertrophic scars and keloids are thickened, raised scars
(see Chapter 41). Keloids are in fact tumors of scar tissue
that extend beyond the wound margins. Hypertrophic scars
tend to resolve with time. Both tend to occur in areas of
high tension, such as the chest, upper back, and shoulders.
Those with a personal or family history are at greater risk. In
either case, scar revision may lead to worsening of the condi-
tion and therefore treatment generally consists of intrale-
sional steroids, and topical pressure devices or garments. If a
thickened scar is anticipated, preventive intralesional steroid

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planning, and this should include attention to detail as high-
lighted by the maxim ‘measure twice – cut once.’
 REFERENCES
1. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endo-
carditis: recommendations by The American Heart Association. Clin
Infect Dis 1997;25:1448–1458.
2. LeVasseur JG, Kennard CD, Finley EM, et al. Dermatologic electrosur-
gery in patients with implantable cardioverter–defibrillators and pace-
makers. Dermatol Surg 1998;24:233–240.
3. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine
for local anesthesia. J Dermatol Surg Oncol 1989;15:1081–1083.
4. Arndt KA, Burton C, Noe JM. Minimizing the pain of local anesthesia.
Plast Reconstr Surg 1983;72:676–679.
5. Marks JG. Allergic contact dermatitis to povidone-iodine. J Am Acad
Dermatol 1982;6:473–475.
6. Hamed LM, Ellis FD, Boudreault G, et al. Hibiclens keratitis. Am J
Ophthalmol 1987;104:50–56.
7. Bicknell PG. Sensorineural deafness following myringoplasty operations.
J Laryngol Otol 1971;85:957–961.
8. Mody BR, McCarthy JE, Sengelmann RD. The apical angle: a mathemati-
cal analysis of the ellipse. Dermatol Surg 2001;27:61–63.
9. Thomas DJ, King AR, Peat BG. Excision margins for non-melanotic skin
cancer. Plast Reconstr Surg 2003;112:57–63.
10. Consensus Development Panel on Early Melanoma. Diagnosis and treat-
ment of early melanoma. JAMA 1992;268:1314–1319.
11. Dzubow LM. The use of fascial placation to facilitate wound closure
following microscopically controlled surgery. J Dermatol Surg Oncol
1989;15:1063–1066.
12. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg
Oncol 1989;15:17–19.
13. Futoryan T, Grande D. Postoperative wound infection rates in dermato-
logic surgery. Dermatol Surg 1995;21:509–514.
14. Cook JL, Perone JB. A prospective evaluation of the incidence of com-
plications associated with Mohs micrographic surgery. Arch Dermatol
2003;139:143–152.
injections as well as pressure dressings may help reduce its
severity.
In areas of significant tension, the scar may spread or widen
rather than thicken. This occurs most often on the shoulders
and upper back. Patients should be advised of the likelihood
of this outcome.
Erythema and telangiectasias may also develop as the scar
matures, and these can quite easily be treated with a pulsed-
dye laser. Alternatively, electrocautery at the lowest possible
setting using an insulated epilating needle can be used to
eradicate these small vessels. Patients should understand that
in most cases the redness will resolve with time.
Incompletely dissolved or ‘spitting’ sutures are not uncom-
mon and patients should be educated about this possibility.
Spitting buried sutures usually occur at 3–6 weeks postop-
eratively and appear as small pimples, pustules, crusting, or
blood blisters along the suture line. When not warned about
this in advance, patients are quite concerned that this is an
infection or a recurrence of the lesion. Treatment consists of
removal of the suture fragment. It is important to do this
early so that it does not fester and cause an unsightly, persist-
ent foreign body reaction.
 SUMMARY
The ellipse or fusiform excision is the workhorse of cutaneous
surgery. It is the foundation and basis for all other advanced
surgical techniques. A thorough understanding of the ellipse
and its variations is essential for anyone involved in surgery
of the skin. The surgical result will be optimized by careful

251
17
Random Pattern Cutaneous Flaps
Jonathan L Cook MD and Glenn D Goldman MD
Summary box
 Random pattern flaps are ideal closures for surgical wounds
that will neither predictably heal by second intention nor be
easily repaired by direct linear closure.
 For each operative wound, several flaps may be suitable,
but one will likely be optimal. To improve outcomes, a
reconstructive surgeon must be able to match an appropriate
repair to a given surgical defect.
 Flap execution requires attention to minute details in design,
and small changes in the sizes or angles of flaps may result
in substantial improvements in outcomes. This is particularly
true for transposition and rotation flaps.
 The plane of flap elevation is crucial. Some flaps should be
elevated within the subcutis, some just above the superficial
fascia, and others at the deep fascia, perichondrium, or
periosteum.
 Most surgical complications associated with random pattern
flap reconstructions are preventable with proper flap design
and meticulous operative technique.
 There is a great deal of literature on surgical reconstruction,
and the art of flap repair requires lifelong learning.
 INTRODUCTION
Many operative defects in dermatologic surgery can be closed
linearly or allowed to heal by second intention. Certain
shallow wounds can be aesthetically repaired with full-thick-
ness skin grafts. Deeper and more critically located wounds
present greater challenges to the reconstructive surgeon, and
often require the skillful execution of local tissue rearrange-
ment (a flap). A flap is a moving construct of skin and sub-
cutaneous tissue created from tissue near an existing surgical
defect (Table 17.1). In distinction to skin grafts, flaps retain
vascularized connections to underlying tissues at their bases.
Flaps provide the surgeon with opportunities not only to
restore function by filling and closing operative wounds but
also to restore natural appearances more elegantly.
Historically, there have been many classification schemes
for surgical flaps. Flaps have been categorized by their vascu-
lar supply (random or arterial/axial), their primary motion
(advancement, rotation, or transposition), their configura-
tions (rhomboid or bilobed, for example), their eponymous
designations (e.g. Rieger, Mustarde), and their locations
(local, regional, or distant). In this chapter, flaps are classified
by their primary motion. Such a classification scheme is tra-
ditionally attractive and conceptually simplistic, but most
flaps combine several different types of tissue motion. For
example, many rotation flaps incorporate tissue advance-
ment, and the classic nasolabial transposition flap involves
substantial unidirectional cheek advancement.
Random pattern flaps are geometrically designed surgical
repairs based on either deep or lateral vascular pedicles that
do not necessarily involve the use of larger named arteries or
the formation and subsequent division of delayed pedicles.
The base of a random pattern flap is supplied by deeper
unnamed musculocutaneous arteries, and the elevated portion
of the flap is perfused by the highly anastomotic subdermal
and dermal vascular network. To survive, random pattern
flaps capitalize on the fact that the vascular supply to skin is
amazingly redundant. Because the normal perfusion of skin is
approximately ten times the blood flow needed to provide
basic nutritional support,1 appropriately designed flaps can
predictably survive. Although the term ‘random’ might seem
to add a sense of casualness to these flap repairs, the design
and execution of successful flap reconstructions is anything
other than random. Only appropriate flap design and proper
surgical technique can ensure reliable operative results.
Considerable skill is needed to perform a flap reconstruc-
tion. The effective reconstructive surgeon must have a thor-
ough knowledge of the reconstructive literature, a detailed
understanding of anatomy and the biomechanical properties
of skin, an eye for geometry and aesthetics, appropriate
manual dexterity, surgical confidence, the ability to prevent
and manage common surgical complications, and, perhaps
most importantly, the mentorship of a dedicated teacher.
This chapter mainly considers facial wound reconstruction,
but the flap principles and techniques can and should be
extrapolated to other anatomic sites of the body.
 HISTORY
Dermatologists’ interests in reconstructive surgical tech-
niques have dramatically accelerated during the past several
decades, but the rudiments of facial reconstruction date to
the antiquities. As early as 700 BC, Indian surgeons used local
flaps in nasal reconstruction. Celsus and Galen, in ancient
Rome, described the use of multiple facial repairs, including
advancement and island pedicle flaps. In Renaissance Italy in

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Part 2  Essential Surgical Skills
refinements to dermatologists, who have acquired high levels
of expertise in the repair of facial surgical wounds.
 PREOPERATIVE PREPARATION
When a surgical flap is used to repair a wound resulting from
the removal of a cutaneous malignancy, confirmation of the
adequacy of tumor removal should first be obtained. It is
undesirable to complete a surgical reconstructive procedure
only to learn that tumor persists at a lateral or deep surgical
margin. Additionally, because flap reconstructions cover oper-
ative defects with inherently thick pieces of tissue, the clinical
manifestations of persistent or recurrent disease may be con-
cealed from the patient and physician for several years. Clin-
ically apparent tumor recurrence following flap reconstruction
is therefore often advanced and may be difficult to treat.
The Mohs micrographic surgical technique (see Chapter
44) offers the highest cure rates for the extirpation of most
cutaneous tumors.4–6 It also conserves appreciable amounts of
normal tissue.7,8 The use of Mohs surgery therefore provides
a reliably complete, yet conservative, excision. For these
reasons, most surgical flaps carried out in the authors’ prac-
tices follow Mohs surgical excisions of various types of skin
cancers.
Cutaneous flaps offer several important advantages in the
repair of facial wounds. Flaps can prevent the functionally
and aesthetically significant distortion that can occur when
wounds are allowed to heal by second intention, and can also
restore a three-dimensional facial form that would be impos-
sible to achieve with the application of a skin graft when there
is significant tissue loss. Flaps move adjacent tissue of similar
color, texture, and thickness into operative defects, and the
aesthetic results from flap reconstructions often exceed
the aesthetic results that would have resulted from simpler
reconstructive alternatives. Because properly designed flaps
have reliable perfusion, flaps can also be used successfully to
cover relatively avascular tissues such as cartilage or bone.
With proper planning and surgical technique, the healing
from flap repairs is often much more rapid than the healing
of granulation or skin grafting. The morbidity and complica-
tions associated with skillfully performed surgical flap recon-
structions should be similar to those of skin grafting
procedures.
However, like all surgical interventions, flap reconstruc-
tions have several potential disadvantages. When flaps are
used to repair conspicuous facial wounds, the surgeon should
provide preoperative counseling that includes discusion of
restoration of the facial appearance as well as function and
obtain detailed informed consent. The artful design and
proper execution of facial flaps are acquired skills honed over
many years of surgical practice. Even a minor miscalculation
in flap design can result in flap failure, postoperative morbid-
ity, and functional or aesthetic compromise. For proper mobi-
lization, flaps generally require relatively long incision lines
and generous undermining. Poorly designed or improperly
implemented flaps may therefore lead to scarring and distor-
tion far beyond the area of the original surgical defect. Surgi-
cal morbidities such as postoperative hemorrhage or damage
to underlying facial motor nerves may result from poor surgi-
cal technique, a lack of knowledge of the underlying anatomy,
or patient-related factors. Failure of a surgical flap as a result
of ischemia can lead to a large and complex wound with a
protracted healing course and a poor aesthetic outcome.
the 1500s, both Gaspare Tagliacozzi and the Braca family
used local and pedicle flap reconstructions for the repair of
auricular and nasal wounds. In the late 1700s, the Indian
forehead flap technique was first published in an English
language journal. Carupe, an English surgeon, published his
experience with the forehead flap in 1816, and his manu-
script was widely circulated throughout Europe.2 This publi-
cation was an extraordinary admission by a European physician
that the historic practice of surgery by apprenticed workers
in India could result in the impressive reconstruction of a
diseased or traumatized nose. It is remarkable to realize that
these early efforts at facial reconstruction were carried out
without aseptic technique, antibiotic prophylaxis, advanced
instrumentation, or the use of effective local or general
anesthesia. Nonetheless, many of the surgical results were
outstanding, particularly when the results are viewed in their
historic context. These early surgeons demonstrated a thor-
ough knowledge of anatomy and an impressive attention to
the aesthetic subtleties of the face.3
Modern facial reconstruction began in the military theater
in World War I. As advances in general medical and surgical
care promoted the survival of soldiers who had been seriously
injured, increasing attention was placed on the complete
rehabilitation of the war’s wounded. Surgeons became much
more interested in surgical techniques to reconstruct the
damaged face, and many of the currently used techniques in
facial reconstructive surgery can trace their origins to this
important period in the early 20th century. Historically, the
greatest contributions to the field of reconstructive surgery
have come from plastic surgeons and otorhinolaryngologists.
In the past several decades, however, there has been an explo-
sion of interest and innovation from the nascent field of
dermatologic surgery. Dermatologic surgeons have contrib-
uted greatly to the field of facial reconstructive surgery, and
many currently used facial flaps owe their developments and
Table 17.1  Definitions
Primary defect
The operative wound to be repaired,
often resulting from tumor removal
Secondary defect
The operative wound created by flap
elevation and closure of the primary
defect
Primary flap motion
The direction of tissue movement that
closes the primary defect
Secondary motion
The direction of tissue movement
that closes the secondary defect that
resulted from the flap’s primary motion
Primary lobe
The portion of a flap that is designed to
cover the primary defect
Secondary lobe
The portion of a flap that is used to
cover the secondary defect
Flap size (surface area)
The entire area of flap elevation
combined with the primary operative
defect
Tension vector
The direction of force on a given
motion of the flap
Pivot point
The point at the base of the flap
about which the flap rotates and/or
transposes

