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Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76 Page 3 of 14

Figure 1. Classic rotation flap. The pivot point is 2.0-2.5 times the diameter of the defect. The distance from the defect’s edge to the
pivot point is the radius for the rotation flap. This creates an arc of rotation that is approximately 4 times the diameter of the defect. A
30° rotation is achieved to allow for closure. Arcs of rotation greater than 30° will generally lead to a standing cone deformity (Burrow’s
triangle).

The forehead, and its accompanying structures, including the glabella, brow, and temporal region, is
comprised of tissue that is less flexible than in other facial subunits making the above goals challenging to
achieve. Primary closure is often the best option, but it can only be performed when there is little tension.
This is realistic only when there are small defects and extensive subgaleal undermining due to the lack of
tissue flexibility. In some patients, closure by secondary intention and/or delayed skin grafting may be the
best option but only if there is a vascularized bed of tissue to support the graft without exposed bone. If
these options fail, transposition flaps can be a viable reconstructive option. The transposition flap transfers
tension of the wound closure from defect to donor site well, but they can easily leave an unacceptable
cosmetic result if not planned meticulously. Incisions should be planned in the typically well-defined
horizontal RSTL of the forehead. However, this presents a challenge when considering younger patients
who have not yet developed forehead rhytids. Secondarily, vertical scars may be cosmetically sound, while
diagonal scars are seldom deemed acceptable. In general, the temptation to attempt a local flap on the
forehead should only be indulged when all other reconstructive options are eliminated. As such, the
following reconstructive techniques are meant to be used as backups to more cosmetically acceptable
[4]
methods .

V to Y closure
Although the V to Y closure is not a flap per se, it bears mentioning because of its utility in closing glabellar
defects. Unlike the forehead, the RSTL of the glabella rests in a vertical orientation. Primary closure of
defects could medialize the brow, creating an unnatural appearance. This can be avoided using the V to Y
technique. In a V to Y closure, a triangular flap is elevated and pulled away from the center of the wound.
The lateral aspects of the wound are then brought to the center to create the Y-shaped scar .
[4]

O to Y and O to T
The O to Y and O to T are non-linear flap techniques that can be used to close circular defects. The O to Y
is suitable when the defect is surrounded by relatively elastic skin. The defect is divided into three equal
parts, and the underlying tissues are widely undermined to achieve maximal advancement. Maximal tension