advancement flap - McGraw-Hill Education Australia & New Zealand

Paver I Stanford I Storey 

dermatologic 

SURGERY 

a MANUAL of DEFECT REPAIR OPTIONS 

DVD INCLUDES 100 SURGICAL VIDEO CLIPS 

18mm 286mm 

18mm

dermatologic 

SURGERY 

a MANUAL of DEFECT REPAIR OPTIONS

Notice 

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and 

drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts 

to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in 

view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor any other party who has 

been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate 

or complete. Readers are encouraged to confirm the information contained herein with other sources. For example, and in particular, 

readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain 

that the information contained in this book is accurate and that changes have not been made in the recommended dose or in the 

contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. 

First published 2011 

Copyright © 2011 McGraw-Hill Australia Pty Limited 

Additional owners of copyright are acknowledged in on-page credits. 

Every effort has been made to trace and acknowledge copyrighted material. The authors and publishers tender their apologies should 

any infringement have occurred. 

Reproduction and communication for educational purposes 

The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is the 

greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that the institution 

(or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and been granted a licence. 

For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15, 233 Castlereagh Street, 

Sydney NSW 2000. Telephone: (02) 9394 7600. Website: www.copyright.com.au 

Reproduction and communication for other purposes 

Apart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of this 

publication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system, 

without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage. 

Enquiries should be made to the publisher via www.mcgraw-hill.com.au or marked for the attention of the permissions editor at the 

address below. 

National Library of Australia Cataloguing-in-Publication Data 

Author: 

Paver, Rob. 

Title: Dermatologic surgery: a manual of defect repair options / 

Rob Paver, Duncan Stanford, Leslie Storey. 

ISBN: 

9780070285392 (hbk.) 

Notes: 

Includes index. Bibliography. 

Subjects: 

skin-surgery, surgery, plastic flaps (surgery) 

Other Authors/Contributors: Stanford, Duncan, Storey, Leslie. 

Dewey Number: 617.477 

Published in Australia by 

McGraw-Hill Australia Pty Ltd 

Level 2, 82 Waterloo Road, North Ryde NSW 2113 

Publisher: Elizabeth Walton 

Associate editor: Fiona Richardson 

Art director: Astred Hicks 

Cover design: Patricia McCallum 

Internal design: Astred Hicks and Patricia McCallum 

Production editor: Michael McGrath 

Copy editor: Marcia Bascombe 

Illustrator: Chris Welch 

Proofreader: Terence Townsend 

Indexer: Shelley Barons 

CD-ROM preparation: 

CD-ROM cover and manual design: 

Typeset in … by Midland Typesetters 

Printed in China on 105 gsm by iBook Printing Ltd.

Robert Paver 

Duncan Stanford 

Leslie Storey 

dermatologic 

SURGERY 

a MANUAL of DEFECT REPAIR OPTIONS

v 

FOREWORD 

Over recent decades, Dermatologic Surgery has 

witnessed tremendous growth and evolution. Expansion of 

both established procedures, as well as the development 

of new surgical techniques, has led to the division of 

Dermatologic Surgery into two separate disciplines: Mohs 

Micrographic Surgery/Surgical Repair and Cosmetic 

Surgery. 

This text addresses the former; the repair of surgical 

defects created by the eradication of skin cancers. Every 

year thousands of Mohs procedures are performed across 

the globe, producing their resultant defects. Dermatologic 

Surgery: a manual of defect repair options is organized 

into two complementary sections; a textbook format 

and corresponding videos. Numerous other texts have 

organized these topics in a similar manner to the written 

text material presented here. What makes this project 

unique is supplementing the standard textbook format 

with an extensive, comprehensive collection of videos 

that correspond to the surgical procedures. Cutting-edge 

teaching methods have finally caught up with present-day 

technology. By being invited into the operating room, 

students at all levels are treated to a stunning personal 

perspective. The experience is like having your own 

private expert mentor. 

The overriding concept here is to perform defect repairs 

employing principles developed for the cosmetic-subunit 

paradigm. These include: if possible, limiting repairs to 

one cosmetic unit; placing scar lines in junction lines 

dividing cosmetic units or the adjoining relaxed skin 

tension lines and, if most of a cosmetic unit is missing, 

excising the remainder and repairing the whole unit. 

To actually see the application of these principles 

unfold on screen is a true learning experience. The videos 

in particular reveal those aspects of the procedure not 

readily demonstrated with static two-dimensional pictures. 

These include: flap design and execution, the tension 

vector of closure, the effect of the tension vector on free 

margins, how to hold instruments, how to handle tissue 

gently, the extent and level of undermining, final trimming 

of tissue before closure and the utility of an assistant. The 

procedures range in difficulty from simple to complicated. 

The videos are edited to show only the important stages 

of the repair and avoid time-consuming repetition. Each 

type of flap is covered, although not each flap within 

every cosmetic unit is presented, thus avoiding needless 

repetition. 

Dermatologic Surgery: a manual of defect repair options 

represents tremendous innovation and a step forward in 

surgical education. The videos show a time sequence 

dynamic that is difficult to achieve in any other format. 