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Chapter 17  Random Pattern Cutaneous Flaps
Most surgical complications that follow reconstructive
facial surgery involve difficulties in hemostasis,10 and there
are therefore many historic suggestions that medications that
promote bleeding should be routinely discontinued in the
perioperative period. The issue of whether or not to continue
the use of anticoagulants during the perioperative period in
patients undergoing facial reconstructive surgery is an active
area of discussion among dermatologic surgeons, especially
because there have been reports of thrombotic complications
(including strokes and myocardial infarctions) when anti­
coagulants have been withheld for cutaneous surgical
procedures.11 The risk of major bleeding following flap
reconstruction in patients who are anticoagulated with war-
farin may be slightly higher than the risk of bleeding without
anticoagulation, but the likelihood of catastrophic hemor-
rhage remains low. If the surgeon does elect to continue the
use of anticoagulants during the perioperative period, it is
reasonable to check a recent international normalized ratio
(INR). If the patient has a markedly elevated INR, warfarin
may be withheld for several days to bring the INR back into
the normal therapeutic range. The authors of this chapter
discontinue warfarin for 3–5 days in selected patients in
whom large flap reconstructions are needed. It is advisable
that the surgeon works with the patient’s primary physician
when medication adjustments are desirable.
Medications that adversely affect platelet function may also
complicate reconstructive surgery. Because aspirin irreversi-
bly inhibits cyclo-oxygenase,12 an enzyme crucial to proper
platelet function, the drug’s effects on hemostasis last for up
to 2 weeks, and any aspirin use may therefore predispose to
intraoperative and postoperative bleeding. Many older indi-
viduals take daily aspirin as prophylaxis against myocardial
infarction and stroke. For patients who have never had a
vascular event, this is primary prevention. Patients with a
history of a medically significant vascular event are taking
aspirin for secondary prevention. Both authors discontinue
aspirin 1 week before surgery for patients on aspirin for
primary prevention, but not for individuals on aspirin for
secondary prevention of further stroke or heart attack. If a
large surgery is planned, it is advised that the surgeon consults
with the primary care doctor before recommending discon-
tinuation of aspirin for patients in this latter group.
Smoking is not a contraindication to flap reconstruction,
but smokers do have higher incidences of flap failure and
distal flap necrosis,13 wound dehiscence,14 and wound infec-
tion.15 The adverse relationship between smoking and facial
surgery was initially described in rhytidectomy patients.
Among these patients, smokers had significantly increased
chances of flap necrosis.16 In studies from the dermatologic
literature, smokers have also been shown to have higher risks
of focal flap loss than their age-matched, non-smoking con-
trols17 (see Chapter 5). As a result of potential ischemia of
the distal or peripheral margins of a flap, the scars that accom-
pany reconstructive surgery in smokers tend to be more
visible than the scars in non-smokers. When feasible, it is
therefore advisable for patients to discontinue smoking
several weeks before and for at least 1 week after flap repairs.
Of course, many patients fail to comply with a physician’s
suggestions to abstain from the use of all tobacco products.
These individuals should be advised that their continued
smoking during the perioperative period puts them at higher
risk of operative complications. In addition, large, aggressive
flaps should generally be avoided or undertaken only with
Finally, the costs associated with large flap repairs can be
greater than the costs associated with less complicated recon-
structive alternatives.
Proper patient selection is critical to flap success. Appropri-
ate screening of a patient’s suitability for a flap repair should
precede any operative intervention. Following tumor removal,
random pattern flap reconstructions can typically be per-
formed safely in all but the most debilitated and medically
fragile patients. Because most procedures by dermatologic
surgeons are carried out in an ambulatory setting with the use
of only local anesthesia, systemic complications associated
with flap repairs are rare.
A large randomized trial has demonstrated that for cataract
surgery, a formal preoperative screening evaluation with
laboratory tests, electrocardiogram, and chest radiography
confers no benefit to the patient or to the physician, and such
medically unnecessary testing certainly adds great expense.9
Dermatologic reconstructive procedures could be conceptual-
ized as analogous to these ophthalmologic procedures, and the
need for extensive preoperative evaluation in most patients
undergoing outpatient reconstructive surgery for small and
moderately sized wounds remains unproven. Unless a patient
has a history of serious, unstable cardiac disease, a significant
bleeding disorder, or concurrent severe medical disease such
as profound immunosuppression or malnutrition, the patient’s
preoperative evaluation for tumor extirpation and flap recon-
struction can typically consist of a well-documented medical
history and a competent physical examination.
In addition to verifying general health, the cutaneous
surgeon should also properly assess the patient’s anatomy for
suitability of a flap reconstruction. This is particularly true
when assessing facial defects because minor degrees of asym-
metry, particularly in the central face, are quite common.
These asymmetries should be demonstrated to the patient
before initiation of the flap procedure. Failure to do this can
lead the patient to believe that the reconstructive procedure
caused the distortion.
When possible, flaps should be designed so that incision
lines do not cross convexities with underlying bone such as
the ramus of mandible, the zygomatic arch, or the clavicle
because hypertrophic scarring is more common in these
situations.
The physician should determine the quality and laxity of
the patient’s skin adjacent to the surgical defect. The mobil-
ity of the skin varies tremendously from location to location
and from patient to patient. A proper evaluation of the skin’s
laxity can easily be accomplished by the surgeon’s probing
hands. The quality of the skin should also be carefully
assessed. Many elderly patients have surprisingly atrophic
skin and subcutaneous tissue, and flaps that require relatively
high wound closure tensions should be avoided in these
patients because the tensile strength of the thinned dermis
will be unable to support the required wound closure ten-
sions. Conversely, areas of thick, sebaceous skin should also
be noted. Highly sebaceous skin has a low compliance, does
not easily stretch or bend, and can be brittle to work with.
In addition, it is generally advantageous to avoid placing inci-
sion lines within thick, sebaceous skin because the resultant
suture lines frequently track and invert. Finally, when pos-
sible, flaps should not rely on pedicles based on previously
scarred or irradiated skin because in addition to the inelastic
nature of this tissue, the perfusion of this skin is often sub-
optimal and usually unpredictable.

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Part 2  Essential Surgical Skills
the most critical blood supply lies in the shallow subcutane-
ous tissues. Flaps elevated in the loose, deeper subcutis there-
fore have, by definition, a predictably reliable blood supply.
If flaps are elevated within the dermis or within the very
shallow subcutaneous fat, a common technique of the surgical
neophyte, the flaps are at risk for ischemic failure given their
unreliable, tenuous perfusion.
Of historical interest, there have been many suggestions in
the surgical literature of appropriate length:width ratios for
successful random patterned flaps. In practice two factors,
torsion and tension, are more accurate predictors of flap
survival than the actual geometry of any flap repair. Parame-
dian forehead flaps, which is an axial flap, and certain banner
flaps can be created at length:width ratios of 6 : 1 or 7 : 1 (or
greater) if the flaps’ arterial supplies are not twisted or kinked
and if all wound closure tensions are directed along the flaps’
secondary motion. Even modestly elevated wound closure
tension can dramatically diminish flap perfusion, and great
care must be taken during the design of any reconstructive
procedure to create a flap that has as much reduced tension
across the primary and secondary defects as possible. Many
ischemic flap failures are due to errors in flap design, where
the seemingly predictable arterial input of the flap is rendered
ineffective because the flap has been twisted and turned
under elevated wound closure tension.
The venous drainage of a flap is equally important to its
arterial supply. In general, the venous drainage of a flap par-
allels the arterial supply, but it is not always an exact match.
While the arterial supply of a flap has a pressure-based viabil-
ity, the venous system is a low or negative pressure system,
and the small veins of a flap can become occluded and fail.
This can result in venous congestion and surface slough, her-
alded by a blue–purple discoloration of the epidermal surface.
In flaps elevated at a deeper plane, the muscle often provides
reliable venous drainage, and flaps with a muscular blood
supply rarely suffer venous congestion or arterial failure.
 TECHNIQUES
Advancement flaps
Tissue may be advanced to close an operative wound either
as a linear repair or as a flap. Many, if not most, surgical
defects are best handled by simple, direct side-to-side closure,
particularly in anatomic areas that have abundant loose skin
adjacent to the primary defect. Such linear repairs typically
distribute tension perpendicular to the line of closure. In
many locations, the resultant fine linear scar is aesthetically
ideal and generally well tolerated, particularly if the scar runs
within or parallel to one of the facial relaxed skin tension
lines. When an operative defect lies near a free margin such
as the vermilion border or close to a defined facial boundary
such as the nasolabial fold, any proposed linear repair may
violate the free margin or the facial boundary and may there-
fore be technically infeasible or aesthetically undesirable. In
such cases, an advancement flap frequently allows for optimal
closure.
The advancement flap is conceptually the simplest of all
flap repairs. In most cases, the tissue movement associated
with these flaps is a unidirectional, uncomplicated advance-
ment of the flap’s leading edge. In addition to moving adja-
cent tissue into the operative defect, advancement flaps
displace the tissue redundancies (dog ears) created by tissue
extreme caution. Nonetheless, with conservative appropriate
flap design and gentle, meticulous operative technique, the
dermatologic surgeon can perform most reconstructive pro-
cedures in smokers with safety and reasonable aesthetic
success.
Preoperative patient counseling is critically important in
reconstructive surgery, especially facial surgery. The patient’s
aesthetic expectations should be carefully evaluated. Patients
should prospectively understand that facial flaps can be rela-
tively complex reconstructions and that occasionally long
and complicated incision lines are required for proper tissue
mobilization. The undermining required for flap mobilization
frequently causes bruising and some postoperative discom-
fort. It is important to stress that flap reconstructions may
take months to mature and that, although uncommon, surgi-
cal revisions may be necessary. In areas prone to sensory
disturbance such as the forehead or upper lip, it is also essen-
tial to inform patients about likely postoperative numbness,
paresthesias, and the potential for developing neuropathic-
type pain. Fortunately, most sensory disturbances associated
with flap repairs are temporary. Because of mass media
efforts to glamorize many plastic surgery procedures as pain-
less, bloodless, and risk free, many patients require substan-
tial education before the flap’s incisions are made. The
physician’s explanations that are provided preoperatively con-
stitute informed consent; those that are provided postopera-
tively are often viewed by patients as self-protecting excuses.
 PHYSIOLOGY OF FLAP PERFUSION
Successful adjacent tissue transfers (flaps) rely on the highly
redundant perfusion of the skin and subcutaneous tissues to
maintain adequate tissue perfusion after flap motion. The
face is endowed with a rich, deep arterial supply from mul-
tiple branches of the internal and external carotid arteries.
External carotid branches such as the facial and superficial
temporal arteries and internal carotid branches such as the
supraorbital, infraorbital, and supratrochlear arteries divide
into a myriad of small vessels that penetrate the facial muscles
and deeper fascial planes. From the subcutaneous and intra-
fascial axial vessels, there are numerous perforating arteries
that feed into an extensive subdermal plexus. This plexus is
extensively redundant with numerous anastomotic connec-
tions. From the subdermal plexus, tiny vessels ascend to an
intradermal plexus that ultimately nourishes the overlying
skin.18–22
True axially patterned flaps, such as cross-lip (Abbe) flaps
and some paramedian forehead flaps, contain larger-caliber
arterial vessels that provide ample, predictable perfusion.
Island pedicle flaps, with intact, deep muscular pedicles,
similarly often contain sizeable arterial branches or richly
anastomosing intramuscular arterioles, making these flaps
particularly hardy and unlikely to suffer ischemic insult
during flap creation or movement (see Chapter 18). Scalp
flaps, which are routinely elevated beneath the galea, typically
contain larger vessels and therefore also have a robust blood
supply.23
Most random pattern flaps are based on the unnamed but
highly redundant vasculature of the subdermal plexus. The
intradermal plexus is, in general, insufficient to sustain flap
viability. The most abundant blood supply to the skin lies just
beneath the dermis in the smaller, dense fat lobules of the
subcutaneous tissue. Accordingly, for random patterned flaps,

