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Schopper et al. Plast Aesthet Res 2022;9:25 https://dx.doi.org/10.20517/2347-9264.2021.72 Page 5 of 10

Figure 4. V-Y. (A) A V-shaped incision is made along a distorted vermillion border to allow for release to normal contour. Arrows
indicate anticipated vectors of tissue movement. (B) Final closure of V-to-Y advancement flap, correcting the vermillion border shape.
(C) Magnified view of the planned incision and closure. The “A” marks the planned advancement, while the “B” and “C” mark the
planned closure. This closure “pushes” the distorted vermillion inferiorly. This figure is used from senior authors’ previous work,
[1]
Shew et al. . Rights retained.
Y approach to closing a defect, with the open end of the V lying along the edge of the defect. The limbs of
the incision can be designed in a curved fashion to help hide the incision in the boundary of an aesthetic
subunit. This flap can be utilized in situations where tension on a cutaneous pedicle would be too high or
cause significant distortion [14-18] .

A modification of the island advancement flap utilizes only the subcutaneous tissue. In this case, the skin
overlying the donor tissue is left in place and only the subcutaneous fat or muscle is advanced to address the
defect. This flap can be useful in addressing volume loss .
[3]

East-west flap
The east-west flap is a technique that utilizes diagonally opposing triangles to advance tissue along a
horizontal plane into a defect while requiring relatively little tissue movement and therefore limiting
distortion of surrounding tissues. The defect is incorporated into a vertically based isosceles triangle and a
releasing triangle is designed along the short edge horizontal cattycorner from the defect triangle. The base
of the releasing triangle is generally half the width of the defect triangle and of similar height. The skin of
both triangles is excised and the resultant flaps are undermined to allow for free opposing movement along
the horizontal or east-west access. Movement of the flaps to close the defect will result in a stair-step final
closure appearance. This flap can be quite useful on the nose as it requires minimal tissue movement/laxity
and therefore limits adjacent secondary movement. Generally, defects best served by an east-west flap are
less than 1.5 cm and longer than they are wide [19-21] [Figure 5].