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Page 2 of 14 Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76

Local flaps are often the workhorse of post-Mohs facial reconstruction as they offer many advantages to the
patient. Local flaps negate issues associated with a secondary donor site, are often able to replace the skin
with like skin, and are capable of being tailored to the specific wound.

Advancement, rotational, and transposition flaps are considered random pattern local flaps, referring to the
arterial blood supply of the flap being derived from perforating musculocutaneous blood vessels within the
flap’s pedicle feeding into the dermal-subcutaneous microcirculatory plexus. This is in contrast to axial
pattern local flaps, which derive arterial blood supply from a cutaneous artery that is incorporated into the
flap itself. A rotation flap is a random pattern flap that involves the movement of adjacent tissue around an
arc of rotation or a pivot point [Figure 1]. The transposition flap is a random pattern flap that involves the
[1]
movement of tissue across an intervening segment of tissue .

In this review, we will focus on options for reconstruction using rotational and transposition flaps.
However, it must be acknowledged that in practice, nearly all local flaps involve some degree of both
advancement and rotation.

FLAP DESIGN
When assessing a patient’s wound and its closure with local flaps, it is important to appreciate that classic
flap designs may need modification to best address each defect. In order to successfully modify the flap to fit
the patient’s needs, multiple aspects of each wound should be considered. Wound depth and the
composition of the missing tissue (skin, subcutaneous fat, muscle, etc.) should be addressed. The tissue’s
character and quality, including skin laxity, thickness, texture, and the presence of sun damage or post-
radiation changes, should be noted. The geometry of the flap itself should be optimized to the facial subunit,
and the surgeon must choose the orientation of resultant scars that are optimal and ideally in line with
relaxed skin tension lines (RSTL).

In addition, the surgeon must consider whether the defect itself should be modified or expanded to create a
more ideal reconstructive situation. For example, triangular defects are considered optimal for
reconstruction with a classical rotation flap . Circular or amorphous defects can be modified into triangular
[2]
defects to improve the conditions for ideal repair. Complex defects may require a combination approach
with multiple local flaps or even the use of a local flap in combination with a skin graft, a pedicled flap, or
closure by secondary intention.

Each region of the face has its own risks and benefits to the use of various local flaps due to the inherent
characteristics of the skin in the region, specifically skin thickness, texture, elasticity, laxity, and
dispensability. For example, the stiffness of the galea and the thickness of the skin in the scalp limit the
ability to twist and rotate flaps during scalp reconstruction .
[3]
ROTATION OR TRANSPOSITION FLAP OPTIONS BY FACIAL SUBUNIT
Forehead
When reconstructing forehead defects, it is key to avoid distortion of the brow position relative to the
contralateral side. Anatomically, male patients tend to have thicker brows that rest at the level of the orbital
rim, while females tend to have thinner brows that rest above the bony orbital rim with a significant arch
that peaks at the level of the lateral limbus or lateral third of the brow. These differences are crucial when
reconstructing the brow to achieve the best cosmetic result. The hairline is also an area where symmetry and
cosmesis should be considered. Particularly in males, incisions dealing with the hairline should be kept high
to accommodate for future hair loss .
[4]