Certainly, videos of surgical procedures have been used as 

teaching tools before. Their use, however, has been mostly 

limited to individual case presentations at professional 

meetings or personal libraries available only to local 

registrars. Now they are available to a more general 

audience of students of all levels. Whether novice or 

experienced practitioner, whether trained in dermatology, 

plastic surgery, or head and neck surgery, everyone will 

find something to add to their surgical armamentarium. 

The accompanying text is organized in a template 

manner. Each cosmetic unit section is introduced with 

a description of the properties of the skin in that unit 

as well as the scope of repair options. Individual 

repairs are illustrated by photographs, line drawings. 

The accompanying text describes the procedure, its 

advantages disadvantages and caveats, as well as 

stressing the take-home main points. Another benefit is 

that long-term outcomes conclude each picture series. The 

reader will become comfortable with this repetitive format. 

Cases with accompanying videos are clearly identified 

with an appropriate symbol. 

Surgeons often become proficient with one or two flap 

techniques and try to apply them to all defects. From 

Dermatologic Surgery: a manual of defect repair options 

they will gain a different perspective that may better suit 

the defect and, in the long run, the patient. 

The authors should be congratulated for sharing their 

expertise. The forethought and time spent to tape and edit 

this wide range of reconstructive procedures reveals the 

heart of a true teacher/educator. Theirs is a contribution 

of significant importance. The initial and prime audience 

is noted to be registrars in training. There is not any 

doubt that this will reach and benefit a wider audience. 

My advice; read the text and view the videos over and 

over again. You will be treated to nuances you didn’t 

appreciate before. 

Stuart J Salasche, MD

vii 

CONTENTS IN BRIEF 

Foreword 

Preface 

About the authors 

Acknowledgments 

v 

xiv 

xvii 

xviii 

SECTION 1 – NOSE 1 

Chapter 1 Nasal Tip 2 

Chapter 2 Nasal Ala 28 

Chapter 3 Nasal Dorsum 56 

Chapter 4 Nasal Sidewall 70 

Chapter 5 Nasal Root 82 

SECTION 2 – FOREHEAD AND TEMPLE 90 

Chapter 6 Central Forehead 92 

Chapter 7 Lateral Forehead 104 

Chapter 8 Eyebrow and Suprabrow 116 

Chapter 9 Temple 126 

SECTION 3 – PERIORAL 140 

Chapter 10 Lateral Upper Lip and Perialar 

Region 142 

Chapter 11 Central Upper Lip 160 

Chapter 12 Vermilion Upper Lip 172 

Chapter 13 Lateral Lower Lip 178 

Chapter 14 Central Lower Lip 188 

Chapter 15 Vermilion Lower Lip 194 

Chapter 16 Chin 202 

SECTION 4 – CHEEKS 208 

Chapter 17 Medial Cheek 211 

Chapter 18 Central Cheek 220 

Chapter 19 Preauricular 230 

Chapter 20 Mandibular 238 

SECTION 5 – EARS 242 

Chapter 21 Upper-third of the Helical Rim 244 

Chapter 22 Middle-third of the Helical Rim 254 

Chapter 23 Conchal Bowl and External 

Auditory Canal 264 

Chapter 24 Anterior Ear 270 

Chapter 25 Posterior Ear 282 

Chapter 26 Ear Lobe 292 

SECTION 6 – PERIOCCULAR 296 

Chapter 27 Lateral Canthus 299 

Chapter 28 Lower Eyelid 306 

Chapter 29 Medial Canthus 320 

Chapter 30 Upper Eyelid 332 

SECTION 7 – SCALP 340 

Chapter 31 Scalp 342 

SECTION 8 – NECK AND MASTOID 354 

Chapter 32 Neck 356 

Chapter 33 Mastoid 364 

SECTION 9 – TRUNK AND LIMBS 372 

Chapter 34 Trunk and Limbs 374 

Index 388

viii 

CONTENTS IN FULL 

Foreword 

Preface 

About the authors 

Acknowledgment s 

v 

xiv 

xvii 

xviii 

SECTION 1 NOSE 1 

CHAPTER 1 NASAL TIP 2 

• Side-to-side closure 4 

• Burow’s exchange advancement flap 6 

• Bilobed flap (Zitelli variation) 