255
Chapter 17  Random Pattern Cutaneous Flaps
were frequently used to repair nasal bridge defects from a
superior glabellar base and forehead defects from a lateral
base on the adjacent forehead or temple. Because nasal skin
is largely inflexible and non-compliant, simple advancement
flaps to repair distal nasal defects must often rely upon sec-
ondary motion at the nasal tip to close the wound. This
motion produces an unaesthetic elevation of the nasal tip, and
more appropriate flap repairs can nearly always be designed.
The leading edge of an advancement flap always requires
undermining to free deep restraints. Wide undermining of
the pedicle base does not necessarily increase mobility24
because this does little to liberate the lateral, superior, and
inferior restraints on flap motion. A pure rectangular advance-
ment flap with a longer length:width ratio is more easily
mobilized than a wider flap,25 and early advancement flap
designs were long unilateral advancements with 3 : 1
length:width ratios advocated. These length:width ratios
were often touted as appropriate designs to minimize the
risks of distal flap necrosis. In reality, it is uncommon to need
an advancement flap with such length, and in clinical practice,
narrow flaps that are excessively long or sutured under unac-
ceptably high wound closure tensions are no more subject to
ischemia than wider flaps created under equally undesirable
conditions.26
When sufficient tissue laxity does not exist to allow for a
simple unilateral advancement flap, a bilateral advancement
flap may be designed such that each flap advances half as far
to meet in the center of an operative wound (Fig. 17.3). The
movement to locations from which they can be excised with
less cosmetic burden. The ideally designed advancement flaps
allow for a limb of the repair to run along a free margin or
within a defined facial boundary. Importantly, advancement
flaps do not generally recruit much additional tissue laxity,
and the tension vector of the flap repair remains parallel to
the primary motion of the flap. Therefore, in distinction to
rotation and transposition flaps, advancement flaps do not
have the advantage of being able to redirect wound closure
tension to a more favorable axis.
Because a pure advancement flap does not recruit much
more tissue laxity than would be available with a simple linear
closure of the wound, some degree of secondary motion near
the flap’s insertion point is often required. If the primary
defect is near a facial structure that cannot be displaced
without undesirable distortion, this potential reliance upon
secondary motion should be anticipated.
Unilateral and bilateral advancement flaps
The classic advancement flap involves the creation of a rec-
tangular pedicle (unilateral advancement flap) or bilateral
rectangular pedicles (H-plasty). As the flap is advanced,
tissue redundancies develop at the pedicle base (Figs 17.1
and 17.2). If the ideal skin contour is to be preserved, these
dog-ear redundancies must be excised, which adds further
complexity to the simple U-shaped scar of the traditional
advancement flap. Historically, simple advancement flaps
Unilateral advancement flap
Figure 17.1  A unilateral
advancement flap displaces
dog ears and creates a
U-shaped scar.
A
B
C
Figure 17.2  (A) A traditional advancement flap has placed one incision line along a normal anatomic boundary (the hairline) and (B)
placed a dog ear within the normal lines of the lateral canthus. (C) One year after surgery.

256
Part 2  Essential Surgical Skills
linear repair, are frequently more suitable. If there is suffi-
cient laxity to allow the direct advancement of two adjacent
flaps, there is nearly always sufficient laxity to allow a primary
linear closure. The surgeon is rewarded for selecting the more
appropriate simple linear repair, with simplicity of design and
operative ease, and the patient is rewarded with a lower risk
procedure, less (if any) sensory loss above the closure, and a
more visually pleasing scar.
Bilateral advancement flap, T-plasty (A–T flap)
The standard bilateral T-plasty repair or A–T (A to T) flap
can be a great improvement over the unilateral and bilateral
rectangular advancement flaps in most facial locations. In the
A–T repair, a linear repair of the operative wound is designed
perpendicular to a free margin or to a pre-existing cosmetic
junction (Fig. 17.4). Instead of extending a primary linear
repair across a cosmetic boundary or free margin, incisions
are designed along the margin of the operative defect, a free
margin, or a cosmetic boundary, perpendicular to the linear
repair axis. In this manner, one line of the repair is hidden in
a cosmetic junction or dynamic rhytid.28
standard bilateral rectangular advancement flap (known as
the H-plasty) is most useful for eyebrow defects, where the
horizontal and vertical scars can be hidden adjacent to and
within the brow, respectively. Often a unilateral advance-
ment flap with short, broad limbs will suffice to close an
eyebrow wound that historically would have been closed
with lengthy bilateral advancements.27 As such, once an
H-plasty is designed, it makes sense to elevate one flap side
at first to determine whether unilateral tissue movement will
be adequate to close the defect before incisions are made
bilaterally.
The H-plasty repair has limited applications in other facial
locations because of the complexity of the required incision
lines. Although the bilateral advancement flap has been
historically suggested as an appropriate repair of forehead
wounds, the horizontally oriented ‘H’ scar resulting from
bilateral tissue advancement is often quite visible. Excision of
the dog-ear redundancies that result from tissue advancement
further complicates the rather unaesthetic arrangement of
the scar. Also, if there is any ischemia of the flap’s advancing
edge(s), this vertical closure is likely to leave behind a slightly
depressed scar. Simpler closures, even a vertically oriented
Bilateral advancement flap
Figure 17.3  Bilateral
advancement flap (H-plasty)
is most suitable for repair of
defects within the eyebrow
where scars can readily be
hidden. Elsewhere the
H-plasty produces a complex
scar and other repairs are
generally favored.
Classic A–T bilateral advancement flap
Figure 17.4  A classic A–T
bilateral advancement flap
allows for the base of the
flap (the horizontal portion of
the T) to be placed within an
existing rhytid or facial
boundary.

257
Chapter 17  Random Pattern Cutaneous Flaps
Closely related to the A–T advancement flap is the O–T
rotation flap. Conceptually similar, the flaps both create a
T-shaped incision. Where the A–T flap relies upon linear
tissue advancement, the O–T flap relies upon flap rotation.
The A–T flap is useful for perialar defects where the top of
the T can be hidden in the alar crease and the vertical limb of
the T can be hidden in the nasolabial fold. Above the brow or
on the forehead, the base of an inverted T can be hidden
either just above or just below the brow or within a horizontal
forehead rhytid. The vertical scar that results from this repair
may be somewhat visible, but it generally fades nicely over
time if the flap is not closed under tension. Although the
classic A–T flap is rather simplistic from a design perspective,
great care must be taken to align the advancing tissue edges.
If the leading edges of the advancement(s) traverse a great
distance to close a large defect, distracting dog-ear redundan-
cies can be produced. Sometimes these tissue redundancies
need to be excised in the areas that the surgeon was initially
reluctant to manipulate, so undermining flap utility. Often, a
single limb advancement flap will suffice to displace a dog ear
far away from a free margin into a natural crease. Whenever
possible a single limb advancement flap is favored because its
inherent simplicity in design minimizes suture lines.
As with all facial flaps, advancement flaps are most useful
when the incisions of the flap can be hidden within cosmetic
unit boundaries or along natural facial expression lines.
Commonly used sites for advancement flaps are the nasal
sidewall superior to the alar crease, the upper lateral lip supe-
rior to the vermilion border, and the supraorbital forehead
lateral to the midpupillary line. For defects in these areas, a
vertical limb extends superiorly from the operative defect and
a horizontal or nearly horizontal limb extends laterally along
a free margin (the alar crease, vermilion border, brow, or
forehead furrow) (Figs 17.5 and 17.6). A dog ear is then
removed laterally either within the alar groove or nasal fold,
the oral commissure, or the lateral canthus or crow’s feet.
This Burow’s-type advancement flap can be viewed simplis-
tically as a flap that displaces the inferior dog-ear redundancy
that would have resulted from a linear closure to an anatomic
site from which it may be much more appropriately excised
(Figs 17.6 and 17.7).29,30 A similar advancement modification,
first described by Webster,31 is often used along the nasofacial
sulcus for operative defects of the lateral nasal sidewall and
cheek or for defects adjacent to the nasal ala. In this case, a
superior dog ear is removed nearly vertically along the naso-
facial sulcus while the inferior limb of the flap curves around
the ala as a crescent. A crescent of redundant tissue is
removed inferiorly to allow proper tissue advancement (Fig.
17.7). The concept of the crescentic advancement flap may
be extended to other common defects. This technique obvi-
ates the need for dog-ear resection because this is accounted
for in flap design with a crescent of excess skin to be excised.
Removing this crescent of tissue prevents unsightly tissue
protrusion in the area of flap harvesting.
Island pedicle flap
The island pedicle flap is a specialized advancement flap. The
island pedicle flap differs from other traditional advancement
flaps in that most of its vascular supply derives from a sub-
cutaneous pedicle. Additionally, all dermal margins of the flap
are severed as the flap is advanced (hence the appropriate
‘island’ nomenclature). The first island pedicle flap was
A
B
C
Figure 17.5  (A) A unilateral advancement flap hides the scar
line along the superior brow. (B) In this case, a dog-ear
redundancy was avoided by removing a crescent of tissue
above the brow. (C) One year after surgery the mature incision
line is hypopigmented.
described by Celsus, but the first modern use of the island
pedicle flap was by Esser in 1917.32 Since the 1940s, many
types of island pedicle flaps have been described, the most
common of which is a triangular flap that derives its blood
supply from a deep and mobile subcutaneous or muscular
pedicle, which remains attached to the central portion of the
flap.33,34 In the plastic surgery literature, this traditional island

