Aesth Plast Surg

DOI 10.1007/s00266-014-0423-2

ORIGINAL ARTICLE

GENERAL RECONSTRUCTION

A New Modified S-plasty for Skin Defect Closure

Huxian Liu Nanze Yu Jun Shi Xiaochun Hu
Xiaojie Lv Yan Han

Received: 4 May 2014 / Accepted: 16 October 2014

Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract
Background Dog-ear, or standing cone deformity, is a
common problem during surgical procedures. Multiple
methods have been reported to correct the deformity but
most create long scars or excessive normal skin loss.
Methods We designed a simple and convenient procedure
to remove small- and medium-sized skin defects. Based on
mathematical calculations, the procedure is an easily
designed surgical technique.
Results All of our patients healed uneventfully with no
significant complications. The procedure not only resulted
in a shortened surgical incision and preserved a greater
amount of healthy skin, but also left a simple S-shaped
curvilinear scar with favorable esthetic outcomes.

Huxian Liu and Nanze Yu have contributed equally to the manuscript.

Electronic supplementary material The online version of this

article (doi:10.1007/s00266-014-0423-2) contains supplementary
material, which is available to authorized users.
H. Liu  J. Shi  Y. Han (&)
Department of Plastic and Reconstructive Surgery, Chinese PLA
General Hospital, No. 28 Fuxing Road, Haidian District, Beijing
100853, China
e-mail: 13720086335@163.com
H. Liu  X. Hu  X. Lv
Department of Plastic Surgery, The Second Artillery General
Hospital of PLA, No. 16 Xinjiekouwai Street, Xicheng District,
Beijing 100088, China
N. Yu
Department of Plastic Surgery, Peking Union Medical College
Hospital, Peking Union Medical College and Chinese Academy
of Medical Science, No. 1 Shuaifuyuan, Dongcheng District,
Beijing 100730, China

Conclusion This novel modified S-plasty is a simple tool

to successfully remove skin defects, with a low deformity
risk.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Excision  New modified S-plasty 
Mathematical calculation  Skin deformity

Introduction
A fusiform-shaped excision is usually considered the most
common method for removal of small- and moderate-sized
skin lesions [1, 2]. However, the technique requires that the
surgeons excel in balancing the scar length, local deformity
(standing cone or dog-ear), and optimal normal tissue
preservation. This is particularly difficult when working in
areas like the face, which require high esthetic standards.
Numerous methods have been designed to achieve such
balance and improve the outcomes, including an elliptical
incision [2], Limberg flap [3], banner flap [4], note flap [5],
leashing technique [6], and others. Weisberg [7] reviewed
nine dog-ear correction methods and presented a general
review of the appropriate management in various situations. A tension-free closure with minimal additional normal skin excision and scarring is the well-accepted
standard for the closure of skin defects [8]. We believe that
proper incision design should also consider the possibility
of dog-ear formation in simplifying the surgical procedure
and obtaining better esthetic outcomes. We designed and
used a novel procedure, a modified S-plasty inspired by the

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Aesth Plast Surg

Tai Chi symbol, which has allowed us to achieve the goals

mentioned earlier, namely, shortening surgical incision and
preserving healthy skin while resulting in a simple
S-shaped curvilinear scar with favorable esthetic outcomes.
We introduce and discuss how to perform this novel
procedure.

Mathematical Calculations
This novel modified S-plasty was inspired by the traditional Chinese symbol Tai Chi (Fig. 1) and the conventional S-shaped procedure [9]. As shown in Fig. 2, the dark
circle represents a round benign lesion, e.g., a nevus, with a
radius of R. When two Tai Chi diagrams are half-overlapped and superimposed on the lesion, an exaggerated
conventional S-plasty incision design forms, with the
excisional area delineated in red and the shaded part representing the amount of normal skin to be removed along
with the lesion (Fig. 2).
Ci denotes the circle of which the center is Oi, (i = 1, 2,
3, 4 for each circle, respectively). If we move C4 clockwise, keeping it inscribed in C2 and circumscribed about C,
the area of the shaded part will decrease, so does the area of
the normal skin to be removed. As we keep moving C4, the
center O4 eventually matches O1, and C4 will diminish to a
point, and the area of the shaded part reaches its minimum.
Although this indicates that no normal skin will be
removed, the end result creates the original unfavorable
round incision and results in a conspicuous dog-ear
deformity. Thus, a struggle between normal skin preservation and preventing deformity has emerged.
During our work, we found that one point acts as an
ideal point both in the design of the incision and in the
results we obtained (Fig. 3). When the center of C4 is
located exactly on the vertical line of O1OO2 passing

Fig. 2 Two half-overlapped Tai Chi symbols superimposed on the

lesion The dark C represents a round-shaped benign lesion with a
radius of R. When two Tai Chi diagrams are half-overlapped and
superimposed on the lesion, an exaggerated conventional S-plasty
incision design forms, with the excisional area delineated in red and
the shaded part representing the amount of normal skin to be
removed. Moving C4, O4, the center of it, will eventually match O1,
and C4 will diminish to a point. In this situation, the area of the shaded
part will reach its minimum and conspicuous dog-ear deformity will
emerge

