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Somenek. Plast Aesthet Res 2022;9:16 https://dx.doi.org/10.20517/2347-9264.2021.84 Page 5 of 10

Rhombic transposition flap
One of the most versatile flaps in the periocular area. The principle is shown in Figure 2A. The 60° to 120°
rhombus can be thought of as two 60° equilateral triangles that are aligned at the bases. All sides are equal in
length, and the designed flap is equal in size to the defect. After the transfer of the flap, the greatest wound
closure tension is at the flap donor site . This is important when considering possible distortion of the
[5]
surrounding tissues.

Unipedicle and bipedicle rectangular advancement flap
2
This versatile flap is appropriate for this area and used for defects as large as 25 cm [Figure 2B]. It can be
particularly useful for defects in the medial upper and lower eyelids as well as those in the eyebrows. The
resulting scar can be designed within the natural creases to avoid injury to the natural lid margin.

V-Y advancement flap
Tend to be useful for epicanthal folds and scar contractures. Their main function is to increase the length of
the palpebral fissure.

Cervicofacial advancement cheek flap
The cervicofacial rotation advancement is a random-pattern flap that provides an excellent match for lid
and cheek reconstruction. The incision runs from the superior aspect of the defect superolaterally to the
preauricular cheek. The incision is then extended crossing under the ear and inferiorly along the lateral
neck. The arterial supply arises from perforators of the facial and submental arteries. The cervical skin is an
excellent source of redundant tissue and allows for proper tissue matching compared to a graft.

Reconstruction of full-thickness lid defects involving margin
Small defect (up to 25% to 50% of lid length)
The lids have an inherent ability to stretch, which is why it is usually possible to reconstruct small defects
that involve 33% or less of the eyelid with direct approximation. This can be accomplished by conversion of
the defect into a pentagonal defect with the vertical sides covering the height of the tarsal plate. This helps to
eliminate dog ear deformities and also create a clean tarsal edge, avoiding misalignment or notching.

The most important suture is the approximation of the tarsus. 6-0 Vicryl suture is used to perfectly align the
eyelid margin. An alternative to Vicryl can be monocryl or polydiaxonone. The lash line is then
approximated with a 6-0 Vicryl followed by repair of the orbicularis oculi muscle. Both of these layers are
crucial to minimize tension to the skin closure and maximize the appearance of the final scar. The skin is
closed with a 6-0 nonabsorbable suture with nylon or polypropylene the preferred choices.

If there is some tension noted, particularly for the defects that range from 33% to 50%, a lateral canthotomy
and cantholysis are performed to gain a few additional millimeters. Taking care to evert the lid margin
wound edges will prevent a notched appearance to the eyelid when using the method of closure.

Tenzel semi-circular advancement flap
Medium defect (50% to 75% of lid length)
The Tenzel semi-circular advancement flap was originally described by Dr. Tenzel and Stewart in 1978. It
[6]
is a very useful technique to repair defects of the eyelid that are full-thickness, ranging from 33%-75% of the
horizontal length of the lower eyelid and 30%-66% of the upper eyelid. The flap is a very similar concept to
the Mustarde rotational flap but uses less tissue rearrangement to repair the eyelid lamellae. The benefit of
this technique is that it is performed in a single-stage operation.