258
Part 2  Essential Surgical Skills
A
B
Figure 17.6  (A) A Burow’s advancement flap allows for dog-ear removal lateral to the oral commissure and for approximate re-creation
of the nasolabial fold. (B) This flap is useful in displacing the dog ear to an area from which it may be more appropriately excised.
A
B
Figure 17.7  (A) A crescentic
advancement flap for nasal sidewall
defects offers the ability to hide one
curvilinear aspect of the repair within the
alar crease and preserves this prominent
cosmetic junction. (B) The curvilinear
crescent of tissue that is excised
prevents dog-ear formation.
repair with an island pedicle flap (Figs 17.9 and 17.10).
Additionally, the island pedicle flap is useful in the recon-
struction of the eyebrow, where the flap can advance the
remaining brow medially to recreate brow continuity and
central facial symmetry. Certain defects of the temple and
forehead are likewise amenable to closure with either a single
or bipedicle island flap repair; however, in many of these
cases, alternative flaps that produce less conspicuous scars
than the triangular-shaped scars of the island pedicle flap are
available.
In designing and executing the island pedicle flap, it is
essential to predict the amount of mobility that will be
achieved when all peripheral margins of the flap have been
severed. Two centimeters in diameter or even larger wounds
of the perinasal area of the upper lip can be repaired with an
island pedicle flap, but in general, defects on the nose ame-
nable to island pedicle flap repairs tend to be smaller (given
the poor compliance of stiff nasal skin and the inability to
rely on secondary motion at the flap’s insertion point without
pedicle flap is frequently referred to as a V to Y advancement
flap.35
The island pedicle flap is remarkable because the flap can
be advanced as far as the motion of the deep pedicle allows.
This mobility is frequently much greater than a similarly
designed flap would advance if dermal margins that restrain
flap motion were retained at the peripheral margins of the
flap (Fig. 17.8). In addition, the island pedicle has a rich blood
supply from underlying vessels and musculature and is not
forced to rely solely upon the anastomotic vascular network
of the dermis for perfusion. As such, the island pedicle flap
is remarkably impervious to ischemia, even when the flap is
inserted under considerable wound closure tension.
Because the traditional island pedicle flap has a con-
spicuous kite-shaped outline, its greatest use is in locations
where one or two of the margins of the flap can be hidden
within a contour line or aesthetic unit boundary. Surgical
defects on the upper lip near the nose–lip–cheek junction and
on the lateral nasal sidewall are particularly well suited for

259
Chapter 17  Random Pattern Cutaneous Flaps
A
Island pedicle flap
B
Flap design for dorsal nasal rotation flap
Defect
Flap design
C
Figure 17.8  (A) Schematic of flap. (B) Island pedicle flap in progress. (C) All lateral ties have been severed, leaving all deep
connections intact. The flap has great mobility on an underlying muscular and fatty pedicle.
A
B
Figure 17.9  (A) Island pedicle repair of perinasal upper lip defect. Note that the flap is slightly undersized. Large wounds of the
upper lip can predictably be repaired with an island pedicle flap based on the rich vascular supply of the underlying orbicularis oris.
(B) One year after surgery there is no retraction of the lip.

260
Part 2  Essential Surgical Skills
In addition to freeing the flap’s tail, the surgeon may need to
undermine the leading edge of the island pedicle flap to some
extent (rarely more than 1 cm) to allow the flap to advance
with minimal wound closure tension and to prevent inversion
as a result of tethering of the leading edge. Failure to mini-
mize the flap tension can result in unanticipated and undesir-
able secondary motion near the flap’s insertion point. In
critical areas, such as along the free margin of the eyelid, this
secondary motion can produce aesthetically significant distor-
tion (an ectropion, for example).
The flap itself should be inset slightly into the operative
defect and secured with several deep sutures, and a flap that
is initially slightly concave will eventually heal as a flap that
is appropriately flush with the surrounding skin. This flap
recession can be routinely achieved, as mentioned above, by
slightly undersizing the flap and by suturing the flap under
slightly increased wound tension.
In addition to the traditional design, many variants of the
island pedicle flap have been discussed in the reconstructive
literature. Curved island pedicle flaps can be particularly
useful on the nose, where the incision lines can be placed
along the alar groove.37 De-epithelialized flaps or even flaps
that have the entire pedicle buried in a subcutaneous tunnel
can occasionally be quite useful in the repair of deep nasal or
medial canthal wounds.38,39 Regardless of the design nuances,
all island pedicle flaps have as their chief advantage a healthy
and protected vascular supply.
Mucosal advancement flap
For operative wounds restricted to the glabrous portion of the
pink lip, repair choices are often limited. Partial-thickness
wounds that do not cross the vermilion border can be allowed
to heal by second intention with minimal scarring. For broader
wounds, an advancement flap from the remaining intraoral
mucosa is often an appropriate repair. The mucosal advance-
ment flap is designed so that the incision line traverses the
producing distracting nasal asymmetry). The island pedicle
flap is particularly well suited to deeper operative wounds
because it carries all tissue layers with it, including skin,
subcutaneous tissue, and some skeletal muscle. Additionally,
the flap’s rich vascular supply makes it appropriate for repairs
in areas of compromised skin vascularity (such as areas of
chronic radiation damage).
Proper design and execution of an island pedicle flap are
necessary for an aesthetic repair. Because the flap has a thick
base, it is particularly subject to developing a protuberant
appearance (the pin-cushioned or trapdoor deformity) during
the early postoperative period. The development of the
trapdoor deformity with this flap is common when the flap
is used to repair wounds on the medial cheek and lip, and
this globular appearance may be permanent. One solution
may be to design a flap that has a smaller breadth than the
diameter of the primary surgical defect and will still gener-
ally allow for closure of the operative wound by relying
upon secondary motion of the skin edge of the wound. This
slight undersizing of the flap places modest wound tension
on the lateral aspects of the island pedicle flap, which theo-
retically diminishes postoperative contraction of the flap
and the risk of developing a subsequent trapdoor defor­
mation.36 The flap is incised with either strictly vertical inci-
sions or with slightly outwardly beveled incisions that include
the adjacent deep subcutaneous fat or underlying muscle.
The peripheral margins of the flap’s incisions are widely
undermined, as is the primary defect. The tapering tail
(approximately the distal third) of the flap must be freed
completely from any lateral or deep restraint, either by blunt
or sharp undermining. This tethering of the tail of the flap is
usually the primary area of restraint that inhibits the flap’s
mobility.
Because the flap must be deeply undermined vertically but
not across its base to allow proper flap mobility, a thorough
knowledge of the underlying anatomy is required. This under-
mining is generally carried out just over the superficial fascia.
A
B
C
Figure 17.10  (A) Island pedicle repair of perinasal cheek defect. The flap can be advanced a great distance on a nasalis muscular
swinging pedicle, which provides reliable blood supply. (B) Note that although the flap was undersized, the surrounding tissues
were undermined, and advanced into the wound as the flap was inset at the time of repair. (C) There is slight flap elevation, a
trapdoor deformity, at 6 months.

261
Chapter 17  Random Pattern Cutaneous Flaps
would be required to close the wound, a parallel incision of
equal length is placed several centimeters lateral or superior
to the primary defect. When both incisions have been made,
a bipedicled, easily mobile flap is created (Fig. 17.11). The
pedicled portion of skin between the defect and parallel inci-
sion is not undermined such that it maintains a rich blood
supply. The other aspects of the defect and incision, however,
are undermined to allow tissue advancement and closure with
minimal tension. Therefore, the diameter of the primary
defect is effectively shared with the secondary defect, and
secondary motion around the original wound is minimized.
The scars that result from the construction of the flap consist
of two fine parallel lines.
Rotation flaps
Many surgical wounds that cannot be closed side-to-side or
with local tissue advancement may be repaired by recruiting
adjacent tissue laxity while directing wound closure tension
vectors away from the primary surgical defect. This redirec-
tion of wound closure tension is the primary purpose of a
rotation flap.
The design of a traditional rotation flap uses a curvilinear
incision along an arc adjacent to the primary surgical defect.
As a rotation flap is created, the direction of wound closure
tension is effectively changed (Fig. 17.12). This allows a rota-
tion flap to use abundant donor tissue located a considerable
distance from the primary defect to close wounds in areas
in which tissue availability is minimal. In addition to reori-
enting tension vectors, rotation flaps also frequently allow
for displacement of dog ears to more favorable locations. If
well designed, rotation flaps create scar lines that are hidden
along facial boundaries or within relaxed skin tension lines
or are camouflaged within hair-bearing skin (Figs 17.13
and 17.14).
As the rotation flap is raised and undermined, the laxity of
the adjacent tissue allows the flap to be rotated into the
primary defect. Like all flaps, rotation flaps are hindered in
their movements by the inherent stiffness of the tissue, espe-
cially at the flap’s pivot point. Because of this pivotal restraint,
the tip of the rotation flap will not extend to the distal margin
of the operative defect unless the tip of the flap is also
entire horizontal length of the border between the cutaneous
and the mucosal portions of the lip. The flap is incised, and
undermined between the plane of the minor salivary glands
and the underlying orbicularis oris musculature.40 This under-
mining plane protects the perfusion of the flap while preserv-
ing the function of the underlying muscle. The flap is sharply
undermined from anterior to posterior, following the natural
curvature of the lip. Extensive undermining may be necessary
into the intraoral mucosa to achieve proper flap mobility;
undermining is generally extended to the area where the mucosa
reflects onto the mandible. Using the principles of simple
tissue advancement, the generously liberated flap can then be
advanced to cover even broad wounds on the lower lip. Because
the actual length of tissue advancement is relatively small and
because the mucosa is quite forgiving, dog-ear redundancies
that result from tissue advancement are not typically signifi-
cant enough to require complete removal. Although the inci-
sion scar of the mucosal advancement flap is often quite subtle,
the modest tension required to advance the flap typically
results in a slightly flattened appearance of the lower lip.
Alternatively, an island pedicle flap can be designed by
advancing mucosal skin anteriorly to fill full-thickness defects
of the pink lip that do not cross the vermilion border.
Advancement must proceed with minimal tension in the
direction of primary movement or lip distortion ensues. One
adverse effect of moving mucosal lip onto the exposed pink
portion of the lip is long-term peeling of this new lip skin as
a result of metaplasia.
Bipedicle advancement flap
The bipedicle flap is a variant of a linear closure technique
that also relies upon local tissue advancement. The flap has
its greatest use on the upper forehead41 and temple, where a
simple linear repair of a large defect may be associated with
unacceptably high wound closure tension or with the produc-
tion of lateral canthal distortion. The flap is constructed as a
rectangular advancement of tissue that basically shares the
diameter of the original surgical defect equally between
primary and secondary defects.
To design the flap, the surgical defect is envisioned as an
elliptical side-to-side closure. To minimize the tension that
A
B
Figure 17.11  (A) Defect on the forehead at the hairline. (B) A bipedicled flap is used to repair a forehead wound. The tightness of
the forehead precluded a simple linear repair, and the wound closure tensions have now been shared between the primary and
secondary defects.

