Flaps: New Twists and Variations on Old Tricks

The subcutaneous pedicle nasolabial transposition flap uses a pedicle with an amount of full-thickness skin that is only one-half the diameter of the primary defect. The other half of the pedicle is formed by the subcutaneous fat in the primary defect.

Once the flap is freed, it is transposed into the defect. No Burow's triangle is needed for proper flap transposition. The subcutaneous fat portion of the pedicle is placed along the adjacent undermined region. Any excess tissue is removed and the defect then is closed.

Compared with the classic nasolabial transposition flap, the subcutaneous pedicle technique provides greater flap mobility because it has a smaller width of full-thickness skin at the base, better "tissue economy" because of its smaller secondary defect and the use of the primary defect itself as part of the flap, and a lower rate of pin cushioning as a result of the fat redistribution involved, Dr. Chow said at the meeting.

▸ Twisted and transposed island pedicle flaps. The traditional island pedicle flap is a random pattern advancement flap that provides excellent vascular supply and can repair small- to intermediate-sized facial defects, but it does have a tendency to form pin cushioning and is difficult to camouflage because all of the incisions cannot be placed within relaxed skin tension lines, explained Dr. Todd E. Holmes, who is a procedural dermatology fellow at the University of Vermont in Burlington.

Dr. Holmes described Mohs cases on the nose, forehead, and cheek in which unilaterally or anteriorly based muscular pedicles were twisted and transposed up to 180°. Traditional advancement of an island pedicle flap in some of the cases would have been "very difficult or not possible," he said.