7 

• Dorsal nasal rotation flap 

10 

• Myocutaneous flaps 

12 

• Unilateral pedicle technique 13 

• Horn variation 14 

• Bilateral pedicle variation technique 15 

• Hunt variation 16 

• Rhombic transposition flap 17 

• Subcutaneous island pedicle flap 18 

• Double-rotation flap (Peng variant) 19 

• Two-stage interpolation flap 20 

• Two-stage paramedian forehead interpolation flap 20 

• Two-stage nasolabial interpolation flap 23 

• Full-thickness skin graft 25 

CHAPTER 2 NASAL ALA 28 

Nasal Ala Repairs for Partial Thickness Defects 


• Bilobed transposition flap (medially or 

laterally based) 30 

• Nasolabial transposition flap (Zitelli variation) 32 



• Myocutaneous island pedicle flap 36 

• Transposed island pedicle flap 37 

• Shark island pedicle flap 38 

• Two-stage nasolabial interpolation flap 40 


• Second intention 44 

xx 

• Composite graft 45 

• Nasolabial turnover island pedicle flap (spear flap) 47 

• Tunnelled (Kearney) variant of the nasolabial 

turnover island pedicle flap 50 

• Combined procedure—mucosa, cartilage, and skin 51 

• Mucosal layer 51 

• Cartilage layer 52 

• Skin 55 

CHAPTER 3 NASAL DORSUM 56 


• Perialar Burow’s exchange advancement flap 59 

• Subcutaneous island pedicle flap 

60 

• Back-cut rotation flap 

62 

• Bilateral single-sided advancement (T-plasty or A-T) flap 63 

• Double-rotation flap (Peng variant) 64 


• Bilobed transposition flap 66 

• Transposed island pedicle flap 67 

• Myocutaneous flap (refer to Chapter 1 Nasal tip) 68 

• Full-thickness skin graft (refer to Chapter 1 Nasal tip) 69 

CHAPTER 4 NASAL SIDEWALL 70 


• Advancement flaps 73 

• Perialar Burow’s exchange advancement flap 73 

• Nasolabial advancement flap 74 


75 


76 

• Transposition flaps 77 


• Nasolabial transposition flap 78 


• Cheek advancement with Burow’s graft 80 

• Full-thickness skin graft 81

Contents 

ix 

CHAPTER 5 NASAL ROOT 82 


• Rhombic transposition flap 

85 


86 


• Procerus myocutaneous flap 88 

• Side-to-side closure with a V-to-Y advancement 

from the glabella 89 

SECTION 2 FOREHEAD AND TEMPLE 90 

CHAPTER 6 CENTRAL FOREHEAD 92 

• Side-to-side (vertical) closure 

94 


• Unilateral single-sided advancement flap (O-to-L) 95 

• Bilateral single-sided advancement flap (O-to-T) 

T-plasty 96 

• Bilateral two-sided advancement flap (O-to-H) 97 

• Rotation flap 98 


• Skin grafts 100 

• Partial closure plus Burow’s graft 100 

• Partial closure plus second intention 101 

CHAPTER 7 LATERAL FOREHEAD 104 



• Unilateral single-sided advancement flap (O-to-L) 

and Burow’s exchange advancement 107 

• Bilateral single-sided advancement 

flap (O-to-T) 108 

• Bilateral two-sided advancement flap (O-to-H) 109 





• Burow’s full-thickness skin graft 113 

• Split-thickness skin graft 114 

CHAPTER 8 EYEBROW AND SUPRABROW 116 

• Side-to-side (horizontal or vertical) closure 118 


• Unilateral single-sided advancement 

flap (O-to-L) 119 


flap (O-to-T) 120 

• Unilateral or bilateral two-sided advancement 

flap (O-to-U or O-to-H) 121 


123 

• Full-thickness skin graft for the suprabrow 124 

Legend 

Preferred option when a standard side-to-side closure is not possible 

Sometimes a side-to-side closure can still be used for a medium to large defect

x DERMATOLOGIC SURGERY A manual of defect repair options 


CHAPTER 9 TEMPLE 

xx 

CHAPTER 11 CENTRAL UPPER LIP 

xx 



130 



• Burow’s exchange advancement flap 

133 

• Tripolar (Mercedes) advancement flap 134 

• Unilateral two-sided advancement flap 

(o-to-U flap) 135 


• Partial closure plus Burow’s full-thickness skin graft 136 




SECTION 3 PERIORAL 140 

CHAPTER 10 LATERAL UPPER LIP AND 

PERIALAR REGION 142 

• Side-to-side closure 

144 

• Wedge excision 146 

• Rotation flap 

148 



• Double advancement (T-plasty or O-T) flap 151 

• Crescentic advancement flaps 153 

• Crescentic advancement with Burow’s triangle 

in lip rhytides 153 

• Crescentic advancement with muscle and 

mucosal wedge 154 

• Crescentic advancement utilizing a horizontal cut 155 

• along vermilion border 155 

• Rotation flap combined with wedge excision 156 

• Transposition flap 157 


• Vertical Side-to-side closure 162 



• Uuilateral, single-sided, (crescentic) 

advancement flap 163 

• Bilateral, single-sided, advancement 

(T-plasty or O-T) flap 164 

• Bilateral, single-sided, advancement (T-plasty 

or O-T) flap with a full-thickness wedge 164 

• Unilateral, two-sided advancement flap 165 

• Bilateral, two-sided advancement flap 166 

• Philtral defects 167 


• Advancement flap (T-plasty) 167 

• Advancement flap (philtral two-sided) 168 



CHAPTER 12 VERMILION UPPER LIP 172 

• Wedge excision 

174 

• Mucosal advancement flap 175 

• Bilateral vermilion rotation flap 176 

• Mucosal V-to-Y island pedicle flap 177 

CHAPTER 13 LATERAL LOWER LIP 


182 

• Burow’s exchange advancement flap 

185 



CHAPTER 14 CENTRAL LOWER LIP 188 


• Bilateral two-sided advancement flap 

192 

xx

Contents 

xi 

CHAPTER 15 VERMILION LOWER LIP 194 

CHAPTER 19 PREAURICULAR 

xx 


• Mucosal advancement flap (surgical vermilionectomy) 

