The earliest documented surgical intervention to rebuild a complicated defect occurred in India in 700 BC. Sushruta published a description of a forehead flap for nasal reconstruction. This information was not available to Western medicine until the late 1700s, when a British surgeon noted the technique still used in India and wrote a brief description in Gentleman’s Quarterly.

Independently, the Italians developed delayed flaps, tube flaps, and flap transfers by using the upper inner arm skin to reconstruct a nose. This technique was published by Tagliacozzi in the 1500s. In modern medicine, the use of local flaps to repair facial defects began to evolve during the mid-1800s. A variety of flaps were used, but the blood supply and the dynamics of the surgery were not well understood. Harold Gilles popularized tube flaps and flap delays and initiated an interest in reconstructive surgery after World War I.¹

Local skin flaps, such as those described in this article, were primarily refined in the 1950s in Europe and the United States by the second generation of plastic surgeons. Ian MacGregor^2,3 recognized the importance of an axial blood supply in flap surgery in the 1970s. Plastic surgeons have subsequently redefined cutaneous blood supply. Countless vascularized flaps have since been developed. The skin flaps discussed in this article are primarily random flaps.^1–3

For each patient, a medical history encompassing smoking, peripheral vascular disease, atherosclerosis, diabetes mellitus, steroids, and previous surgeries should be elicited, because of the effects of these factors on wound healing and skin perfusion.

In managing the excisional defect, the surgeon must first assess the size and depth of the wound, as well as the nature of any exposed underlying internal anatomy. A defect containing exposed bone, nerves, or blood vessels usually necessitates a more advanced closure than would a less complicated wound.

The quality of the surrounding skin is also of great importance. Skin quality may vary from young, tight, and elastic to aged, dry, and lax. The wrinkled skin of an older patient produces less obvious scarring and offers the opportunity to conceal scars within skin tension lines. Skin that is more oily or heavily pigmented generally yields a less favorable scar. Color match is also of importance in deciding on the flap donor site. The presence of actinic damage, skin diseases, and premalignant satellite lesions should be considered. Finally, location is of major concern. Defects adjacent to critical anatomic structures, such as the eyelids, the nares, the oral commissure, and the external auditory meatus, must be reconstructed so as to avoid distorting the anatomy unique to those areas. Any alteration of these surrounding landmarks may compromise functional and aesthetic results. Previous surgical incisions and traumatic scars should also be assessed before the closure of the defect is designed.

Well-planned and -executed reconstruction of facial defects is particularly important because of the visibility of the result and the potential for functional deficits. However, the principles presented here may be applied to the management of all complicated wounds.

In the repair of facial tumor defects, the most important consideration is the management of the tumor. Incompletely excised tumor should not be covered by a flap. Skin adjacent to a tumor resection margin should not be turned over to line the nasal cavity or any other site where it will be difficult to examine. In patients who have a history of multiple or recurrent skin cancers, a strategy must be developed to allow for serial repairs. No bridges should be burned along the way. When planning a reconstruction, one must protect function first, then consider the cosmetic issues. It is crucial to discuss options with patients so that they can offer any biases that must be respected. A good-looking static repair that compromises dynamic function is unacceptable. The anatomic boundaries of the face are the allies of a good plastic surgeon. They must be respected and will be helpful in camouflaging scars.

Many defects can be treated with primary closure, secondary healing, or skin grafts. However, if, after careful assessment of the lesion, defect, and patient, the surgeon determines that the patient needs a flap for closure, he or she can apply techniques that produce the optimal aesthetic outcome.

The paramount consideration in tumor excision should be the complete removal of the tumor. Although the surgeon should have a number of reconstructive options in mind, the planned reconstruction should not dictate the extent of tumor excision. The surgeon must remain open to alternative reconstructive techniques. If the defect obtained in excising the tumor cannot reasonably be reconstructed at the time of the operation, the wound should be dressed and the reconstruction reconsidered and delayed, or the patient should be referred to another surgeon specializing in these repairs. This option is clearly preferable to a suboptimal reconstruction.

Undermining is performed to mobilize the tissue in areas surrounding the defect and to facilitate the draping of skin over the wound. The use of undermining allows the surgeon to move some portions of the wound and not others to avoid the distortion of nearby anatomy, such as the nasolabial fold or the oral commissure. However, because tight closures make for unsightly scars, alternatives should be considered before undermining the edges of a gaping or complicated wound. Undermining can destroy some of the options for flap repair. The reconstruction should be well planned before any undermining. In addition, the surgeon can use closure of the defect in layers to avoid any tension at the wound closure site that might result in dehiscence, wound healing problems, or widened scars.