262
Part 2  Essential Surgical Skills
placement of structures surrounding the primary defect.
However, ischemic failure of a well-designed rotation flap,
handled gently, and closed under minimal tension, is quite
rare.
Because rotation flaps require long incision lines to achieve
appropriate flap motion, in many facial locations other flap
options are often more palatable. Rotation flaps have their
greatest use in the closure of scalp, temple, and cheek defects
and other non-facial areas. In selected cases, rotation flaps can
be useful on the nose. On the scalp, a lack of adjacent skin
mobility requires rotation flaps to be especially long to close
even small-to-moderate sized operative wounds. On the
cheek, rotation flaps are particularly useful to repair medially
located wounds, because the rotation flap can effectively
mobilize the large reservoir of loose skin in the entire area of
the lateral cheek.43 Infraorbital wounds on the eyelid and
cheeks can be closed with rotation flaps that recruit substan-
tial laxity from the temple.
Special rotation flaps
Dorsal nasal rotation flap
In 1967, Rieger introduced the dorsal nasal rotation flap as
an alternative to island or nasolabial flaps for the reconstruc-
tion of distal nasal wounds.44 The dorsal nasal flap is most
useful for medium-sized defects that are too large to be
repaired with bilobed transposition flaps or too small to
warrant the use of two-staged pedicled flaps. The flap
described by Rieger is a full-thickness rotation of the entire
nasal dorsum with a glabellar backcut to improve flap mobil-
ity. The flap is designed with a long sweeping arc that extends
from the distal aspect of the defect contralaterally to the
nasofacial sulcus, past the contralateral medial canthus, and
to a midpoint just superior to the glabella (Fig. 17.18). To
include the abundantly perfused underlying nasal muscula-
ture, the flap is elevated at the level of the perichondrium
and periosteum. The inclusion of facial musculature in the
base of the flap makes distal ischemia unlikely. The point of
pivotal restraint with the dorsal nasal flap is in the areas of
the ipsilateral medial canthal tendon and the attachment
of the nasal musculature to the nasofacial sulcus. As with all
rotation flaps, undermining in the area of pivotal restraint can
advanced under some tension and/or the recipient edge is
mobilized toward the flap tip (secondary motion). To com-
pensate for pivotal restraint, minimize tension on the flap,
and eliminate the need for secondary motion around the
operative defect, the arc of the rotation can be oversized and
offset so that it extends vertically beyond the distal extent
of the operative defect42 (Fig. 17.15). When the flap’s rota-
tion is subsequently executed, the extended tip of the flap
then rests without tension where it meets the distant point
of the primary defect. A rotation flap can often be closed
without undermining beneath the point of pivotal restraint;
however, for optimal flap motion, this area of restraint should
be undermined (Fig. 17.16). This is particularly important
with the dorsal nasal flap, where maximal rotation is required
to close a defect in the inelastic skin of the distal nose.
Occasionally, a backcut into the rotation flap’s body can
improve flap mobility (Fig. 17.17), particularly on relatively
immobile skin such as the scalp. This must be done con-
servatively because cutting too far into the pedicle base may
interfere with blood supply to the flap. In addition to reori-
enting tension vectors, rotation flaps serve to exchange
primary defects for displaced secondary defects.
Random pattern flaps do not ‘create’ new tissue, and the
entire purpose of any flap, including the rotation flap, is to
trade the existing primary surgical defect for an adjacent
secondary defect that can be closed more easily. The manage-
ment of the secondary defect created upon flap movement is
often the most challenging part of a rotation flap repair. If a
rotation flap with a short arc is designed, the width of the
secondary defect created upon flap rotation will be propor-
tionally larger, and the potential for unacceptable secondary
motion and inappropriately high wound closure tension is
magnified.
A longer arc of flap rotation allows easier closure of the
narrowed secondary defect, and the likelihood for flap
survival is increased to a point as a result of the minimiza-
tion of wound closure tensions. Of course, if the pedicle is
very long compared to its base width, flap survival may be
impaired.
Typically the incision lines for a rotation flap need to be
longer than one would initially expect if the flap is to be
placed under minimal tension and to avoid unwanted dis-
Primary closure tension vector
Secondary closure tension vector
Lessened primary closure tension vector
Rotation flap
Figure 17.12  A rotation flap
recruits laxity and creates
motion in several directions,
so diminishing closure
tension at the primary defect.

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Chapter 17  Random Pattern Cutaneous Flaps
A
B
C
Figure 17.13  (A) Rotation flap on the chin allows for repair of a
large defect. (B) Most of the scar is hidden in the mental
crease. (C) Minimal hair loss is noted along closure line.
A
B
Figure 17.14  (A) A rotation flap for repairing a defect spanning
the medial lower eyelid and cheek. Tension is directed by a
suspension suture placed from the dermis of the tip of the flap
to the nasal periosteum. (B) Curvilinear scars along the
nasofacial sulcus and infraorbital crease will be minimally
visible.
necessary to extend the backcut superiorly onto the glabella
or to extend the flap’s curvilinear excision far laterally onto
the contralateral nasal sidewall except to hide the scar.
Because of the inherent stiffness of sebaceous nasal skin,
the rotation of the nasal dorsum required to close wounds
with this flap can introduce significant potential for develop-
ing alar asymmetry. By understanding the basic principles of
rotation flap reconstruction, the surgeon can prevent this
untoward effect in most cases.45 To prevent this distortion,
the restraint of the flap in the area of the pivot point needs
to be addressed. Adequate undermining of the rotation axis
alleviates pivotal restraint, which allows the flap to redrape
over the distal nasal defect under minimal tension. When
undermining the pedicle, it is essential to be at the level of
the periosteum to preserve the sizeable arterial branches that
perfuse the flap. To reduce the likelihood of nasal distortion,
most of the flap’s secondary defect is distributed along the
flap’s arc of rotation along the nasofacial sulcus where there
is considerable tissue mobility. Side-to-side closure can easily
be achieved in this area by proper undermining of the adja-
cent cheek tissue. Although longer incision lines may create
improve flap mobility, but this undermining should be per-
formed cautiously given the need to protect the flap’s vascu-
lar input at its base. Properly performed, the dorsal nasal flap
can be used to repair distal nasal defects up to 2 cm in diam-
eter. Of course, the dorsal nasal flap can be suitably modified
for smaller defects. With such smaller flaps, it is not always

264
Part 2  Essential Surgical Skills
aesthetic concerns in the early postoperative period (particu-
larly along the more sebaceous, distal areas of the nose), a
longer arc of flap rotation will minimize the width of the
secondary defect at any particular point, and this minimiza-
tion will reduce the likelihood of the alar or medial canthal
distortion that can result from an improperly designed dorsal
nasal flap repair. In essence, longer Rieger flaps often produce
superior aesthetic results.
Tenzel and Mustarde rotation flaps
In 1966, Mustarde described a cheek rotation flap for lower
eyelid reconstruction.46 In 1975, Tenzel and Stewart described
a similar rotation flap from the temple to repair full-thickness
lower eyelid defects.47 The classic Mustarde flap is a large
rotation of cheek and temple skin with extension of the flap
incision into the preauricular cheek. The classic Tenzel sem-
icircular flap is a similarly designed rotation of skin and orbic-
ularis oculi muscle from the temple and lateral canthal areas
(Fig 17.19). The classic Tenzel flap also incorporates a can-
tholysis of one crus of the lateral canthal tendon to promote
easier flap rotation. Originally described by the author as an
advancement flap, the Tenzel flap actually constitutes a com-
bination of advancement and rotation about a pivot point on
the zygoma. A superiorly arcing semicircular incision lateral
to the canthus allows recruitment of adjacent tissue to recon-
struct the lower lid. Both the Mustarde and Tenzel flaps use
A
B
Secondary motion
Primary motion
Tension
Placement and creation of tip of a rotation flap
Figure 17.15  (A) If the rotation flap is designed as a simple arc taken off a round operative defect, the tip rotates and falls short of
its destination – it will only meet the far edge of an operative wound if the flap tip is advanced in a secondary motion. (B) Oversizing
the tip and leading edge of the rotation flap beyond the extent of the operative defect compensates for pivotal restraint and allows
for closure of the primary defect without tension on the tip of the flap and without much secondary motion.
This entire area undermined
Undermining area of pivotal restraint
Optimal flap mobilization
Figure 17.16  For optimal flap mobilization, the base of a
rotation flap is undermined to minimize pivotal restraint.

265
Chapter 17  Random Pattern Cutaneous Flaps
Backcut on a rotation flap
Figure 17.17  A backcut on a rotation flap facilitates closure by introducing an added component of flap advancement (arrows) and
diminishing pivotal restraint. If the backcut is too large, decreasing pedicle size may affect flap viability.
A
C
B
Flap design for dorsal nasal rotation flap
Defect
Flap design
D
Figure 17.18  (A–B) A dorsal nasal flap is used to repair a distal nasal defect. (C) Despite the long incision line required to create
the flap, the final aesthetic result is favorable. (D) One year postoperatively.

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Part 2  Essential Surgical Skills
These useful rotation flap reconstructions have commonly
been modified,48 and they are reliable flaps to repair defects
of the lower eyelid. The most commonly used flap variant
is a modified Tenzel flap to repair skin defects of the mid
to lateral lower eyelid (Figs 17.20 and 17.21). From the
superior extent of the surgical defect, a curvilinear rota-
tion is extended laterally and superiorly past the lateral
canthus and onto the temple. As with the traditional rota-
tion flaps mentioned above, the superior extension of the
flap’s design allows the flap’s rotation to overcome the
‘shortening’ associated with pivotal restraint. If the arc of
rotation is not extended superiorly, the eyelid may be required
the primary rotational motion of the flap to support the
eyelid, and both flaps direct all wound closure tensions toward
the temple superolaterally and toward the cheek medially.
Unwanted vertical tension along the eyelid margin is avoided,
and the appropriate position of the lower lid is maintained.
Similar to the design of the rotating dorsal nasal flap, the
Mustarde and Tenzel flaps’ long arcs of rotation allow redis-
tribution of the volume of the primary defect along a nar-
rowed secondary defect. Because the secondary defect with
both these flaps is within the compliant and mobile skin of
the temple and cheek, distortion of the surrounding struc-
tures is minimized.
Tenzel flap – a lower eyelid flap combining rotation and advancement
A
B
C
D
E
F
Figure 17.19  A classic Tenzel flap is a rotation flap utilized to repair lid margin defects. A full-thickness defect of the lower lid (A) is
too large to close. An arciform incision is created superior and lateral to the lateral canthus (B). The flap is elevated laterally above
orbicularis oculi and medially is dissected off of the lateral canthal tendon (C). The lower crus of the lateral canthal tendon is
identified and released by transection (lateral cantholysis) (D), and a dog ear of tissue is excised inferior to the operative wound.
The lid margin wound is repaired under minimal tension (E) and a tacking suture may be utilized to stabilize the center of the flap to
the lateral canthal rim periosteum. This places all tension on the lateral aspect of the flap and suspends the flap in place, thus
limiting the potential for a lateral ectropion. (F) Flap completed.

267
Chapter 17  Random Pattern Cutaneous Flaps
A
B
Figure 17.20  (A) A modified Tenzel flap combines features of rotation and advancement. The direction of flap motion is indicated by
an arrow, and the likely extent of flap undermining is also detailed. (B) A rotation flap is placed without tension on the lower lid.
A
B
C
D
Figure 17.21  (A) With infraorbital rotation flaps, extending the incision superiorly near the lateral canthus oversizes the flap and
supports the eyelid, preventing the tendency to produce an ectropion. (B) The flap is undermined just above orbicularis musculature
superiorly and above the superficial musculoaponeurotic system (SMAS) inferiorly. The flap is folded back to expose the level of
undermining. (C) The site immediately postoperatively. (D) Ninety days postoperatively.

