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- Presentation
Transposition Flaps in Mohs Surgery: Design, Variations, and Clinical Applications
Description
The speaker introduces transposition flaps in Mohs surgery, excluding bilobed and trilobed flaps, and explains that they work by lifting tissue from a donor reservoir over intervening normal skin to close a primary defect while creating a secondary defect. She emphasizes their versatility, ability to redirect tension away from free margins, and efficiency in moving tissue from distant skin reservoirs. The talk reviews classic design principles of the Lindberg rhombic flap, including converting the defect into a rhombus with 60- and 120-degree angles, choosing an obtuse angle, and using wide undermining to allow the flap to transpose with minimal tension. Variations discussed include the Dufourmentel flap, which has a wider pedicle and shorter rotation arc and is useful near free margins, the Webster flap, which has a narrower pedicle and more tension-sharing but greater risk of distortion or ischemia, and the double Webster modification for reducing horizontal tension. Other transposition designs covered are the nasolabial flap for nasal ala and sidewall defects, the Z-plasty for scar revision, and the rhombic with double Z variation to increase flap mobility. The speaker also describes operative concepts such as dog-ear removal, wide undermining, and closure of the secondary defect first. Clinical examples show use of these flaps on the nasal bridge, sidewall, cheek, neck, temple, forehead, ear, and even the hand, with attention to avoiding alar retraction, ectropion, and other free-margin distortion. Overall, transposition flaps are presented as highly adaptable and cosmetically effective reconstructive tools once their mechanics are understood.
View moreConclusions
- Transposition flaps are presented as highly versatile workhorse repairs for dermatologic/Mohs reconstruction, especially when direct closure is not ideal.
- Their main advantage is that they recruit adjacent or distant tissue while redirecting tension away from critical free margins and functional landmarks.
- Classic rhombic (Limberg) flaps work well for defects on the upper nose, forehead, temple, canthi, and ear, with obtuse-angle designs generally preferred to reduce scar length and rotation arc.
- The Dufourmental modification improves flap survival and lowers pivotal restraint and vertical tension by using a wider pedicle, making it especially useful near free margins.
- The Webster variation increases tension sharing and reduces tissue cone, but its narrower pedicle can increase horizontal tension and risk distortion or ischemia.
- Double Webster and rhombic-with-double-Z designs are useful when extra movement or tension redistribution is needed, though they create more complex scars.
- Nasolabial transposition flaps are effective one-stage options for nasal ala and sidewall defects, but they can blunt natural nasal creases and should be reserved for selected cases.
- Z-plasty is mainly valuable for scar revision, webbing, and contracture release because it lengthens scars and restores mobility or creases.
- For successful transposition flaps, wide undermining and careful flap movement are emphasized as key steps to reduce tension and improve outcome.
- The clinical examples suggest these flaps can achieve good cosmetic and functional results across many Mohs defect locations, including the nose, cheek, eyelid-adjacent areas, temple, ear, forehead, and hand.
- Overall, the presentation concludes that once the geometry is mastered, transposition flaps are a dependable and adaptable reconstructive option with consistently good outcomes.
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