FLAP

 Skin flaps used to reconstruct the periocular tissues are almost always local flaps with a random
pattern blood supply
 The general rule that random pattern flaps should have a length/breadth ratio of 1 :1 can be
relaxed in reconstruction of the face because of the rich blood supply compared with the skin of
the trunk or limbs
 Skin flaps are undermined within the layer superficial to the facial muscles (usually the
subcutaneous fat or fascia) to allow movement to their new site with a minimum of tension
 If the skin is very thin both the support and the blood supply of the flap are improved if the
dissection is just deep to the orbicularis muscle layer.
 There are three basic patterns in the design of skin flaps : advancement, rotation and
transposition flaps
 The transfer of the flap into the primary defect creates a secondary defect which requires
closure separately
 In an advancement flap or a rotation flap the secondary defect is ‘virtual’ – the base of the flap
is stretched to allow closure of the primary defect without the creation of a true secondary
defect. It is made possible by wide undermining of the skin around the flap
 The disadvantage of these flaps is that they tend to pull back toward the origin of the flap,
creating tension at the site of the primary defect
 Tension must be strictly horizontal, not vertical, if lid margin distortion is to be avoided.

Advancement Flap in the cheek:

Advancement flaps in the lower lid

A simple advancement or sliding flap may be used if the leading edge has to be advanced up to about
one-third of the lid to achieve closure of the defect without undue tension.
O to Z Rotation Flap

A rotation flap is a local flap which can be thought of as several clock-hours of a clock face.

The ‘O to Z’ flap is a double rotation flap useful for smaller defects

Mustarde cheek rotation flap

The Mustardé cheek rotation flap is used to reconstruct large defects of the lower lid up to the whole lid
length and, in particular, those defects with a large vertical component extending into the cheek.

Transposition flaps

In the face the length/breadth ratio may be greater than 1:1

A secondary defect is created at the donor site which may be closed directly or with a free skin graft.
COMPLICATION AND MANAGEMENT

In the early postoperative period part of the flap may necrose.

Occasionally a larger area may necrose requiring later grafting after at least 6 weeks

The wide, shallow defect in the lid may be reconstructed, but it is often difficult to achieve a completely
satisfactory lower lid position. A Hughes’ procedure may be effective

Upper lid to lower lid transposition flap – based laterally

This flap is used for defects in the lower lid which extend to the lateral canthus
Upper lid to lower lid transposition flap – based medially

This flap is used for defects in the lower lid which extend to the medial canthus
Nasojugal transposition flap

This flap is useful for defects of the medial half of the lower lid but not beyond the medial end of the lid

Reconstruct the posterior lamella with a suitable graft or a tarsoconjunctival flap

Lateral cheek to lower lid transposition flap

Large lower lid defects which extend to the lateral canthus can be reconstructed with a transposed flap
based near the outer canthus, extending down into the cheek.
Rhombic transposition flap

A rhombus is a parallelogram with oblique angles and equal sides. A defect of this shape constructed
around the site of excision of a tumour can be filled with a rhombic flap

Bilobed transposition flap

This flap is used for small to medium sized defects. A primary flap, about 75% of the diameter of the
primary defect, is marked. A secondary flap is marked with a diameter of 50% to 60% of the primary flap

The flaps should not be transposed through more than 60 to 70 degree

Glabellar flaps

A full-thickness skin graft may be used for superficial defects at the inner canthus.

If the defect is deep, a glabellar flap is preferred. It does not require a posterior lamellar reconstruction
Glabellar flap and Cutler-Beard bridge flap combined

Glabellar flap and Hughes’ tarsoconjunctival flap combined

Midline forehead flap