• 

196 

Bilateral vermilion rotation flap 198 

• Mucosal V-to-Y island pedicle flap 200 


CHAPTER 16 CHIN 202 


• Single- or double-rotation flaps 205 


SECTION 4 CHEEK 208 

CHAPTER 17 MEDIAL CHEEK 211 


• Nasolabial advancement flap 213 



CHAPTER 18 CENTRAL CHEEK 220 


• Advancement flap 223 


• Subcutaneous island pedicle 225 

• Rotating Lenticular subcutaneous island 

pedicle flap 226 







• Combined flap and Burow’s full-thickness 

skin graft 236 


CHAPTER 20 MANDIBLE 238 



241 

SECTION 5 EARS 242 

CHAPTER 21 UPPER-THIRD OF THE 

HELICAL RIM 244 



• ‘Banner’ Transposition flap 248 

• Superior helical rim advancement flap 250 


• Helical crus rotation flap 252 

• Full-thickness skin graft 253

xii DERMATOLOGIC SURGERY A manual of defect repair options 


CHAPTER 22 

MIDDLE-THIRD OF THE 

HELICAL RIM 254 



• Helical rim advancement flap 258 

• Helical rim advancement flap 

(partial-thickness variant) 260 


• Two-stage postauricular pedicle interpolation flap 262 

CHAPTER 23 CONCHA BOWL 

AND EXTERNAL 

AUDITORY CANAL 264 

• Full-thickness skin fraft 266 

• Pull-through flap 267 



CHAPTER 24 ANTERIOR EAR 270 



• Full-thickness skin graft 

276 

• Pull-through flap 

277 




CHAPTER 25 POSTERIOR EAR 282 



285 



286 

• Bilobed flap 

287 




• Second intention healing 291 

CHAPTER 26 EAR LOBE 292 



294 

• Transposition flap—one or two stage 295 

SECTION 6 PERIOCULAR 296 

CHAPTER 27 LATERAL CANTHUS 300 



301 



• Bilobed flap 303 


CHAPTER 28 LOWER EYELID 306 



309 

• Advancement flap 

311 


• ‘Banner’ Transposition flap from the upper eyelid 313 




CHAPTER 29 MEDIAL CANTHUS 320 


• Transposition flap 

323 


• Procerus myocutaneous flap 

325 

• glabella back-cut rotation flap 326

Contents 

xiii 




• Z-Plasty repair 331 

CHAPTER 30 UPPER EYELID 332 

• Side-to-side (horizontal) closure 334 


335 





SECTION 7 SCALP 340 

CHAPTER 31 SCALP 342 


• Single and double rotation flaps 

346 



• Purse-string closure 350 

• Variations of second intention healing 351 


• Large flaps with split-thickness graft to the 

secondary defect 352 

SECTION 8 NECK AND MASTOID 354 

CHAPTER 32 NECK 


358 


(T-plasty or O-T) flap 360 




• skin grafts 362 

CHAPTER 33 MASTOID 364 



367 


• Unilateral or bilateral single-sided advancement flap 

(Burow’s exchange advancement flap and T-plasty) 369 

• Full-thickness skin graft including Burow’s graft 370 


SECTION 9 TRUNK AND LIMBS 372 

CHAPTER 34 TRUNK AND LIMBS 374 


376 

• Tripolar (Mercedes) advancement flap 

379 


380 


381 


• Keystone island pedicle flap 383 

• Side-to-side OR FLAP closure with a Burow’s graft 385 


xx

xiv DERMATOLOGIC SURGERY A manual of defect repair options 

PREFACE 

THE AIM 

This book is a practical, “how-to-do-it” manual of 

cutaneous defect repair options in dermatologic 

surgery. We have compiled all of the repairs that we 

find useful and that lead to consistently good results, 

and presented them in a logical, consistent format 

supported by extensive use of diagrams and 

photographs. This is supplemented by a DVD which 

closely simulates looking over the shoulder of an 

experienced mentor, which we believe is one of the 

best ways to learn dermatologic surgery. 

While this manual is comprehensive in scope, it 

does not attempt to cover every repair possible at 

every site. Certain repairs have not been included as 

they are either not performed by the authors or are 

thought to be inferior to the options we do provide. The 

repairs featured in the various sections of the manual 

reflect the experiences of the surgeons at the Skin & 

Cancer Foundation Australia (Westmead). The nose, for 

example, is the most common site and one of the most 

challenging we operate on. As a result the nose has an 

extensive section in this manual, whereas the periocular 

region is a less common site and has a much smaller 

section. Many of the more difficult periocular defects are 

repaired by our visiting oculoplastic surgeons but we 

have limited our discussion to repairs we consider within 

the skill of the typical dermatologic surgeon. 

This manual assumes the reader already has basic 

skills in cutaneous surgery. The book is not a complete 

guide to surgery, and basic aspects of surgery, such 

as local anesthesia, instrumentation, suturing, skin 

physiology, preoperative assessment, postoperative care, 

and management of complications, are not included. 

