Flap Basics I

Rotation and Transposition Flaps

Sidney J. Starkman, MD, Carson T. Williams, MD, David A. Sherris, MD*

KEYWORDS
 Mohs  Reconstruction  Rotation flap  Transposition flap  Bilobe  Rhombic

KEY POINTS
 Local facial flaps offer a good option for repair of Mohs micrographic surgery for cutaneous lesions.
 Rotation flaps are curvilinear in nature and rotate adjacent tissue into a defect.
 Transposition flaps are linear and pivot toward a defect over an incomplete bridge of tissue.
 Rhombic and bilobe flaps incorporate components of transposition and rotation flaps and serve as
the workhorse flaps of Mohs reconstruction.
 Local facial flaps are hearty, only suffering rare, mild complications.

BACKGROUND results with minimal distortion of the surrounding

facial landmarks. Local flaps used for facial recon-
Modern evolution in techniques of facial recon- struction are classified by a variety of methods,
struction have dramatically increased the possibil- including blood supply, flap contents, and the
ities for repair of facial defects. The need for method of transfer. Rotation flaps are curvilinear
advanced facial reconstruction has grown signifi- flaps that pivot into the defect. Transposition flaps
cantly since the advances of Mohs micrographic are linear and pivot toward the defect over an
surgery, which represents the gold standard for incomplete bridge of skin. This is in contrast to
malignancies of the face and neck.1 Use of imme- interpolation flaps, which pivot toward defects
diate fresh tissue fixation allows for Mohs surgical over intact bridges of skin. The rhombic flap,
excisions to be performed quickly, facilitating bilobe flap, O-T/O-Z flap, and note flap are types
expedient repair. In many cases of complex facial of transposition flaps, some of which include
defects resulting from the extirpation of advanced both transposition and rotation components.
cutaneous malignancies, primary wound closure is
impossible. In these instances, ideal results can be ROTATION FLAPS
obtained through recruitment of adjacent tissue
with the use of local and regional flaps. Advances Rotation flaps are designed with curvilinear orien-
in local flap techniques have raised the bar in facial tation in the direction of the defect that they pivot
reconstruction; however, acceptable results to toward. Although these flaps are rotational in their
both the surgeon and the patient require high direction, they also span the defect by stretching
levels of planning and surgical technique. the elastic tissues. This leads to the points of
Defects resulting from Mohs surgery and other greatest wound closure tension occurring along
traumatic injuries can typically be repaired with the distal border of the flap rather than along the
grafts or local flaps. Between these options, local length of the flap.2 The secondary defect that oc-
flaps are often preferred because of their superior curs following execution of a rotational flap is
facialplastic.theclinics.com

color match and texture. A well-planned and determined by the size of the flap, with a larger-
executed local flap can lead to excellent cosmetic rotation flap leading to a narrower and longer

Disclosure: The authors have nothing to disclose.

Department of Otolaryngology, University at Buffalo, 1237 Delaware Avenue, Buffalo, NY 14209, USA
* Corresponding author.
E-mail address: dsherris@buffalo.edu

Facial Plast Surg Clin N Am 25 (2017) 313–321

http://dx.doi.org/10.1016/j.fsc.2017.03.004
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314 Starkman et al