268
Part 2  Essential Surgical Skills
to undergo secondary motion to meet the leading edge of
the flap.
If any of this tension is vertically oriented, an iatrogenic
ectropion can develop. The flap is elevated just above the
orbicularis oculi superomedially, above the medial insertions
of the superficial musculoaponeurotic system (SMAS) infe-
riorly, and over the superficial temporal fascia superolaterally.
All tension is directed horizontally along the vector of the
primary motion to support the lower eyelid and prevent
ectropion formation. It is important to thin the superior
aspect of the flap adequately to avoid placing a thick flap
adjacent to the remaining thin tissue on the lower eyelid. The
modified Tenzel flap often produces temporary edema of the
lower lid because of the obstruction of the laterally draining
lymphatic channels, but this edema rarely persists beyond
several weeks. A similarly modified Mustarde flap can be used
for extensive cheek defects.
O–Z (O-to-Z) rotation flap
When there is insufficient laxity to close a surgical defect
with a single rotation flap, bilateral rotation flaps can be
created. Because bilateral rotation flaps convert a circular
operative defect into a Z-shaped incision line, this combina-
tion of rotation flaps is often called an O–Z flap. The con-
struction of an O–Z flap is similar to the construction of a
traditional rotation flap; therefore, attention should be
directed toward compensating for the pivotal restraint of the
flaps. The flap lengths should also be sufficiently long to
minimize the width of the secondary defects because this will
facilitate flap closure and minimize wound tension. In the
design of the O–Z flap, however, there is great flexibility. The
paired flaps can be designed to rely upon pure rotational
movement, or there can be varying amounts of flap advance-
ment introduced into the operative design. The surgeon
should appropriately select how much tissue advancement or
rotation can be accomplished without producing anatomic
distortion of the surrounding structures and in such a way as
to hide scars. As with traditional rotation flaps, the movement
of O–Z flaps produces paired dog-ear redundancies near the
flaps’ pivot points, and these redundancies should be excised
to produce proper flap contour. This adds another dimension
to the O–Z flap’s potentially distracting incision lines. The
O–Z repair has its greatest application on the scalp,49 where
the prominent incision lines are hidden beneath a blanket of
hair (Fig. 17.22).
Transposition flaps
In design, transposition flaps are the most complex of the
random pattern flaps. Transposition is an inherently more
complicated tissue movement than simple advancement or
rotation, and the less experienced surgeon typically has a
more difficult time envisioning the proper design and predict-
ing the tension vectors of these flaps. Tissue transposition is
used when the characteristics of a surgical wound preclude
closure by a simpler method of flap repair. Transposition flaps
allow for complete redirection of wound closure tension by
moving tissue from an area of surplus to an area of need by
transposition of skin across intervening islands of unaffected
tissue. Because the transposition flap effectively redirects
wound closure tension, the flap can be used to close difficult
wounds near free margins such as the ala, lip, proximal helix,
or eyelid. For example, in a nasolabial transposition flap, loose
tissue in the area of the medial cheek can be transposed over
an unaffected lateral ala to cover a more medially located
nasal ala or nasal tip wound. Because the cheek transposition
flap is not directly advancing or rotating into the surgical
defect on the medial ala, the important nose–cheek–lip junc-
tion is maintained instead of blunted.
Transposition flaps are affected by pivotal restraint in a
manner analogous to rotation flaps. This pivotal restraint
causes the transposed flap to ‘fall short’ of its intended target
(the primary defect) unless the restraint is accounted for in
proper flap design and undermining. Transposition flaps are
defined by greater degrees of flap movement, which produces
greater degrees of effective flap ‘shortening.’ As such, the
surgeon who is just beginning to perform these more difficult
transposition flap repairs should make the primary lobe of the
flap slightly longer than initially considered appropriate until
a more complete understanding of the nuances of flap trans-
position and pivotal restraint can be achieved.
The most commonly used transposition flaps are the rhom-
boid (rhombic) transposition flap, the bilobed transposi-
tion flap, the banner transposition flap, and the nasolabial
transposition flap. Many challenging surgical wounds can be
reconstructed with these repairs, and their skillful execution
is an essential technique for the advanced reconstructive
surgeon.
Rhomboid transposition flap
Probably the most well known of the random pattern flaps is
the rhomboid or rhombic transposition flap. Limberg
described the rhomboid transposition flap (Fig. 17.23) in
1946, and his work was translated into English in 1966.50
Modifications of the Limberg flap were introduced in 1962
by Dufourmentel.51 A rhombus is an equilateral parallelo-
gram. The classic rhomboid flap is only suited to rhomboidal-
shaped defects with equally sized sides and angles of 60° and
120°. The flap is designed by bisecting one of the 120° angles
and extending a line equal to the length of one side of the
rhombus from the tip of this angle away from the rhombus.
From the distal extent of this line, a line of equal length is
extended in either direction parallel to one side of the
rhombus. By following this strategy for rhombic flap design,
four separate flaps may be drawn for a single rhomboidal-
shaped defect. The selection of the one flap most appropri-
ately suited to repair the surgical defect is dictated by the
laxity of adjacent skin and the presence of various anatomic
structures in the vicinity of the wound.52
The great advance of the rhomboid flap was the ability to
direct all tension away from one axis of a given defect. As the
rhomboid transposition flap is elevated and transposed, all
tension on the flap is directed toward closing the secondary
defect. By suturing closed the secondary defect first, the flap
is essentially ‘pushed’ into place in the primary defect without
the need for secondary movement around the primary defect.
This is particularly beneficial for defects that extend near a
free margin that might be distorted by simpler reconstructive
alternatives. A rhomboid flap is satisfactorily executed only
when substantial tissue laxity exists or can be created adja-
cent to the defect at the base of the flap, therefore allowing
easy closure of the secondary defect. There should also be
sufficient tissue laxity so that the flap can transpose into the
primary defect without undue tension. This usually requires
that a line that bisects the apex of the flap runs along or

269
Chapter 17  Random Pattern Cutaneous Flaps
A
B
C
D
E
F
G
Figure 17.22  Bilateral rotation flaps can be utilized to repair large wounds on the
scalp. (A) Large scalp operative wound with planned O–Z bilateral rotation. (B–C) Flaps
are incised and elevated beneath fascia. (D) Closure of the primary defect with creation
of secondary defects. (E) Final closure. (F) Repair at 4 months. Note absence of
alopecia. (G) Normal frontal hairline.

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Part 2  Essential Surgical Skills
In its most suitable applications, the rhomboid transposi-
tion flap is an elegant repair, with the scar from the primary
defect hidden within a cosmetic line and with wound closure
tensions appropriately redirected away from the primary defect.
At its worst, the flap is an unnecessarily complicated repair
that leaves as its sequela a large, unaesthetic question mark-
shaped scar surrounding a protruding, pin-cushioned flap.
Bilobed transposition flap
The bilobed flap, initially described by Esser in 191858 and
refined by Zitelli in 1989,59 is particularly useful for repairing
difficult wounds on the distal nose (Fig. 17.26). Conceptu-
ally, the flap is more complicated than simple transposition
flaps. After all, the bilobed flap is an intricate arrangement of
two connected transposition flaps, and the potentials for mis-
judging pivotal restraint and the management of the second-
ary and tertiary defects are therefore magnified. Although the
bilobed flap is categorized as a transposition flap, like the
rhomboid flap, there are significant degrees of flap rotation
incorporated into the flap’s design. When properly used, the
bilobed flap offers an unparalleled opportunity to restore
sebaceous skin to the convexity of the distal nose, and the
flap is useful for repairing nasal wounds up to approximately
1.5 cm in diameter. Despite the bilobed flap’s potentials for
aesthetic success, the flap can produce dramatic distortion of
the alar margins and apparent incision lines when poorly
designed or executed.
As with all flaps, the bilobed flap’s true value lies in its
ability to recruit tissue from an area in which it is abundant
(i.e. the proximal nasal dorsum) and transfer it to an area
in which it is limited (i.e. the nasal tip). The usefulness of
the bilobed flap is significantly increased by the flap’s great
flexibility in design. Depending on the stiffness and availa-
bility of nasal skin, the surgeon can alter the primary and
secondary lobes’ sizes, origination points, locations, and
angles of motion.60 Although this seemingly adds great com-
plexity to the bilobed flap’s design, this flexibility allows the
parallel to a relaxed skin tension line.53 The basic rhomboid
flap is useful for defects of the medial canthus, upper nose,
lower eyelid, temple, and peripheral cheek.54–56 If classically
designed with 60° angles at the apices of the rhomboidal
defect, the transposition flap will produce dog-ear redundan-
cies. This flap is also prone to developing trapdoor phenom-
ena. It is therefore essential to undermine circumferentially
beneath the base of the flap and around the margin of the
primary defect.
Although the classic rhomboid flap is often avoided because
of the limitations that the flap’s design imposes, a modified
rhomboid flap can be particularly useful in the closure of
some facial defects (Figs 17.24 and 17.25). Instead of the
geometrically complicated traditional flap design, a modified
transposition flap is taken at a tangent off the circular primary
defect. Attention is placed upon keeping the apex angle of
the flap to a minimum, ideally less than 30°, so that a dog-ear
redundancy near this point is accounted for. The modified
flap is easily transposed into the primary defect, and the flap
effectively redirects wound closure tensions. This modified
transposition flap is commonly used in the reconstruction of
lateral nasal sidewall and lateral brow defects.
Throughout the 1970s the rhomboid transposition flap
enjoyed great popularity in the surgical literature. Tumor
removal and closure were planned so that a rhomboidal
defect could initially be created. The surgical literature from
that era is replete with examples of rhomboid transposition
flaps that were used to close many defects that could have
been repaired in a simpler manner had the tumor been
excised and the margins checked before planning a recon-
structive procedure. Numerous reports that detailed the use
of multiple small rhomboid flaps to close rather uncompli-
cated facial wounds on the nose or cheek also followed.57
Although the creation of the flaps certainly testified to the
surgeon’s command of geometric principles, the flaps often
created unnecessarily complicated incision lines, and simpler,
more aesthetically pleasing reconstructive alternatives could
usually have been selected.
Dog ear
120˚
60˚
Standard rhomboid transposition flap
Figure 17.23  The standard
rhomboid transposition flap
as designed by Limberg.
The major advantage of the
rhomboid flap is to redirect
tension away from the
operative wound to a
secondary area of laxity
straddling a relaxed skin
tension line.

271
Chapter 17  Random Pattern Cutaneous Flaps
B
C
A
D
E
Figure 17.24  (A) Modified rhomboid flap for repair of a medial canthal wound. The flap is taken at a tangent to the operative wound
and the angle of the flap is more acute than the traditional 60°. This design facilitates closure of the secondary defect within a
glabellar fold. Closure of the secondary defect ‘pushes’ the flap into the primary defect and prevents the epicanthal web formation
caused by tension at the medial canthus. (B) Flap undermined. (C) Closure of the secondary defect first ‘pushes’ the flap into the
primary defect. (D) Flap placed. (E) Ninety days postoperatively.

272
Part 2  Essential Surgical Skills
areas with a predictable vascular supply, and they must have
substantial mobility and laxity at their bases. The banner flap
is particularly suited to oval or oblong defects that are ori-
ented essentially perpendicular to the line of harvest of the
flap. Defects of the upper helical rim are amenable to recon-
struction with banner flaps elevated either from the postau-
ricular or preauricular sulcus61 (Figs 17.29 and 17.30). Nasal
bridge and medial canthal defects are also frequently closed
in elegant fashion by glabellar banner flaps, the originations
of which are hidden within glabellar creases62 (Figs 17.31 and
17.32). Medial lower eyelid defects are suitable for repair
with a banner flap transposed from the nasofacial sulcus.
Finally, lateral lower eyelid defects may be repaired with
banner flaps harvested from the ipsilateral upper eyelid.63
These flaps are also useful to close extremity wounds. The
nasolabial flap is essentially a banner flap with approximately
60° of transposition, and is discussed in detail below.
The base of a banner transposition flap must be undermined
sufficiently to allow for ideal transposition and to promote
circumferential wound contraction during healing. Although
banner flaps are ideal repairs for certain wounds, they are
highly prone to developing the trapdoor deformity. When
repairing a wound with a banner flap (and most flaps for that
matter), it is useful to slightly undersize the flap and to
undermine the recipient defect. It may also be useful to
firmly tack the flap to the underlying wound in one or several
locations to prevent the development of a potential dead
space along the lengthy flap.
Nasolabial transposition flap
Used to reconstruct lateral and central alar wounds, the
nasolabial transposition flap is often touted as a ‘workhorse’
flap for the reconstructive surgeon. Despite its simple design,
the nasolabial flap is often a difficult flap with which to
achieve reproducibly excellent results, and takes considerable
experience to use properly. The flap is harvested from the
relatively sebaceous skin in the medial cheek just adjacent to
the ipsilateral melolabial fold. The flap is thinned as it is
raised, and once undermined (to the superior base as well as
surgeon to expertly use the flap to reconstruct difficult nasal
wounds.
After the appropriate bilobed flap design has been selected,
the flap is sharply incised. Critical to the predictability of the
flap’s perfusion is the inclusion of nasalis musculature in the
base of the flap. Wide undermining promotes flap mobility,
minimizes wound closure tensions, and helps prevent inferior
displacement of the ipsilateral alar margin as the stiff, seba-
ceous flap moves distally (Figs 17.27 and 17.28). If the lobes
of the flaps have been ideally sized (in general, the first lobe
measures approximately 75% of the area of the defect, the
second lobe approximately 40% of the area of the primary
lobe to allow for a modest degree of secondary movement)
and if the entire nasal dorsum is widely undermined, the
bilobed flap easily extends even to the infratip lobule of
the nose to fill a defect. Because the incision lines of the
bilobed flap are geometric and do not fall into already exist-
ing facial lines, great attention must be paid toward securing
the flap with expert surgical technique if the flap is to be well
hidden.
Although the bilobed flap is most commonly used to recon-
struct distal nasal wounds, the flap, because of its abilities
to transfer skin from distant areas into a surgical defect, also
has a use in the reconstruction of difficult wounds on the
chin, the lateral cheek, the hand, and the posterior ear. In
these extranasal sites, the surgeon can take advantage of the
ability to use secondary motion to assist in the closure of
the flap donor wounds, and great variances can therefore be
made in the sizing of both the primary and the secondary
lobes of the flap to accommodate the surgeon’s needs for
tissue transfer.
Banner transposition flap
Banner flaps are long, narrow, transposition flaps with a high
length:width ratio, usually measuring 3 : 1 to 5 : 1. These flaps
are designed and elevated along existing facial junctions or
relaxed skin tension lines and are transposed 90° (or even
more) to cover adjacent operative wounds. Because of their
large length:width ratio, banner flaps must be elevated in
135˚
45˚
Modified rhomboid flap
Figure 17.25  Pivotal
restraint requires a
component of advancement
for the tip of a standard
Limberg flap to reach its
destination. Lengthening
all sides of the flap and
decreasing the angle at the
apex of the secondary defect
can reduce pivotal restraint
and allow for more facile
closure.