THE TARGET AUDIENCE 

The manual is primarily aimed at dermatologic surgeons 

with good surgical skills who wish to expand their 

knowledge of repair options to allow closure of more 

difficult defects. However, it also, provides something for 

novices looking to extend their skills as well as for the 

expert preparing a teaching session. While the authors 

are dermatologists, we hope that any practitioner treating 

skin cancer, as well as trainees wishing to learn, will find 

the manual a useful resource. 

NECK 1% 

TRUNK AND LIMBS 2% 

SCALP 3% 

PERIORAL AREA 6% 

NOSE 41% 

BCC 92% 

CHEEK 9% 

RARER TUMORS 1% 

e.g. MAC, AFX etc. 

SCC 7% 

EARS 10% 

PERIOCULAR AREA 13% 

FOREHEAD & 

TEMPLE 15% 

MOHS CASES AT THE SKIN & CANCER FOUNDATION 

AUSTRALIA, 2007 BY ANATOMICAL SITE 

MOHS CASES AT THE SKIN & CANCER FOUNDATION 

AUSTRALIA, 2007 BY HISTOLOGICAL TYPE

Preface xv 

THE MANUAL’S FORMAT 

The manual is divided into nine sections representing 

the various body regions—eight for head and neck, and 

one for trunk and limbs. The head and neck sections are 

further subdivided into chapters representing the cosmetic 

subunits within each region. Each chapter starts with 

an overview and a list of the common repair options 

for that region or subunit. Next, each repair option is 

discussed by listing the advantages and disadvantages, 

followed by a stepwise description of the technique 

for each procedure. Practical tips are highlighted and 

risks and complications are mentioned where relevant. 

Some repetition is deliberate so that the reader is not 

constantly turning pages to previous sections. 

The book is extensively illustrated with photos and 

diagrams, and the accompanying DVD includes over 

100 video demonstrations with commentary, providing a 

“bird’s eye view” of the key points of the operation. These 

are clearly referenced in the text. 

THE SKIN & CANCER FOUNDATION 

AUSTRALIA (WESTMEAD) 

The Skin & Cancer Foundation Australia (SCFA) is a 

specialized medical organization dedicated to providing 

high-quality services in the areas of dermatology and 

dermatopathology. The foundation was established in 

1978 in Sydney to provide expert dermatological services 

and to promote teaching, training, research, and education 

related to dermatology. 

The foundation provides an extensive range of teaching to 

medical students, nurses, visiting overseas doctors, residents 

and registrars, Mohs Fellows and consultant dermatologists. 

The Westmead facility was opened in 1994 and is 

the oldest Mohs training unit in Australia. The day surgery 

facility has eight operating theaters dedicated to cutaneous 

surgery, 13 dermatologic surgeons and five visiting 

oculoplastic surgeons. Our surgeons perform more than 

2000 Mohs surgery procedures each year, representing 

about a quarter of all Mohs cases performed in Australia. 

The following data represents surgical statistics from the 

Skin & Cancer Foundation Australia (Westmead) for 2007 

A percentage of the proceeds of this book is being 

donated to the SCFA. 

5–5.9 cm 2% 

4–4.9 cm 3% 

6–10 cm 1% 

xvi DERMATOLOGIC SURGERY A manual of defect repair options 

PREFACE 

HOW THE MANUAL CAME ABOUT 

The idea for this book grew out of the teaching activities 

performed at the Skin and Cancer Foundation Australia 

(Westmead). While we use all the traditional teaching 

methods, we have found that the best method is actually 

observing the surgery and then performing it with a 

mentor offering advice along the way. Of course, this is 

not possible for many surgeons. In addition, the closures 

vary and a particular closure may not be performed 

very frequently, therefore the visiting surgeon may never 

see that closure. Consequently, we started videoing 

procedures and editing them with a voiceover to produce 

short and concise videos that demonstrate important 

aspects of each procedure. This has proven to be a 

valuable learning tool. 

The initial videos produced were of basic procedures 

in dermatology, and these have now been successfully 

incorporated into a national online teaching program for 

Australian general practitioners and medical students. This 

led to the idea of a similar collection of teaching videos 

for people with more advanced surgical skills and the 

initial videos were produced as a learning guide for the 

dermatology trainees sitting their exams. 

In 2007 a research fellow at the foundation cataloged 

and photo-documented the repairs used to close all Mohs 

surgery defects produced at the foundation over a twelvemonth 

period. This data was well received when it was 

presented by Dr Leslie Storey at the annual meeting of the 

Australasian College of Dermatologists in 2008. 

It seemed that these two learning experiences—lists 

of repair options for varying defects in various sites 

and videos explaining how to perform each of the 

procedures—would be a good combination for teaching 

purposes. Initially the thought was to produce a DVD only, 

but the idea grew in discussion between the authors. It 

seemed that a manual with a full description of all the 

options, including illustrations and images of repairs, 

in combination with a collection of selected videos 

might offer a better all-round teaching aid for those 

seeking information about repairs of cutaneous defects in 

dermatologic surgery.

xvii 

ABOUT THE AUTHORS 

DR ROBERT PAVER MB BS FACD FACMS 

Rob graduated in Dermatology in 1985 and completed a Mohs Surgery Fellowship in San Francisco in 1987. He 

established a Mohs Fellowship training program in Sydney in 1991 where he remains the Program Director. Rob is 

Convenor of the Australasian College of Dermatologists GP Training Task Force and Mohs Fellowship Training Program 

Task Force. 