secondary defect. A narrower secondary defect of the arc of the flap.6 This can allow for orienta-
will lead to less tension on closure of the wound; tions that promote lymphatic drainage, and also
however, this exists only up to a certain point. Lar- that minimize vascular and nervous disruption.
rabee and Galt3 demonstrated there is minimal The flap is very robust with strong vascular flow
benefit to extending the arc of rotation flaps due to its broad-based design. The surgeon can
beyond 90 from the axis of the defect. also often position the single long arc of the flap
The ideal defect for rotation flaps are triangular within a relaxed skin tension line (RSTL) or
in shape. The height-width ratio of the triangle aesthetic unit for greater scar camouflage.
ideally should be 2:1. The arc of rotation extending The rotation flap has utility for many types of
from the base of the triangle should be a symmet- facial defects; however, because of the curved
ric curve, with the radius of the curve being 1 to 2 incision of the flap, it sometimes does not lie
times the height of the triangle (Fig. 1A). For cleanly within an RSTL. In cases in which the inci-
optimal results with rotation flaps, the defects sion does not lie within an RSTL, the scar can be
can be modified into triangular shapes via conser- less camouflaged and more noticeable than in
vative excision of normal tissue.4 Burow triangles other methods of repair. Because of the degree
are often used to assist with closing the secondary of rotation, these flaps often develop standing
defect. The length of the flap should be 4 times the cutaneous deformities at their base. These defor-
width of the base of the triangular defect (see mities cannot be initially excised, as that would
Fig. 1B, C). This ratio obviates the need for exci- compromise the vascular supply to the tissues.
sion of a Burow triangle to equalize the defects. Rotation flaps are not the optimal choice in repair
Enlarging the flaps beyond the 4:1 ratio does not of central cheek defects or most nasal defects. In
significantly decrease the wound closure tension; men, the rotation flap can distort the hair-bearing
however, a longer flap can be useful in areas of skin of the sideburn medially toward the malar
limited skin mobility.5 eminence. The skin of the nasal tip is very inelastic,
Wide undermining is performed to allow for piv- making recruitment difficult. Additionally, the donor
oting of the flap toward the defect. Undermining site scars along the nose do not typically fall cleanly
can also reduce the extent of standing cutaneous between the nasal aesthetic subunits. Most nasal
deformity by shifting the deformity slightly away defects are better repaired with other flaps, such
from the flap’s base. When a standing cutaneous as the bilobe or rhombic flap.
deformity persists in spite of these techniques,
secondary excision of the deformity is warranted. BILOBE FLAP
In most instances, a standing cutaneous deformity
will flatten over 6 weeks postoperatively. Addition- The bilobe flap is generally considered one of the
ally, close attention must be paid to the closure of “workhorse” flaps of facial reconstruction. Classi-
deep layers, ensuring close approximation at the fied as both rotational and transpositional, the
points of maximal tension and meticulous eversion bilobe flap is a transposition flap because it is
of the skin edges. elevated and mobilized toward an adjacent defect
Rotation flaps have several significant advan- and transposed over an incomplete bridge of skin,
tages in the repair of facial defects. There is a great and a rotational flap because it pivots around a
amount of flexibility in the planning and orientation specific point and maintains its radius.7 It is

Fig. 1. Basic rotation flap. (A) A Burow triangle is drawn that encompasses the defect. The legs of the triangle are
approximately twice the diameter of the defect. (B) The arc of the rotation flap measures 4 times the defect diam-
eter. (C) The final outcome of the basic rotation flap.

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 Flap Basics I: Rotation and Transposition Flaps 315

particularly useful when a single transposition flap closely match the thickness of the defect area.
exerts too much tension on the closure. The bilobe When there is a considerable mismatch, a delayed
flap is able to more effectively transfer tension closure may be beneficial by allowing a deeper
across a greater angle of rotation and therefore defect time to granulate in its base. This allows for
distributes the load both more equally and with a a flap that may not need much alteration and
larger component being placed away from the pri- produces a more even level to the healed flap and
mary defect. surrounding skin.
Originally described for nasal tip reconstruction When designing a bilobe flap, first measure the
by Esser in 1918, the bilobe flap continues to serve radius of the defect. Once obtained, mark a point
the facial plastic surgeon during post-Mohs micro- to the side of the defect, preferably laterally, equal
graphic surgery defect repair.8 Although the use of to the radius of the defect. Next, measure 2 arcs:
the bilobe flap can be used in many parts of the one equal to 2 times radius and the other 3 times
body, its utility is greatest in areas that need to the radius, spanning the entire area of the defect
minimize tension in the area directly adjacent to and planned area for flap rotation. Once the 2
the primary defect, like the nasal dorsum, sidewall, arcs are marked, use the diameter distance of
and tip subunits (Fig. 2).7,9 the defect to measure the base of the first lobe
As described previously, this flap is best used for along the first arc immediately adjacent to the
defects of the nasal tip, dorsum, and sidewall equal defect, ensuring the middle of the lobe is 45 to
to or less than 1.5 to 2.0 cm.10 Extension to the 50 from the center of the defect. The height of
nasal ala reduces this flap’s efficacy as the scarring the first lobe should extend to the line of the sec-
that occurs will many times cause cephalic eleva- ond arc, therefore making its height equal to the
tion, retraction, and/or distortion of the alar rim radius of the defect. Next, again measuring along
leading to lesser cosmetic outcomes.11 The the first arc line, the second lobe should be a dis-
Zitelli-modified bilobe flap is designed with a total tance slightly smaller than the first lobe, and again
arc of rotation 100 or less, with each limb of the 45 to 50 from the middle of the first lobe or 90 to
flap rotating 45 to 50 .12 The flap is routinely based 100 away from the middle of the defect. Its height
medially along the nasal dorsum or laterally along is a distance twice that of the first lobe, and of a
the nasofacial groove, with laterally based flaps slightly more triangular shape. Finally, mark the
resulting in better concealed scars. The bilobe standing cutaneous deformity between the edge
flap is most successful when the skin is elevated of the defect and the initial mark placed equal to
in the subcutaneous plane and the raised lobes 1 radius of the defect (Fig. 3).11

Fig. 2. (A) Bilobe flap of the right nasal sidewall. (B) Bilobe flap of the left nasal sidewall to reconstruct a nasal tip
defect.