273
Chapter 17  Random Pattern Cutaneous Flaps
mined so that medial advancement of the cheek occurs
readily, and deep tacking sutures can be used to anchor the
pivot point of the flap (which is superolaterally based) to the
piriform aperture near the junction of the lateral ala to
the isthmus of the upper lip. Once the flap has been suitably
anchored, the flap should basically fall into place with minimal
tension to fill the alar defect. The distal portion of the flap
that will be inset into the defect should be thinned (almost
to the dermis) to prevent the unsightly pin-cushioning of the
flap that is rather common. Additionally, the flap should be
carefully trimmed to fit the defect and prevent retraction of
the alar margin.
Similar to the design flexibility seen with the bilobed trans-
position flap, the nasolabial flap has numerous modifications
that can enhance the usefulness of the flap. Bilateral nasola-
bial flaps can be used to repair larger nasal wounds, although
the paramedian forehead flap is typically a more aesthetically
circumferentially around the primary and secondary defects)
it is transposed into the alar wound. The anticipated dog-ear
redundancy superior to the primary defect can be removed
prospectively to facilitate flap motion and restore contour
(Fig. 17.33).
Historically, the nasolabial flap has been a two-step surgical
reconstruction of the nose. After the initial flap transfer, a
revision procedure was required to thin the inevitably protu-
berant flap. However, with proper attention to flap design
and technique, the nasolabial flap can be an appropriate sin-
gle-stage repair.64 To achieve predictable results, the superior
dog ear above the primary defect should be designed to be
tall and narrow with no more than a 30° apical angle. The
flap’s origin within the melolabial fold should extend far
enough inferiorly to compensate for the ‘shortening’ that
occurs as the flap is transposed onto the nose. Importantly,
the flap’s donor site on the cheek should be widely under-
A
B
Bilobed flap
Figure 17.26  The bilobed
flap was initially described
by Esser (A), and Zitelli
significantly improved the
flap’s design (B) by
introducing the prospective
removal of the Burow’s
triangle and reducing the
angles of flap transposition
required to close the primary
and secondary defects.

274
Part 2  Essential Surgical Skills
A
B
C
Figure 17.27  A bilobed flap for a distal nasal defect is designed with a 90° axis for facile transposition. The arc of transposition and
rotation of the flap is carefully delineated to appropriately size the primary and secondary lobes. Superolateral orientation of the
dog-ear removal at the inferior aspect of the flap prevents alar distortion. (A) Flap design. (B) Execution. (C) Final result 90 days
postoperatively, no revision. Dermabrasion or laser resurfacing may be used to improve the contour of the incision line.
A
B
C
D
Figure 17.28  The undermining of the bilobed flap is at the level of periosteum/
perichondrium. This allows the flap to move easily and close with minimal tension.
As a result, there is little opportunity to introduce nasal asymmetry. (A) Flap design.
(B) Widely undermined over periosteum and perichondrium. (C) Flap easily moved
into place before suturing. (D) Ninety days postoperatively, no revision.

275
Chapter 17  Random Pattern Cutaneous Flaps
A
B
C
D
E
F
Figure 17.29  Proximal helical rim defects can be repaired with a long, thin banner flap from the preauricular or postauricular sulcus.
These flaps are based on a rich vascular supply from branches of the temporal artery. The base of the flap is undermined at the
superficial fascia, but the distal portion of the flap may be thinned to the dermis to recreate a suitable thickness for the helical rim.
No tension should be placed on the distal flap, and the flap should simply drape over the exposed cartilage. (A) Defect. (B) Banner
flap designed into the postauricular sulcus. (C) Flap developed by undermining at the level of the fascia in the sulcus. (D) Flap
elevated to show the level of undermining, which is proximally at the level of the superficial fascia and distally just below the dermis.
(E) Flap inset into defect and closed under minimum tension. (F) Final result after 1 year.

276
Part 2  Essential Surgical Skills
 OPTIMIZING OUTCOMES
A
B
C
Figure 17.30  A wound of the mid to upper helical rim is repaired with a helical rim advancement flap. (A–B) An incision is created
along the helix, and the flap is elevated at the level of the perichondrium. It is necessary to extend the incision to the lobule in order
to achieve adequate flap motion. A redundant tissue cone is removed along the leading edge of the flap on the posterior surface of
the ear. (C) The resultant reconstruction leads to a smooth, rounded helical rim with a normal shape.
Optimizing outcomes
 A minor miscalculation in flap design can result in flap failure,
postoperative morbidity, and functional or aesthetic
compromise. The surgeon should provide proper preoperative
counseling and obtain detailed informed consent.
 Most flap failures on the face can be traced to crucial errors
in flap design or poor surgical practices. The successful
creation of facial flaps involves finding the correct balance
between flap liberation and vascular preservation. For proper
mobilization, flaps generally require relatively long incision
lines and generous undermining.
 Surgical morbidities such as postoperative hemorrhage or
damage to underlying facial motor nerves may result from
poor surgical technique, a lack of knowledge of the
underlying anatomy, or patient-related factors. Proper patient
selection and surgical expertise and knowledge are critical for
flap success.
 Most surgical complications that follow facial flap repairs
result from difficulties in hemostasis. Careful attention should
be placed on proper patient selection, the occasional use of
preoperative screening laboratory tests, and thorough
intraoperative hemostasis.
 Pin-cushioning is easier to prevent than to manage. The most
important technique to reduce the risk of this complication is
to properly size the flap.
appropriate reconstructive alternative for these difficult
defects. For full-thickness alar defects, the nasolabial flap can
also be designed with a long enough pedicle so as to ‘fold’
upon itself at the alar margin. With this folding nasolabial
flap, the donor tissue along the medial cheek can serve as both
the internal nasal lining and the external nasal coverage.65 The
predictability of the nasolabial flap’s perfusion is well dem-
onstrated by the manipulations that these folded flaps can
undergo without suffering ischemia.66
The pedicled transposition flap is yet another modification
that can be used for defects of the lateral nose that are more
medial and are not immediately adjacent to the nasofacial
sulcus. In these scenarios, when a nasolabial flap is deemed
desirable, it must transpose over the lateral alar segment that
is intact to be inset. As such, a pedicle of skin bridges this
gap and the flap must later be divided. Division of a pedicled
flap occurs only once flap viability has been ascertained,
which generally occurs at around 3 weeks.
The disadvantages of the nasolabial flap are readily appar-
ent. Long, complex incisions are required to raise the flap,
and because it originates at the melolabial fold it has a
potential to place terminal beard hair onto the nose in male
patients. The flap predictably flattens the alar groove, and a
secondary procedure to reintroduce the shadowed concavity
of this area is required to maximize the final aesthetic
outcome. Finally, the flap is highly prone to developing the
trapdoor deformity (Fig. 17.34) and appropriate attention
should be placed on meticulous operative technique with
undermining at the recipient site, insetting the flap with deep
sutures and not oversizing the flap. For these reasons, pedi-
cled flaps from the cheek occasionally offer more predictable
results in nasal reconstruction. However, the single-staged
nasolabial flap remains an important, if somewhat more dif-
ficult to master, reconstructive alternative for challenging
alar wounds.
The purpose of performing any flap repair is to return the
skin and soft tissues to a configuration that is as near normal
as the dynamics of the surrounding tissue will allow. With
experience, flap reconstructions can be conceptualized and
executed with safety and reproducibly good functional and

277
Chapter 17  Random Pattern Cutaneous Flaps
A
B
C
D
Figure 17.31  (A) Nasal banner flap hides
the donor scar within a glabellar crease.
(B) This flap is elevated above the level
of the procerus and corrugator muscles
to expose the area undermined over
muscle and bone. (C) Flap executed.
(D) Ninety days postoperatively, no
revision.
aesthetic results. Designing and executing flap repairs requires
meticulous attention to detail at all steps, from planning the
reconstruction to placing the final suture.
Surgical planning
A properly performed flap reconstruction will close a wound
without undue tension or distortion of a free margin. A crit-
ical aspect of surgical planning and informed consent is to
inform the patient why the flap is needed and what the flap
repair entails. Some patients will have low aesthetic expecta-
tions and will accept any reasonable surgical outcome. Other
patients will expect essentially bloodless, painless, scarless,
and complication-free surgery and postoperative course.
Although many surgeons rationalize that elderly patients have
lower aesthetic demands than younger patients, recent dra-
matic increases in the numbers of older patients undergoing
elective cosmetic surgery67 suggest that they also have high
aesthetic expectations. Therefore, reconstructive surgeons
should strive for a good cosmetic outcome in all patients
willing to consider a flap repair.
The concepts of skin grafting and direct wound closures are
often easily understood by the lay public. Flap repairs involve
complicated geometric tissue rearrangements; many patients
will not readily understand why so many incisions are required
to close what they perceive to be a relatively small wound.
As part of the informed consent process, the surgeon should
discuss the proposed reconstructive procedure with the
patient with the aid of a mirror. Not surprisingly, some
patients will refuse to view an operative wound, and the
informed consent can therefore be achieved with only a thor-
ough discussion of the anticipated flap procedure. In addition
to an explanation of the flap’s design and execution, the
reconstructive surgeon should also inform the patient of pre-
dictable surgical sequelae, including transient hemorrhage,
bruising, swelling, discomfort, and suture line visibility, as
well as less likely sequelae, including nerve injury, infection,
tumor recurrence, and contour deformity.
The planning of a surgical flap as a reconstructive alternative
first involves the exclusion of simpler wound management
strategies such as second intention healing, primary linear
closure or skin grafting. If the surgical wound is large, deep,