Fig. 3 Illustration showing the new modified S-plasty or Tai Chi

style procedure. When the center of C4 is located exactly on the
vertical line of O1OO2 passing through point O2, the radius of the C4,
r, equals 2/3R, which is the radius of the lesion. Line segment AD, the
p
axis line of the incision, its length equals 2 5 R

Fig. 1 Traditional Chinese Tai Chi symbol

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through point O2, the radius of the C4, r, equals 2/3R. Line
segment AD, the axis line of the incision, its length equals
p
2 5 R (4.47R). Because the incision only comprises isometric sides and acute angles, the chance of dog-ear formation is very low. The convex parts of the curves, or the
left part of the curve ABO1 and the right part of the curve
DCO2, are essentially two local flaps. These flaps can
significantly reduce the central tension, the cause of a

Aesth Plast Surg

stretched, even hypertrophic scar, when they are stretching

to cover the defect, because of greater skin viscoelasticity.
We believe this procedure addresses all of the incisional
concerns: scar length, local deformity, optimal preservation
of normal tissue, central tension, and the overall incision
shape. Compared with the traditional elliptical incision
(Fig. 4) and the modified Limberg flap (Fig. 5), our novel
modified S-plasty, or Tai Chi style procedure better
addresses the above-mentioned aspects, as shown in
Table 1.

Modified S-plasty Procedure

We have used the procedure to excise small- and mediumsized benign skin lesions. First, the edge of the lesion is
clearly marked and the radius is carefully measured. Line
AD, the long axis of the incision, is properly designed to
align with the relaxed skin tension lines. The curvilinear
lines were applied later to complete the planned incision
marks. In practice, a reverse design method was frequently used, i.e., we traced the lesion onto cellophane and
then precisely outlined the Tai Chi symbol. The cellophane
was then replaced on the lesion to design the final incision
shape. The lesion and normal surrounding skin were then
infused with 0.5 % lidocaine (1:200,000 epinephrine).
Following local anesthesia, the lesion was excised following the pre-designed incision lines. A #11 blade was

Fig. 4 Illustration showing the conventional elliptical incision. To

avoid the formation of dog-ears, the long axis of the incision must be
more than three times the diameter of the lesion. The radius of the C5
equals 5R and a large section of normal skin needs to be removed

Fig. 5 Illustration showing the modified Limberg flap. A rhombus

composed of two equilateral triangles is positioned over the lesion. A
local flap is designed, elevated, and rotated to cover the defect with no
deformity

Table 1 Comparison of the modified S-plasty procedure with fusiform excision and modified Limberg flap
New
modified
S-plasty

Fusiform
excision

Modified
Limberg
flap

Length-to-width ratio of
the incision

2.24:1

3:1

2.31:1

The length of the scar

2.87R

3.27R

4.62R

Normal skin excision

0.41R2

1.26R2

0.37R2

Area ratio of excised

normal skin to the lesion

51.72 %

160.22 %

47.02 %

Shape of the scar

S-shaped

Linear

Zigzag

preferred when removing small lesions because of its

simplicity in achieving smooth incision curves. Proper
undermining of the two local flaps and the adjacent tissue
facilitates the rotation and guarantees a tension-free closure. Two approximating sutures may be placed at the tips
of the curves when beginning to close to minimize the
formation of dog-ears. Over a 3-year period, the new
modified S-plasty or Tai Chi style procedure was successfully used in our department in 38 patients ranging in
age from 4 to 68 years. The skin defects resulted from
excision of a skin lesion on the face and neck in 16 patients
(26 defects), scalp in 7 patients (7 defects), trunk in 5
patients (8 defects), and limbs in 11 patients (17 defects).
The defect size ranged from 0.8 to 4 cm in diameter. The
defect locations and patient information are shown in
Table 2. Fifteen children were operated on under general
anesthesia with local infiltration anesthesia, while the
remainder of the patients received local infiltration

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Aesth Plast Surg

Table 2 Defect location and patient information
Defect location

Cases

Number of
defect (n)

Face and neck

16

26

Average of defect
width (mm)
9.58

Trunk

19.25

Scalp

17.43

Limb

11

17

13.00

Total

38a

58

12.86b

One patient had a face and a scalp defect

Average of all defects

anesthesia only. All of the incisions were closed in layers

and healed uneventfully with no significant complications
and good esthetic results.

