Symmetric bilateral transposition flap: a very versatile option in facial dermatological surgery

Repair following excision of large tumours of the face can be problematic; primary closure may not be achievable and grafting or secondary intention healing carry the risk of necrosis and lengthy healing times. Flaps are usually associated with earlier healing and better cosmetic results, as the skin used for closure is similar to the tissue requiring repair. However, large wound sizes and difficulty in finding a suitable donor area means flaps can be complicated to perform. The aim of this paper was to identify a comparatively quick and simple alternative to standard repair techniques for the closure of large wound defects in critical anatomical areas, when the only realistic alternative would be grafting, offering both good cosmetic results and minimal risk of complications.

We have developed a flap, modified from the classic, single lobe transposition flap. Two similar lobes placed symmetrically and perpendicularly to two opposite sides of the surgical wound are incised with fulcra centred on two opposite corners. The flaps are then rotated by approximately 80-90º into position side by side, sutured to the borders of the surgical wound and finally together with a longitudinal suture. The principle behind this flap is the split of the covering surface into 2 small units, rather than using a large single lobe, which, for large wounds, would make closure of the single donor area by first intention impossible. The split of the donor area in 2 smaller subunits makes it easier to close the two donor areas and allows a larger amount of tissue to be harvested.

We have developed a twinned symmetric transposition flap to close large wounds on the face when the only realistic alternative would have been the use of grafting. It offers minimal distortion, and is both quick and simple to perform. The use of tissue similar to the original defect ensures good cosmetic results. Healing times were usually very rapid and complications limited to a very few cases of end flap necrosis. This technique is not applicable where donor areas fall in anatomic spots where harvesting of the lobes is impossible, e.g. when the wound is too close to the hair line and transposition of the lobes would cause the transfer of hairy skin to an area where the presence of hair is not desirable.