Currently Rob is in private practice in Sydney, a consultant dermatologist at Westmead Hospital and Medical Director 

at the Skin and Cancer Foundation Australia (Westmead). 

DR DUNCAN STANFORD MB BS MSC (MED) FACD FACMS 

Duncan graduated in Dermatology in 2001 and completed his Mohs Surgery Fellowship in Sydney, in 2002. He is a 

Clinical Senior Lecturer at the University of Wollongong, an Assistant Editor of the Australasian Journal of Dermatology 

and a member of the Board of Censors for the Australasian College of Dermatologists. 

Duncan is in private practice on the South Coast of New South Wales, and performs Mohs surgery and laser 

procedures at the Skin and Cancer Foundation Australia (Westmead). 

ASSOCIATE PROFESSOR LESLIE STOREY MD FACMS 

Leslie graduated in Dermatology in 2005 and completed a Mohs Surgery Fellowship in 

Loma Linda, California, in 2006. After completing her Mohs Fellowship she spent two years in Sydney at the Skin and 

Cancer Foundation, working as a consultant dermatologist and Mohs Surgeon, during which time she set in motion the 

process of creating this book. 

Leslie is currently an Assistant Clinical Professor of Dermatology at the University of California San Francisco in Fresno 

(UCSF Fresno), and heads its Division of Dermatologic Surgery. She teaches general and surgical dermatology to UCSF 

Fresno medical students and UCSF Fresno primary care residents, both through lectures and in the clinic.

xviii DERMATOLOGIC SURGERY A manual of defect repair options 

ACKNOWLEDGMENTS 

GENERAL ACKNOWLEDGMENT 

The authors would like to acknowledge the tremendous 

contribution the Skin & Cancer Foundation Australia 

(SCFA) has made to the development of dermatology and 

in particular, dermatologic surgery, in Australia. It has 

provided the facility to build our Mohs surgery unit and to 

run our Surgery and Laser Fellowship programs. Without 

this institution, Mohs surgery in Australia would not be as 

accessible to patients and trainees as it is today. 

Teaching young and motivated people is one of the 

most rewarding aspects of professional life. A wonderful 

thing about teaching is that you also learn from your 

students. We would like to thank all the registrars, 

fellows, and consultants who have studied at the Skin & 

Cancer Foundation Australia. Many of the things we have 

included in this book have evolved through the process of 

teaching. 

Working in a large facility with many other doctors 

provides a wonderful environment for the exchange 

of ideas and professional development. Many of the 

consultants at the foundation have directly and indirectly 

contributed to this publication. We would like to thank 

them all, but in particular, Dr Chris Kearney, Dr Shawn 

Richards, Dr Michelle Hunt, Dr Howard Studniberg, 

Dr Rhonda Harvey, and Dr Paul Salmon from New 

Zealand, who have all contributed images for the book. 

McGraw-Hill have been absolutely first class in the way 

they have helped us as novice authors. We would like 

to thank their whole team, but in particular, Lizzy Walton 

(Publisher—Medical Division), Fiona Richardson (Associate 

editor), Michael McGrath (Senior production editor), and 

Astred Hicks (Art director), as well as Chris Welch, our 

brilliant illustrator. 

DR ROBERT PAVER 

Producing a textbook, and filming and editing videos, 

are all very time-consuming processes which have a big 

impact on the daily life, not only of the authors but also 

their families. In that regard I am very lucky to have such 

a loving and supportive wife, Deirdre, and four wonderful 

children, all of whom I would like to thank for their 

understanding and acceptance of my preoccupation with 

this project over the past two years. 

My father, Dr Ken Paver, has been an inspirational 

figure and exceptional role model for me in dermatology 

and in life. He was the driving force behind the 

establishment of the Skin & Cancer Foundation Australia 

in Sydney. He also realised that Mohs surgery was a new 

frontier for dermatology and, as a result, arranged for Prof 

Perry Robins in 1978 and Prof Ted Tromovitch in 1981 to 

visit Sydney as keynote speakers for foundation seminars, 

to help establish Mohs surgery in Australia. 

As a result of their visits I was enthused by the concept 

of Mohs surgery and applied for the Mohs surgery 

fellowship with Drs Tromovitch, Stegman, and Glogau in 

San Francisco. They accepted my application and I am 

eternally grateful to them for their excellent teaching and 

mentoring. 

Finally, and most importantly, the production of this 

book has been a joint effort of the three authors. I feel 

blessed to have been able to work on this project with 

such wonderful people. Their enthusiasm and never 

complaining attitude has made a large and complicated 

task so much easier. I have thoroughly enjoyed working 

with them and I would to thank them for that privilege.