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316 Starkman et al

defect, most often 6-0 prolene or nylon. The area

Key should have a light compression dressing placed
=r for 24 to 48 hours following the procedure and su-
= 2r
= 3r tures removed 5 to 7 days postoperatively.
Although the bilobe flap is extremely versatile in
facial reconstruction, it is not without its down-
sides. Because of its curvilinear incisions not lying
parallel to the RSTLs, a potential downside to the
°
use of the bilobe flap is its risk of trapdoor defor-
45
mity.12 Careful preoperative planning and design,
along with close attention to tension-free closure
90°
and good skin eversion are usually successful in
Pivot point
preventing this. Nevertheless, dermabrasion of
the entire area 6 to 8 weeks following the initial
procedure is often advocated to conceal the slight
Fig. 3. Schematic of the ideal bilobe flap. Note the scar when one seeks additional cosmesis.
first lobe is approximately the same size as the defect
and the center of which is 45 from the center of the
defect. The second lobe is approximately half the size O-T/O-Z FLAP
of the first lobe, is 90 from the center of the defect,
and is more triangular in shape. Mohs micrographic surgery leaves circular defects,
making their closure in certain areas of the face a
challenge to the reconstructive surgeon. Rear-
It is important to remember, when lesions are rangement of tissues to convert the circular defect
excised using the Mohs technique, they have a to one that more closely approximates the natural
resulting edge that is beveled inward. To aid in RSTLs is beneficial for acceptable cosmetic
proper inset of the flap with good eversion, it is healing.
necessary to first bevel the edges outward before The O-T flap converts a circular defect to one
laying the flap into position. Once the flap has been that is approximately “T” shaped once closure is
precisely designed, incisions along the lobes are completed (Fig. 5). Incorporating rotation and
performed. Wide undermining is crucial to ensure advancement, it is able to recruit adjacent tissue
adequate mobilization of the 2 lobes and for from a specific area around the defect while leav-
tension-free closure. The defect created by lifting ing one of its borders undisturbed. This is impor-
and mobilizing the second lobe should be fully tant in facial regions like the forehead, temple,
closed first. Only after it has been closed, the first and lips, where distortion created by closure and
lobe should then be sutured into place covering scar contracture lead to unsatisfactory results.
the initial defect. At this point, the standing cuta- This flap is commonly used in the temple region
neous deformity is determined and it is resected abutting the hairline. The undisturbed border, the
to relieve tension and provide close skin approxi- top of the “T,” should be placed along the hairline
mation. Finally, the second lobe is trimmed to in a vertical fashion. The circular defect and a
size and sutured into position within the defect standing cutaneous deformity are resected simul-
created by the first lobe (Fig. 4). taneously in a “V” shape. Next, the area of rotation
Suture selection should consist of a permanent and advancement is widely undermined in a sub-
monofilament appropriate for the size of the cutaneous plane above the facial nerve and the

Fig. 4. Bilobe flap elevation, mobilization, and inset. (A) Design of a bilobe flap. (B) Resection of the defect and
standing cutaneous deformity and elevation and mobilization of the 2 lobes toward the defect. (C) Closure of a
bilobe flap. The second lobe should be trimmed and sutured into the first lobe defect initially, followed by
closure of the second lobe defect, and finally the initial defect closed with the first lobe after appropriate
trimming.

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 Flap Basics I: Rotation and Transposition Flaps 317

Fig. 5. O-T flap. (A) The defect is converted from nearly circular to triangular in shape with the broad base of the
triangle lying perpendicular to the straight limb. (B) Resultant defect and direction of movement. (C) Resultant
appearance after closure.

