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  • Presentation

Basics of Flap Design and Execution in Dermatologic Surgery

Description

The speaker gave a practical overview of flap design and execution in dermatologic surgery, emphasizing that flaps are used when secondary intention or linear closure is not ideal, especially in cosmetically sensitive areas or where tissue laxity is limited. A flap is defined as skin and subcutaneous tissue with an intact vascular supply that is moved from a donor site to close a wound. The talk covered flap terminology, including primary and secondary defects, flap base, tension vectors, and key sutures, and stressed preparing the wound with uniform depth and appropriate sizing to reduce pin cushioning. Flaps were classified by blood supply and, more usefully, by movement: advancement, rotation, transposition, and interpolation. Advancement flaps, including O-to-T, O-to-L, and island pedicle/V-to-Y variants, were presented as useful for redirecting Burow’s triangles and preserving cosmetic landmarks such as the eyelid, lip, and nasolabial fold. Rotation flaps were described as curvilinear tissue movements commonly used on the scalp and cheek, while transposition flaps, including rhombic and bilobed flaps, were highlighted for moving tissue over intact skin and carefully placing standing cones. Interpolation flaps, such as nasolabial and paramedian forehead flaps, were shown for deeper or larger defects needing staged reconstruction and structural support, with a reminder to counsel patients about staged procedures and possible later thinning. The speaker repeatedly stressed that not every wound needs a flap, that vascular supply and reach must be respected, and that creative combinations of techniques can be used to achieve the best functional and cosmetic outcomes.

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Conclusions

  • Flaps are most useful when a wound is unlikely to heal well by secondary intention, cannot be closed linearly, or needs tissue replacement that preserves function and cosmesis.
  • Compared with grafts, flaps often provide better tissue match and allow surgeons to redistribute tension while borrowing laxity from adjacent skin.
  • Good flap design depends on understanding the primary defect, secondary defect, pedicle/base, tension vectors, and where Burow’s triangles or standing cones will end up.
  • Successful flap execution requires a uniform wound base, uniform flap depth, appropriate sizing, and careful attention to minimizing pincushioning.
  • Advancement flaps are effective for shifting tissue directly into a defect and are especially useful for relocating redundancy to more favorable scar locations.
  • Rotation flaps are best when tissue needs to move in an arc around a pivot point, often to close scalp or cheek defects while avoiding distortion of nearby structures.
  • Transposition flaps, including rhombic and bilobed flaps, are valuable when tissue must be moved over intact skin to close defects in cosmetically sensitive areas.
  • Interpolation flaps are especially useful for larger or deeper defects when bulk, structural support, or reliable vascularization is needed, even though they require staged reconstruction.
  • The best flap choice is highly site-specific, with the nose, lip, glabella, cheek, ear, and forehead each favoring different designs and modifications.
  • Aesthetic and functional outcomes improve when surgeons respect free margins, protect adjacent landmarks, and choose the direction of flap movement to avoid distortion.
  • Many difficult defects can be managed successfully by combining techniques, such as partial secondary intention, grafting, and flap reconstruction in the same repair.
  • Long-term results are generally good when flap reach, vascular supply, and patient goals are carefully considered, but some staged repairs may need later refinement.
  • Patient preference matters greatly, since some patients prioritize avoiding wound care or staged procedures even when those choices require more complex flap planning.
  • Overall, there is no single flap that fits all defects, and creative, anatomy-driven individualized planning is the central lesson of the presentation.
  • Flaps and Grafts in Dermatologic Surgery, Ashley Wysong and Shauna Higgins, Ch 2.
  • Facial Flap Surgery, Glenn Goldman.
  • Moving from the O-Z flap to the O-S flap for scalp reconstruction: A new geometrical model.#10.1016/j.jpra.2024.08.008