Acknowledgments xix 

DR DUNCAN STANFORD 

I am truly a fortunate ‘child’ of the Skin & Cancer 

Foundation Australia: initially as a dermatology trainee, 

then as a Mohs Fellow, and now as a consultant. I owe 

a great debt to the remarkable Rob Paver, as well as to 

Shawn Richards, Michelle Hunt, and Howard Studniberg. 

All of them have been so generous with their time and 

sage advice, and their superb work sets such a high 

standard to aspire to. 

The lovely Leslie Storey was a bright light at the 

foundation for two years and she left such an impact that 

we still greatly miss her. I have a lot to thank her for but 

single out her quiet resolve to excel, which pushed us all 

to try new things (including writing a book). I, too, would 

like to thank Rob and Leslie for the honor of working on 

this project with them. 

My wife, Lucie, and my two daughters, who I love 

so dearly, have shown great tolerance and forbearance 

as I’ve worked on this somewhat daunting project. As a 

medical educator, Lucie has also been able to give wise 

counsel during the later stages of the book’s development. 

DR LESLIE STOREY 

I owe a great deal to the Skin & Cancer Foundation 

Australia, and specifically to Rob Paver, for the 

opportunity to work in Australia. I have learned an 

immense amount directly from working with both Rob as 

well as Duncan Stanford. All the surgeons at the Skin 

& Cancer Foundation have taught me some aspect of 

dermatologic surgery. I would like to thank Dr Artemi, 

Dr Kearney, Dr Hunt, Dr Satchel, Dr See, Dr Kalouche, 

Dr Lee, Dr Studniberg, and Dr Richards. I would also like 

to thank Dr Abel Torres who was my first mentor. 

My experience overseas would not have been possible 

without the loving support of my mother, father, brothers, 

husband, and three children. My husband, Wes, has 

been my pillar of strength throughout our life together. 

My mother and father taught me the importance of hard 

work and the need to continually learn. They have been 

outstanding role models.

126

127 

CHAPTER 

TEMPLE 9 

The temple is a common area for skin cancer. As discussed in the 

introduction to this section, the most important issues in this area 

are the danger zone for the temporal branch of the facial nerve 

and the superficial temporal artery. The temporal branch of the 

facial nerve innovates to the frontalis muscle and gives rise to the 

movements of facial expression for the eyebrows and forehead. 

The area is composed of skin, subcutaneous fat, superficial 

temporal fascia (STF), deep temporal fascia (DTF), and temporalis 

muscle. The nerve lies immediately beneath the STF. The course 

of the nerve places it at risk of injury during surgery over the 

zygomatic arch and on the temple and lateral forehead. Its usual 

course is from a point 5 mm below the tragus to a point 15 mm 

above the lateral extremity of the brow. Over the zygomatic arch, 

it is found about 2.5 cm lateral to the lateral canthus, placing it 

about halfway between the lateral canthus and the superior helix 

(see page 105 for a diagram of the facial nerve). 

There are several considerations when choosing a closure for 

a temple defect. Any closure in this area can put tension on the 

lateral canthus or the eyebrow. A small amount of distortion is 

acceptable as it will settle after a few weeks. Extra tension can 

leave the patient with a raised eyebrow or distortion of the lateral 

canthus and eyelids. 

Side-to-side closure is often possible due to the laxity in the 

preauricular region beneath the temple. Redundant skin from this 

area can also be advanced, transposed or rotated superiorly. If 

none of these is an option, skin grafts may be used. If the defect 

is located in the concave area of the temple, second intention 

healing is also an option. 

REPAIR OPTIONS: 

TEMPLE 




• Advancement flaps 

• Burow’s exchange advancement 

flap 

• Tripolar (Mercedes) advancement 


• Unilateral two-sided advancement 


• Skin grafts 

• Partial closure plus Burow’s 

full-thickness skin graft 

• Full-thickness skin graft 

• Split-thickness skin graft 

• Second intention 

Preferred options when 

standard side-to-side closure 

is not possible

128 DERMATOLOGIC SURGERY A Manual of Defect Repair Options 

TEMPLE 

SIDE-TO-SIDE CLOSURE 

ADVANTAGES 

• The closure stays within the surgical area 

• Scars can sit within, run parallel to, or are 

extensions of, the radial rhytides emanating from 

the lateral canthus (crow’s feet) 

• Suitable for closure of quite large defects 

DISADVANTAGES 

• A long, straight line results from closure of larger 

defects 

A 

B 

C 

Figure 9.1 Horizontal side-to-side closure with M-plasty 

at the medial end in the crow’s feet rhytides. An 

M-plasty at the lateral canthus is an excellent technique 

to shorten the length of an ellipse for closure of large 

defects on the temple.

Temple CHAPTER 9 129 

TECHNIQUE 

1 

Using skin hooks, test for the best direction of 

closure. Ellipses are often best oriented in a radial 

fashion as an extension of the creases radiating 

out from the lateral canthus in horizontal and 

oblique directions. Rarely for small defects 

oriented vertically, a vertical ellipse is required. 