skin edges are prepared for closure. The opposing NOTE FLAP
edges from the resected area are closed, primarily
forming the bottom portion of the “T.” The top of Roughly resembling the musical eighth note, the
the “T” runs adjacent to the hairline and all edges aptly named note flap is a simple transposition
are closed using nonabsorbable monofilament su- flap (Fig. 7). An adjacent “V,” or triangular, shaped
tures, being certain to relieve tension at all points area of skin is used to cover the defect and the
and produce good wound edge eversion. skin edges of the donor site are simply closed pri-
Because of the formation of the “T” shape, this marily. To create this flap, a point approximately
flap inherently creates a scar perpendicular to equal to radius of the defect is marked away
the RSTLs of the facial subunits. Knowing this, uti- from the defect and 2 lines are marked from oppo-
lization of the O-Z flap, or double rotation flap, can site sides of the perimeter of the defect coursing
be beneficial. Like the O-T, this flap also has rota- back to the marked point. This represents the
tional and advancement components and is usu- “V”-shaped area to be excised. Next, a similar-
ally used in similar areas, like the cheek and sized V-shaped area is marked next to this with
temple. The versatility of the O-Z flap comes a long limb of each intersecting one another at
from its ability to minimize distortion of important their ends. Once marked, the defect and standing
structures because the tension vectors are primar- cutaneous deformity are resected and the entire
ily parallel to the limbs of the repair (Fig. 6).13 area is widely undermined in a subcutaneous
Here, adjacent flaps are based on opposing plane. The second V-shaped area is transposed
sides, which creates scars that run more obliquely over the triangular bridge of skin and set into the
to one another and allows them to more closely defect area. The defect created by raising the
approximate the RSTLs. Resection of the lesion flap is first closed primarily and then the flap is
leaves a circular defect, and 2 lines from opposite trimmed and sutured into place. Opposite the
sides of the periphery as mirror arcs of one another standing cutaneous deformity “V” of resected tis-
are drawn. Incisions along these lines are made sue, a small Burow triangle may be necessary to
down to the subcutaneous plane and wide under- avoid skin excess and to accomplish better
mining is performed for increased tissue mobility. wound eversion and closure.
Once adequate tissue mobility has been achieved,
the skin flaps are advanced and rotated into the RHOMBIC FLAP
defect and the edges of the flaps are sutured to
one another creating the middle portion of the The rhombic flap is another “workhorse” flap for
“Z.” Next, the remaining wound edges are closed many of the smaller cutaneous defects of the
in an interrupted manner with nonabsorbable head and neck. It is a transposition flap and pivots
monofilament sutures. over an incomplete bridge of skin (Fig. 8). The

Fig. 6. O-Z flap. (A) Double opposing rotation flaps are raised and rotated into the skin defect. (B) Resultant
appearance after closure.

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318 Starkman et al

Fig. 7. Note flap. (A) Design of an ideal note flap. The vertical tangential limb is approximately 1.5 times the
diameter of the defect and the second limb lies at approximately 60 from the first limb and is approximately
the length of the defect diameter. (B) Note flap elevation and mobilization. (C) Closure of the note flap.

rhombic flap uses specifically engineered vectors it is not possible to orient all of them within RSTLs.
and results in a predictable scar and point of Therefore, the flap orientation is dictated by the
maximum tension. The traditional rhombic flap lines of maximal extensibility. The vectors of
used the Limberg design, based around a defect maximum tension are designed to lie within these
with 60-degree and 120-degree angles and limbs lines of maximal extensibility to minimize wound
of equal length (Fig. 9A).14 A first limb is then tension. A disadvantage of the Limberg flap is
extended outwardly from the short axis of the the amount of discarded normal tissue needed to
rhomboid defect, equal in length to one side of convert a defect into a geometric rhombus.16
the defect. A second limb of equal length is then Subsequently, modifications, including the
extended from the end of the first limb, back to- Dufourmentel and Webster designs, were intro-
ward the primary defect at a 60 angle. The point duced to address the pitfalls of the Limberg design.
of maximum tension (58%) corresponds to distal Dufourmentel adjusted the design to accommo-
end of the closure of the secondary defect (see date defects that were squarer, and the Webster
Fig. 9B, C).15 Because the resultant scars from modification uses a rhombic flap with 30 edges
closure of a rhombic flap run in multiple directions, that transposes a narrower flap into the defect.17
Theoretically, this minimizes the risk of “dog ear”
deformity. The narrower Webster flap distributes
the wound tension more evenly around the flap,
and decreases the amounts of distortion to the sur-
rounding facial structures. Furthermore, the use of
Z-plasties has expanded the potential applications
of the rhombic flap for larger effects of the face. The
Z-plasty allows for greater mobilization of the flap
at the expense of a longer scar.
For closure of larger facial defects, bilateral
rhombic flaps can be used. The main utility of
these flaps is for large defects of the nasal tip
and dorsum, offering acceptable color and texture
match. Bilateral rhombic flaps use identical geom-
etry and principles as single rhombic flaps, except
2 locations adjacent to the defect are used for tis-
sue recruitment instead of 1. The use of 2 flaps al-
lows for each individual flap to be smaller, as each
must cover only half of the defect. However, this
technique does result in additional scar limbs.
When designing the flaps symmetrically posi-
Fig. 8. Rhombic flap. A nearly circular defect is con- tioned on either side of the nose, the wound
verted to a rhomboid and planned incisions are closure tensions are identical. Repair of a defect
marked. over the nasal dorsum often slightly elevates the

