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Presentation

O2T Advancement Flaps and Mercedes Repairs for Complex Skin Defect Reconstruction

Description

The speaker, a Stanford Mohs surgeon, presents O-to-T advancement flaps and Mercedes repairs as practical workhorse techniques for reconstructing complex skin defects. She reviews the main advantages of O-to-T flaps, including excellent vascularity, a broad base, ability to move Burow’s triangles to cosmetic boundaries, a single-incision design, and ease of teaching and modification for trainees. She also notes drawbacks such as significant undermining, one-vector tissue recruitment, and greater bleeding risk, especially in patients on blood thinners or with sebaceous, tight skin. Using clinical examples, she highlights common uses on the forehead, neck, submental area, joints, cheek-eyelid junction, and nose, emphasizing careful planning around landmarks like the brow, hairline, alar rim, and subunit junctions. She stresses practical pearls: enlarge rather than under-size the flap when needed, use skin hooks instead of forceps to avoid epidermal trauma, and remove non-dissolving sutures on time to prevent track marks. Several cases illustrate good cosmetic outcomes as well as complications such as necrosis, atrophic or hypopigmented scarring, and issues related to tight or sebaceous skin. She concludes that O-to-T flaps and Mercedes repairs can be combined with grafts or interpolation flaps for larger, more complex defects, particularly when standard linear closure is not feasible.

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Conclusions

O-T advancement flaps are versatile workhorse repairs for defects on the forehead, neck, nose, and around joints or subunit junctions where a simple linear closure would be suboptimal.
The flap is especially useful for training surgeons because it is straightforward to design, forgiving to adjust intraoperatively, and allows incremental undermining until tension is acceptable.
Successful outcomes depend on careful technique, including repeated undermining, testing apposition with skin hooks, and excising standing cones last to avoid excess tension and distortion.
Sebaceous, tight, sun-damaged forehead skin is challenging and may require larger flaps and more secure sutures to reduce bleeding, necrosis, and atrophic scarring.
Nonabsorbable sutures may provide better hemostasis and wound support than fast-absorbing sutures, particularly in anticoagulated patients or in thicker, less elastic skin.
O-T flaps can produce good cosmetic outcomes on the forehead, neck, and nasolabial-adjacent areas when incisions are hidden in cosmetic boundaries or rhytids.
The base of the neck and submental region benefit from O-T style advancement because available laxity can be recruited while avoiding extension of scars onto the face.
At mobile areas such as the antecubital fossa, O-T closures help reduce the risk of contracture across joints.
On the nose, O-T flaps are best suited to selected defects above the alar rim and on more convex or narrow nasal contours, with caution in concave noses to avoid deformity.
Mercedes or three-point advancement repairs distribute tension in multiple directions and can be paired with Burrow’s full-thickness skin grafts for larger or more complex defects.
Combination repairs, including O-T flaps with grafts or interpolation flaps, are valuable when defects are too large for a single technique alone.
Overall, these reconstruction methods can yield acceptable to excellent long-term outcomes when flap choice is matched to location, tissue characteristics, and postoperative wound management.

Baker, S. Chapter 9: Advancement Flaps, https://clinicalgate.com/advancement-flaps-2/
Tamir, Birkby, and Berg, 1999, Journal of Cutaneous Medicine and Surgery