When using elliptic skin excisions, one should make the long axis four times greater in length than the smaller axis. When an ellipse is made too short or one side of the ellipse is of unequal length, the skin may bunch at one end of the closure. This effect is known as a dog ear. In any wound, whether its sides are of equal or unequal length, the ends of the defect should be closed first to avoid unnecessary dog ears. Any redundancies can be dealt with in the middle of the wound during closure. Irregularities or pleats in the midportion of the wound generally resolve over time. Excising dog ears when they occur is simple. This excision is accomplished by extending the elliptic excision or by cutting the corner of the excision into a Burow’s triangle. Alternatively, placing a small right angle or 45° bend in the affected end of the wound closure can produce a satisfactory result. Finally, a V-shaped excision of the lateral ellipse can be used, resulting in an M-plasty closure.

The final outcome in any closure depends on the proper assessment of the defect and the selection of an appropriate closure technique. Primary closure involving direct approximation of the wound edges is a first option. An intermediate closure consists of approximation and closure of deeper tissue levels before final skin closure. Complex closure entails approximation and adjustment of the wound edges by means of undermining, the excision of any dog ears, or trimming of wound edges before closure. Finally, the options of skin grafting, allografting, and flap repair must be considered.

When a wound cannot be closed primarily, the options are as follows: secondary wound healing, skin grafting (discussed elsewhere), or local tissue transposition. Healing by secondary intention consists of two phenomena. The major means of size reduction of the defect is wound contracture, accompanied by re-epithelization to a lesser extent. Wound contracture may result in distortion of nearby mobile anatomic features, such as the oral commissure or the epicanthi. The contraction of scar tissue alters the orientation of the surrounding normal anatomy, which may result in an unacceptable cosmetic outcome and, more importantly, in poor function.

Healing by secondary intention is a viable option in fixed areas away from important anatomy, such as the middle of the forehead, the cheek, or the neck. In areas adjacent to important, easily deformable anatomic structures, transposition flaps are often a better wound closure approach.^4,5

Local skin flaps offer several advantages. Well-designed flaps borrow skin from areas of relative excess and transpose it to fill a defect. The skin provided is a close match in both color and texture, the donor site can be closed directly, and scar contracture is minimal. However, these flaps require experience and planning. Preliminarily drawing two or three flap design options for the defect may provide the surgeon with the best visualization of the optimal choice of flap for the particular area and defect. The choice of flap depends on the location and size of the defect, the quality of the surrounding skin, and the location of adjacent excess tissue. One should anticipate the appearance of the donor site scar and, when possible, plan to leave the scar in a natural crease line (eg, the nasolabial fold). When one raises the flap and moves it into the defect, key sutures should be applied and the overall flap position should be evaluated. If there is distortion of adjacent structures, one should reposition the key sutures and re-evaluate again for optimal position and least degree of tension. In addition, once the flap is in place and tacked down with temporary key sutures, it should be assessed for adequate perfusion. Further adjustments may be necessary. Closing the donor site first will relieve tension at the inset location. For example, closure of the Y lower limb in a V-Y flap helps push the flap to the inset position, and suturing on the bias further helps advance the flap into its recipient position. Once the final position of the flap is determined, it can be inset using the basic techniques already mentioned.

Flaps were first classified as random or axial by McGregor and Morgan³ in 1973. Random flaps had no specific vascular supply. Axial flaps had an arterial and venous blood supply in the long axis of the flap. Further contributions to the classification of flaps were made by Daniel and Williams,⁶ Webster,⁷ Kunert,⁸ and Cormack and Lamberty.⁹ A random cutaneous flap’s blood supply is derived from the dermal-subdermal plexuses of blood vessels, which originate from direct cutaneous, fasciocutaneous, or musculocutaneous vessels. One example is the rhomboid flap. The arterial, axial, and direct cutaneous flaps are based on septocutaneous arteries. These septocutaneous arteries come either from segmental or muscular vessels, pass through the fascia between muscles, and provide blood supply to the fascia and skin. They also give off branches to the muscle. The cutaneous portion of the septocutaneous arteries runs parallel to the skin surface and has venous comitantes running along with the artery above the muscle. An example is a forehead flap. In summary, survival of the skin flap is dependent on the vascular anatomy incorporated in the flap.^10–12