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 Flap Basics I: Rotation and Transposition Flaps 319

Fig. 9. Rhombic flap. (A) Design of an ideal rhombic flap. The vector of tension is the B-C limb in this schematic
and not an incision line. (B) Elevation and mobilization of rhombic flap into position. (C) Closure of the defect
with the rhombic flap. The point of maximal tension should be approximated first followed by the remaining
flap closure.

nasal tip, which is particularly useful in patients factor for microvascular compromise and poor
with tip ptosis. The medial corners of the rhombic wound healing. Other medical conditions, such as
flaps overlap in the middle of the defect and redun- uncontrolled hypertension, collagen disorders, dia-
dant tissue is carefully excised. betes mellitus, and previous irradiation, should be
approached with caution and detailed conversa-
WOUND CARE tions with the patient should be had to highlight
these conditions’ ability to compromise wound
Following inset and closure of the local flap, metic- healing.
ulous wound care is critical to optimizing the Thorough flap design preoperatively cannot be
viability and outcome of the facial reconstruction. overemphasized. When determining the correct
Topical antibiotic ointment is applied to the inci- flap for the defect in question, one must consider
sion lines and a nonadhesive dressing is placed surrounding immobile structures, adequate areas
over the surgical site. With a topical adhesive, a of tissue recruitment, RSTLs, facial aesthetic sub-
compression dressing is placed over the defect units, and the resultant scar. Areas such as the
for 24 hours following the surgical repair, after nose possess complex topography and are the
which the surgical site is left open to air. All pa- focal point of facial anatomy requiring attention
tients are instructed to avoid strenuous exercise, to small details of defect analysis and flap design.
as well as direct exposure to sunlight, for 4 to Overall, complications of local facial flaps are
6 weeks postoperatively. All undermined skin mild.11 Although the face has an extremely
and incisions are more prone to early tanning vigorous vascular supply, most complications of
and burning. Sutures are removed from the face facial flaps are secondary to the inflow or outflow
5 to 7 days postoperatively. of blood to the flap. Venous congestion is most
On an outpatient basis, patients are instructed common and can significantly affect flap healing.
to clean their incisions twice daily with hydrogen Usually caused by compression of the veins, signs
peroxide, followed by a moisturizing ointment. of this condition reflect trapped venous blood.
Hydrogen peroxide serves to remove crust from Warmth, edema, and dark discoloration that
the surgical incisions, and also helps minimize blanches with digital pressure, lend evidence the
the width of the scarring. Hydrogen peroxide is flap is congested. A pinprick should reveal dark,
applied for 3 days postoperatively, after which venous blood. Management is aimed at relieving
the incisions can be cleaned with mild soap and the compression. Simply removing several sutures
water. Continued moist coverage with topical oint- to allow expansion may be enough to relieve the
ment during the duration of wound healing is crit- congestion. Release of any tight dressings or bol-
ical to ideal cosmetic outcomes. sters should occur immediately. If unrelieved by
these simple maneuvers, consider the use of
COMPLICATIONS transcutaneous leech therapy or hyperbaric oxy-
gen therapy.
Like most other areas of surgery and medicine, pre- Arterial ischemia is a rare, but arguably more
venting complications is far superior to managing serious threat to flap health than venous conges-
them postoperatively. Therefore, prevention be- tion. Characterized by a pale-colored, cool, flat
gins with a detailed patient history focusing on as- flap that does not blanch with pressure, ischemic
pects that may predispose to poor wound healing flaps do not bleed with pinprick due to impaired
or postoperative wound care adherence. Preoper- perfusion. Microvascular disease at baseline
atively, cigarette smoking is the single greatest risk significantly increases the chance of ischemia,

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320 Starkman et al

but with a thorough preoperative assessment with understanding of the unique characteristics of
careful patient selection and education about each type of flap, along with the specifics of facial
smoking cessation, the chances of encountering subunit reconstruction, will continue to offer pa-
this complication are lessened. tients a safe, functional, and aesthetically pleasing
Acute management of flap ischemia involves outcome of post-Mohs reconstruction.
pharmacologic agents administered to vasodilate
and thin the blood. Subcutaneous heparin, with ACKNOWLEDGMENTS
or without additional dipyridamole, should be
given at the first signs of flap ischemia. Hyperbaric The authors gratefully acknowledge the work of
oxygen therapy has also shown benefits, however, Amanda Widzinski for her illustrations of the flaps
its utility in the acute setting is less effective. included in this article.
Other complications like hypertrophic scarring,
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