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Page 4 of 14 Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76

occurs at the center of the wound, where the three parts meet in the center of the defect. The three points
should not be directly sutured together as this may strangulate the blood supply to the flap tips. Lastly, one
must be cognizant of scar location. This technique will produce a stellate scar and should only be used in
situations where this cosmetic result is acceptable. A surgeon would be hard-pressed to place a stellate scar
in the flat forehead, but the method may be more cosmetically acceptable near the hairline or temporal
[1]
tufts .
The O to T closure is similar to the O to Y but is most suitable for defects in which about half of the
surrounding skin is significantly more elastic than the other half [Figure 2]. The elastic skin can then be
raised as a single flap to close half the defect, converting the arc of the wound edge to the horizontal bar of
the T. The remainder of the wound is closed similarly to the O to Y; two equal flaps are raised, undermined,
[1]
and brought to the center of the wound, creating the vertical portion of the T-shaped scar . To minimize
wound tension, a flap can be constructed in which its height is twice the defect diameter, its base is two
defect diameters, and there are roughly three defect diameters of undermining in each direction. These
exact measurements will vary depending on defect size, size of standing cones created, and proximity of
surrounding structures. Scar placement when performing an O to T is an advantage when compared to the
O to Y flap in the forehead. The base of the scar can be well hidden in the hairline or the brow, leaving only
one vertical scar that is less camouflaged, making this technique more useful .
[5,6]
Cheek
The cheek is comprised of tissues that are very mobile, and, like the forehead, is relatively flat and
featureless. This makes reconstruction more straightforward when compared with the topographic
reconstructive challenges of other areas of the face. However, the large, flat plane of the cheek makes
camouflaging scars challenging, and thus hiding scars in cheek reconstruction in the boundary of adjacent
face subunits is optimal. Despite the lack of true subunits, it is helpful to divide the cheek into different
areas: midcheek, inferior, preauricular, melolabial, and infraorbital .
[7]

In males, the cheek is largely covered with thick, coarse, bearded skin, making scar camouflage more
forgiving. In contrast, females’ cheek skin is thin and covered only with vellus hairs, making scars are more
visible. When reconstructing the cheek, one must be cognizant of the parotid duct and the facial nerve and
[7]
address them if involved to avoid permanent functional deficit .
Although it may be tempting to close cheek wounds primarily because of the tissue’s laxity, one must
remember that cheek tissues are in constant motion due to talking, chewing, and facial expression. As the
tissues flex and relax, healing scars have a tendency to widen. Therefore, cheek closures should be
performed in multiple layers; the addition of small skin bandages may also be used to facilitate appropriate
healing .
[7]

Rhombic flaps
The unirhombic and birhombic transposition flaps are random-pattern local flaps that can be used on small
to medium-sized defects that cannot be closed primarily. It is most useful when the surrounding skin is
relatively elastic and can be used in many areas of the face, including the cheek, eyelids, chin, forehead, and
[8]
temple, but we will review their use in the cheek . One of the first rhombic transposition flaps described by
Alexander Limberg in 1946 . The term Limberg flap was coined to describe his original design consisting of
[9]
a rhombus-shaped flap with 60 and 120-degree angles that is transposed to cover a similarly shaped defect
[Figure 3]. Round defects are trimmed to match the shape of the rhombus prior to the flap’s transposition.
Variations of the Limberg flap have been developed over the years, including the Dufourmentel flap and