Case Reports
Case 1
A 4-year-old girl presented with a congenital pigmented
nevus located on her right cheek. The lesion measured
1.3 cm 9 1.7 cm (Fig. 6a) and the modified S-plasty or
Tai Chi procedure incision was designed following the
relaxed skin tension lines (Fig. 6b). The lesion was excised

Fig. 6 Case 1 A 4-year-old girl

presented with a congenital
pigmented nevus located on her
right cheek. The lesion
measured 1.3 cm 9 1.7 cm (a).
The Tai Chi procedure was
designed following the relaxed
skin tension lines (b). The lesion
was completely excised under
general anesthesia and local
infiltration anesthesia (c). The
defect was closed in layers, and
good esthetic results were
achieved 8 months after surgery,
with no dog-ear deformity and a
mild scar of reasonable length
(d)

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under general anesthesia and local infiltration anesthesia

(Fig. 6c). The defect was closed in layers, and good
esthetic results were achieved eight months after surgery,
with no dog-ear deformity and a mild scar of reasonable
length (Fig. 6d).
Case 2
A 31-year-old woman was admitted to our division with a
larger sebaceous nevus on her right occipital scalp region.
The nevus measured 2.5 cm 9 3.0 cm, and the modified
S-plasty was carefully designed (Fig. 7a). The lesion was
excised under local anesthesia and produced a large scalp
defect approximately 3.0 cm 9 4.0 cm. This would
require a rotational flap for full coverage using conventional plastic surgical techniques (Fig. 7b). Figure 7c
shows the defect with approximation sutures resulting in a
tension-free repair after properly undermining the galea
aponeurosis (Fig. 7c). There were no postoperative complications, and the scar was almost invisible nine months
postoperatively (Fig. 7d).

Discussion
The fusiform incision is a common technique used by
surgeons for primary closure of defects resulting from

Aesth Plast Surg

Fig. 7 Case 2 A 31-year-old
woman was admitted to our
division with a large sebaceous
nevus on her right occipital
scalp region measuring
2.5 cm 9 3.0 cm over which
the Tai Chi incision was
carefully designed (a). The
lesion was excised under local
anesthesia creating a large scalp
defect. This would require a
rotational flap for coverage with
conventional plastic surgical
techniques (b). The defect is
shown with approximation
sutures (c) following the
tension-free repair after
properly undermining the galea
aponeurosis. There were no
postoperative complications,
and the scar was almost
invisible 9 months
postoperatively (d)

excision of certain lesions. The technique provides a simple

and convenient approach with satisfactory outcomes [2].
However, dog-ears appear frequently in clinical practice
[10]. When correcting the deformity, large dog-ears simply
result in small dog-ears without extending the incisions.
When the length-to-width ratio of an elliptical incision is
34.5, dog-ears rarely appear [11]. However, it is worth
noting that the actual scar will be much longer and more
conspicuous when a curved incision is sutured linearly. The
final zigzag-shaped scar of the Limberg flap procedure
would appear to be an improvement but the result is
achieved at the expense of a scar four times longer than the
lesion diameter.
The efficiency of a technique for the closure of a circular
defect is inversely related to the amount of healthy tissue
excised during the procedure [12]. All of the current
techniques require more or less removal of normal tissue to
create sharp angles [2] or to form a suitable shape for a flap
[3], sometimes both [4]. The amount of additional normal
skin excised in our procedure is considerably less than with
an elliptical incision and slightly more compared with the
modified Limberg flap; however, it is notable that the shape
of the removed normal skin is regular with our procedure,
which simplifies skin grafting procedures when multiple
lesions exist.
Our procedure, inspired by the traditional Chinese Tai
Chi symbol provides a precise and practical design for

modified S-plasty. Based on accurate mathematical calculations, it eliminates the problems associated with conventional S-plasty techniques [9, 13, 14]. The procedure
has the following advantages: (1) It ends with two sharp
angles at each side, avoiding even the smallest dog-ears.
(2) It possesses two symmetrical and smooth curves, which
contribute to convenient suturing. (3) The convex parts of
the curves are essentially two local flaps with excellent
natural viscoelasticity, significantly reducing the central
tension when rotated to cover the defect. (4) The length of
the scar will not be markedly extended after suturing
because the tension is dispersed in multiple directions. (5)
S-shaped scars are more relaxed, follow skin tension lines,
and are much less noticeable. (6) Valuable normal skin is
well-preserved.

Conclusion
The modified S-plasty procedure provides plastic and dermatological surgeons a manageable and reliable technique
for skin lesion excision. Because the formation and correction of potential dog-ears are comprehensively considered
during conception of the operation, the results are more
predictable and reliable. This novel modified S-plasty is a
simple tool to successfully remove skin defects, with a low
deformity risk. The procedure can also be reversely applied

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Aesth Plast Surg

to donor sites providing another option for harvesting fullthickness skin grafts, which expands its versatility.
Acknowledgments We express our sincere thanks to Miss Qu, postdoctoral fellow in Mathematics at the University, for calculating the
model figures. The authors declare that they received no funding for
this study.
Conflict of interest
of interest.

The authors declare that they have no conflict

Ethical approval The study was approved by the Institutional

Review Board of our hospital. All procedures performed in studies
involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards. Written informed consent was obtained
from each patient involved in this study.

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