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Page 6 of 14 Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76

Figure 4. Webster flap. The Webster variation of the classic rhombic flap requires less tissue rotation and reduces wound tension. The
flap is designed with a W-plasty inferiorly (A). The hash marks show tissue to be removed prior to the inset of the flap (B). Note the
transposition of each corner of the Webster flap labeled a, b, c, d (C).

The flap is designed by first drawing a line tangential to the circular defect along RSTL that is roughly 1.5
times the diameter of the defect. Next, a second line about the length of the defect’s diameter is drawn 50 to
60 degrees away from the first to create a triangle. The triangular flap can then be elevated and transposed
into a position to close the defect. At times the tip of the triangle may need to be trimmed to facilitate
closure . Lastly, if a defect is unable to be closed satisfactorily with one note flap, a bilateral note flap can
[14]
be performed by making the same incisions and transposition opposite to the first.

Cheek rotational flaps
Larger cheek defects require the transfer of more distant tissue. The cervicofacial flap is useful in such
situations because of the excellent color and texture match of the surrounding neck and lateral face skin
used in the reconstruction . They can be posteriorly or anteriorly based and can be elevated in a
[15]
subcutaneous or sub-superficial musculoaponeurotic system (SMAS) plane. Some authors advocate for sub-
SMAS dissections in smokers and those who have been irradiated to help prevent flap necrosis. However,
others believe that the increased operative time, the risk to the facial nerve, and the technical complexity of
sub-SMAS dissection are not outweighed by the theoretical advantage .
[16]

Cervicofacial flaps are designed in several different ways depending on the degree of tissue advancement
and rotation needed to cover the defect. Typically, the incision courses along the superior border of the
cheek, inferiorly along the preauricular crease, and around the earlobe toward the hairline. The flap can also
be extended inferiorly to the chest in order to recruit more tissue. After broadly raising the flap, it is rotated
in position and secured. Large flaps can be quite heavy and can pull surrounding tissue inferiorly if not
secured properly. When insetting the flap, it is necessary to tack the flap to the underlying tissues, typically
the periosteum, with a bone anchor or a heavy non-absorbable suture. The rest of the closure can proceed in
the standard layered fashion .
[7]
Some anterior cheek or mid-cheek defects can be closed using a bilobed technique. First, the cervicofacial
rotation flap recruits all the surrounding cheek tissue to close the primary defect. Then postauricular tissue
is used to close the secondary defect along with the preauricular areas.

Eyelid and periocular region
The complex anatomy, form, and function of the periorbital tissues present a substantial challenge for
optimal reconstruction, and numerous techniques have been described to reconstruct the periorbital region
and eyelid. In addition to subtle cosmetic implications, improper reconstruction can leave a patient with