278
Part 2  Essential Surgical Skills
or complicated, a flap reconstruction is likely to offer aes-
thetic and functional results superior to the results of other
reconstructive alternatives. The most simple flap option
should always be selected. Despite their advantages, flaps do
require long incision lines that can be quite noticeable, and all
attempts to limit the visibility of these incision scars should
be undertaken. Because the entire premise of a flap recon-
struction involves relocation of the primary surgical defect to
an area in which there is more tissue availability and less cos-
metic penalty, the surgeon should initially carefully assess the
laxity and quality of the tissue immediately surrounding the
primary defect. Wound closure tensions should be appropri-
ately directed away from critical anatomic structures such as
the eyelid or eyebrow margin, the vermilion border, or the
alar rim. The tension required to close the donor site of the
flap should also be carefully assessed before initiation of
the surgical procedure to verify that these structures will not
be distorted. Finally, the most appropriate flap should be
demarcated using marking ink with the patient upright
and demonstrating relaxed skin tension lines and facial expres-
sion lines where incision lines can be hidden. This should be
done before distorting the area with the infiltration of local
anesthetic.
In addition to planning for the surgical repair and preparing
the patient, the surgeon should also properly prepare himself
or herself to optimize operative outcomes. The experienced
dermatologic surgeon with a competent assistant can com-
plete many moderately complex random pattern flap recon-
structions in less than 90 minutes, but appropriate scheduling
of operative procedures should be allowed so that the surgeon
is not unnecessarily rushed. The accurate performance of flap
reconstructive procedures depends upon the surgeon’s ability
to perform consistently. Distractions during this process need
to be minimized. The surgical tray should be arranged in a
predictable manner, and the comfort of the surgeon should
be assured before the operation. The operating room must be
designed for ergonomic comfort because there are suggestions
in the literature that the motions associated with the frequent
performance of medical procedures can result in repetitive
use injuries in physicians (see Chapter 48).68,69
Anesthesia
Most random pattern facial reconstructions can be carried out
using only local anesthesia. A combination of facial nerve
blocks and local infiltration anesthesia will allow for the repair
of all but the largest and most complicated surgical defects.
The most common anesthetic used by the dermatologic
reconstructive surgeon is 1% lidocaine with 1 : 100 000 parts
epinephrine. A longer-acting local anesthetic such as bupi-
vacaine may be added if the anticipated surgical procedure
will be lengthy. For large surgical defects, there is occasionally
a need for tumescent anesthesia using larger volumes of
diluted lidocaine (known as tumescent anesthesia).70 Tumes-
cent anesthesia offers the benefit of excellent local anesthe-
sia, enhanced hemostasis, and lower peak serum levels of
anesthetic, but the larger volumes of injected anesthetic can
cause tissue distortion and tension intraoperatively as well as
prolonged postoperative facial edema.
Epinephrine is routinely added to the anesthetic solution
to provide suitable hemostasis, and the use of epinephrine
greatly facilitates the speed and safety of facial reconstructive
procedures. Additionally, the duration of anesthesia is pro-
A
B
C
Figure 17.32  A banner transposition flap from the glabella is
designed to repair an eccentric operative wound of the nasal
bridge and superior medial canthal region. (A) The base of the
flap and point of pivotal restraint are carefully undermined to
provide a perpendicular redirection of tension vectors. (B) All
tension is directed horizontally on the brow, and the flap
transposes downward and into the operative wound without
tension. (C) The final repair at 3 months.

279
Chapter 17  Random Pattern Cutaneous Flaps
ing complicated pedicled flaps. By avoiding the use of general
anesthesia or conscious sedation, patient postoperative
recovery can be hastened, overall morbidity diminished, and
operative expenditures minimized. Especially in those with a
history of anxiety or panic disorder, and occasionally for
nervous patients, oral anxiolytics or analgesics can be used,
but most patients can tolerate extensive reconstructive facial
flap surgery with the use of only injected local anesthetics.
This must be assessed on a case-by-case basis.
Incision
After sufficient anesthesia is obtained, the operative site is
prepped and draped in a standard surgical manner. Because
flap reconstructive procedures involve the introduction of
foreign materials (suture) into the operative site, these pro-
cedures should be carried out only under strictly sterile con-
ditions to minimize the risk of postoperative wound infection.
To improve the accuracy of flap surgery, the physician should
surgically prepare the entire face so that any intraoperative
complications such as the development of facial asymmetry
A
B
C
D
Figure 17.33  The nasolabial flap is
elevated lateral to the nasolabial fold. It
is elevated at the depth of the subcutis
within the larger looser fat lobules
overlying the facial musculature. The
portion of the flap to be inserted into
the operative defect is thinned to the
superficial subcutis. The alar crease may
be recreated with a tacking suture. A
typical result is shown in which the
border of the flap is slightly visible. In
this case, a cartilage graft was also used
to stabilize the ala. (A) Nasolabial flap
design. (B) Flap undermined in deep
subcutaneous tissue. (C) Flap inset and
closure done. (D) Ninety days
postoperatively, no revision.
longed and the peak serum levels of anesthetic are minimized
with the addition of epinephrine to a certain point. Histori-
cally, there have been concerns that the profound pharmaco-
logic vasoconstriction associated with the use of epinephrine
can result in flap death or even necrosis of adjacent tissue in
watershed areas such as the nasal tip, ear lobe, penis, or digit,
but reconstructive procedures carried out with the use of
epinephrine in these anatomic areas have not been associated
with higher levels of tissue ischemia or surgical complications
in those without peripheral vascular disease (see Chapter 3).
In fact, even digital block anesthesia with the use of epine-
phrine has been shown to be undeniably safe.71 Additionally,
the early concerns that the concomitant administration of
β-blockers and epinephrine would result in unopposed
α-adrenergic stimulation and serious hypertension were
proven to be unfounded.72 The use of epinephrine may blanch
a flap and the surrounding tissues during an operative recon-
struction, but this relative intraoperative pallor does not indi-
cate prolonged ischemia and does not predict flap failure.
Local anesthesia is safe and appropriate for the overwhelm-
ing majority of skin cancer reconstructive procedures includ-

280
Part 2  Essential Surgical Skills
can be recognized and corrected. Thereafter, the flap is
incised with a scalpel. Lateral traction on the skin during the
incision facilitates the creation of an even wound edge. Defin-
itive incisions to the subcutaneous fat should be performed
initially to prevent fraying of the flap’s incised margins.
During the incision and liberation of the flap, all efforts
should be made to minimally handle the tissue. Tissue forceps
with teeth and skin hooks are much less traumatic than
forceps with flat blades, and should be used exclusively to
manipulate tissue. Any unnecessary manipulation of the
wound’s edges can cause subtle degrees of tissue ischemia
that can impact on the aesthetic quality of the final scar.
Plane of flap elevation and
surgical undermining
A flap needs to be freed from its attachments to the deeper
subcutaneous tissues before it can be effectively transferred
to a recipient site. Flap elevation loosens the flap from its
restricting connections and undermining minimizes the
wound closure tensions on the flap. Because elevated wound
closure tensions accurately predict the risk of ischemic flap
loss,73 adequate undermining should always be performed.
Undermining is effective, and animal studies have demon-
strated that the force required for a one-dimensional closure
of a linear repair of an in-vivo porcine operative wound is
reduced between 18.6% and 47.4% with simple undermining
of the wound’s edges.74 Undermining of the flap, the tissue
surrounding the flap, and the primary defect may also mini-
mize the risk of developing pin-cushioning in the later post-
operative period because the wound contractile forces are
distributed in more directions and over much greater dis-
tances.75 Undermining comes at a cost, however. Undermin-
ing, particularly at a flap’s base, can transect vital arterial
input to the flap, and overly aggressive undermining can
therefore introduce an ischemic risk. Paradoxically, under-
mining that is too extensive can also impede tissue move-
ment.76 The successful dermatologic surgeon therefore
approaches flap undermining as carefully as flap design. For
rotation and transposition flaps, undermining is even more
vital, because the flap must move a greater distance and must
do so in two or even three dimensions.
Undermining may be carried out either bluntly or sharply.
Sharp undermining with a scalpel or iris or Shea undermining
scissors under direct visualization is preferred by many sur-
geons because the flap can be elevated within a uniform and
predictable plane.77 Sharp undermining produces less blunt
force trauma and shear force on surrounding structures and
can limit postoperative swelling. Blunt undermining on the
other hand can be useful when undermining near vital neu-
rovascular structures that need to be spared. When a fascial
plane such as the SMAS or muscular plane is encountered,
undermining can often be accomplished with great precision
using electrosection.
Flaps are elevated and undermined in defined planes based
on anatomic location (Table 17.2, Fig. 17.35). For ideal flap
repairs, the thickness of the elevated flap should closely
match the depth of the primary surgical defect except when
the defect is deeper than the plane desired. Cheek flaps are
usually elevated within the subcutaneous fat. Flaps that are
elevated within the subcutis should generally be undermined
in the larger, looser fat lobules near the mid to deep subcutis.
The fat lobules of the superficial subcutis are smaller, laced
with fibrous tissue, and richly vascularized, making flap eleva-
tion more challenging. Thicker subcutaneous flaps have a
more predictable pattern of perfusion, and elevation just
above a superficial fascial plane will often produce greater flap
mobility than elevation in the superficial subcutaneous plane.
This plane of dissection is also used for all closures on the
neck, trunk, and extremities as well.
The cutaneous surgeon should have a well-honed knowl-
edge of the underlying anatomic structures because deeper
Table 17.2  Undermining planes in flap reconstructions
LOCATION
PREFERRED
UNDERMINING
PLANE
STRUCTURES TO BE
AWARE OF
Nose
Submuscular fascia/
perichondrium/
periosteum
Nasociliary nerve, angular
artery
Lip
Just above
orbicularis oris
Multiple branches of labial
artery
Ear
Just above
perichondrium
Eyelid
Just above
orbicularis oculi
Scalp
Just above or just
beneath galea
Scalp arteries
Cheek
Mid to deep
subcutaneous fat
Parotid duct, buccal
branches of the facial
nerve
Forehead
Just above frontalis
Supraorbital and
supratrochlear arteries
and nerves
Temple
Just above
superficial fascia
Temporal branch of facial
nerve, superficial temporal
artery
Figure 17.34  Trapdoor (or pin-cushion) deformity of a
nasolabial flap forms 4 months after surgery despite meticulous
design and operative technique. This may respond to
intralesional corticosteroid injections, otherwise a surgical
revision procedure may be required.

281
Chapter 17  Random Pattern Cutaneous Flaps
because they consider that this plane allows the most proper
tissue movement while minimizing the scar formation that
inevitably accompanies any surgical intervention.78 Flaps on
the ear should be undermined over perichondrium while
those involving periorbital skin should be undermined just
above orbicularis oculi musculature.
Hemostasis
Because flaps often require wide undermining for creation,
they typically have higher rates of associated bleeding com-
plications than side-to-side or skin graft repairs. Animal
studies and clinical observations have demonstrated that
hemorrhagic complications associated with flap reconstruc-
tive procedures dramatically increase the likelihood of
ischemic flap failure.79 Postoperative hemorrhage is also trau-
matic to the patient, and frequently painful. With meticulous
intraoperative hemostasis, the risk of postoperative hemor-
rhagic complications can be minimized. Before closure, all
visibly bleeding vessels should be effectively addressed.
Small-caliber bleeding vessels can be sealed with electroco-
agulation or bipolar cautery interventions, but vessels with a
A
B
C
D
Figure 17.35  Preferred flap elevation planes. (A) Nose: perichondrium and periosteum. (B) Ear: perichondrium. (C) Forehead: just
above the frontalis muscle. (D) Lower eyelid: just above the orbicularis oculi muscle.
undermining introduces significant risks of transecting vital
structures. Flaps on the forehead are typically elevated just
above the frontalis musculature. Although this plane of eleva-
tion requires careful separation of the subcutis from the
underlying skeletal muscle, it prevents the numbness and
arterial transection that can occur with deeper flap elevation.
Scalp flaps are most appropriately elevated beneath the galea
in the bloodless tissue plane immediately above the perios-
teum. Because the flap elevated under the galea has limited
tissue mobility/stretch, incision in the galea or excisions of a
portion of the galea may be useful to provide an added com-
ponent of tissue advancement.
Many lip flaps are elevated just above the orbicularis oris.
Some small nasal flaps are elevated above the nasal muscula-
ture, while more complicated flaps, such as the bilobed trans-
position flap and the dorsal nasal flap, are most appropriately
elevated just above the perichondrium. This deeper plane of
undermining on the nose is associated with far less hemor-
rhage than undermining within the nasalis musculature, and
the inclusion of richly perfused skeletal muscle with the bases
of these flaps makes the flaps nearly immune to ischemia.
Rhinoplasty surgeons also choose this plane of undermining