Place the skin hooks on the medial and lateral 

borders and pull the defect closed to evaluate any 

tension on the eyebrow or eyelids. Sometimes 

these vertically shaped defects still need to be 

2 

3 

4 

closed horizontally or obliquely with a large 

ellipse to prevent tension on the lateral eyelids. 

Undermine in the subcutaneous plane avoiding 

the nerves and vessels. 

After hemostasis is achieved, place a few 

absorbable sutures to close the defect. 

Insert the superfi cial sutures. 

A 

B 

C 

Figure 9.2 Side-to-side closure oriented obliquely 

radiating out from the lateral canthus


RHOMBIC TRANSPOSITION FLAP 

SEE VIDEO 38 I TEMPLE RHOMBIC TRANSPOSITION FLAP 

ADVANTAGES 

• Utilizes skin laxity from cheek and preauricular 

region 

• Good skin match 

DISADVANTAGES 

• For small to medium-sized defects only 

• Pincushioning may occur 

• Care must be taken to avoid moving hair onto the 

temple 

A 

B 

C 

Figure 9.3 Rhombic transposition fl ap sourced from skin 

lateral and inferior to the defect


TECHNIQUE 

Refer to Figure 1.18 in Chapter 1 Nasal tip (page 17). 

1 

2 

3 

Draw a line from the defect toward the area of 

skin laxity medial or lateral to the defect and 

parallel to an imaginary extension of the crows 

feet across the temple. 

Draw the second line from the end of the fi rst, 

angling at 60 degrees away from the fi rst line and 

down towards the cheek. It should be the same 

length as the fi rst line. 

Anesthetize the area and incise the fl ap. 

Undermine the fl ap superfi cially in the 

subcutaneous plane avoiding the temporal branch 

of the facial nerve and the temporal artery if 

possible. Also undermine widely in the superfi cial 

4 

5 

6 

plane around the defect and, in particular, the 

skin inferior to the fl ap where the skin laxity is 

found. 

After hemostasis is achieved, place the fi rst 

subcutaneous suture to close the donor site, 

pulling the skin up from the cheek towards the 

zygoma. 

Trim the fl ap to fi t the defect. Some surgeons 

prefer to extend the defect into a geometric shape 

for the fl ap to sit in, believing that geometric 

shapes leave less scarring. A few absorbable 

sutures may then be inserted around the fl ap. 


A 

B 

C 

Figure 9.4 A transposition fl ap from skin medial and 

inferior to the defect can move a long way up onto 

the temple due to the laxity of the cheek, allowing 

substantial advancing movement of the fl ap up over 

the zygoma as well as transposing into the defect.


ROTATION FLAP 

SEE VIDEO 39 AND 40 I TEMPLE ROTATION FLAP AND TEMPLE ROTATION FLAP (LARGE) 

ADVANTAGES 

• Suitable for closure of medium to large defects 

• A curving variation of the Burow’s exchange 

advancement fl ap 

• A portion of the scar will hide in the rhytides, along 

the hairline and in the hair itself 

DISADVANTAGES 

• Lateral eyebrow may be twisted upward a little 

• Care must be taken not to injure the nerve when 

undermining and watch for the arteries 

• Care must be taken to avoid moving hair onto the 

temple 

• Scar may be visible where it runs obliquely across 

the temple 

TECHNIQUE 

Refer to the technique described for a rotation fl ap in 

Chapter 7 Lateral forehead and Figure 7.4 (page 110). 

arc needs to be approximately two to three times 

the size of the defect. 

1 

2 

3 

Draw an arc from the superolateral aspect of the 

defect in or adjacent to the hairline, similar to 

the single-sided advancement fl ap but curving 

laterally and inferiorly toward the preauricular 

area. 

For defects not adjacent to the hair the arc will 

need to curve around beneath the hairline to 

avoid moving hair out onto the temple, while for 

defects adjacent to the hair the arc can run in the 

hairline and down in front of the ear. 

Now draw the rotation pucker at the anterior 

edge of the defect. The area of the fl ap within the 

4 

5 

6 

After anesthesia is obtained, incise the fl ap and 

undermine in the superfi cial plane (to avoid 

injury to the facial nerve). Also undermine the 

skin inferior to the fl ap down onto the cheek to 

allow upward movement of the fl ap with suturing. 

The rotation pucker is then excised to produce an 

oblique line across the temple. 

After hemostasis is achieved, place absorbable 

sutures to pull the fl ap across the defect. The 

remaining absorbable sutures are placed along the 

arc following the rule of halves principle. 


A 

B 

C 

Figure 9.5 Rotate fl ap for a defect on the temple


ADVANCEMENT FLAPS 

BUROW’S EXCHANGE ADVANCEMENT FLAP 

SEE VIDEO 41 I TEMPLE BUROW’S EXCHANGE ADVANCEMENT FLAP 

ADVANTAGES 

• Utilizes skin laxity from the temple and lateral 

cheek 


DISADVANTAGES 

• Possible eyebrow elevation 

• Not as good for large, vertically oriented defects 

• Can cause reorientation of the skin rhytides 

TECHNIQUE 

1 

2 

3 

Outline the flap by drawing a line from the 

inferolateral border of the defect down the 

preauricular fold. The line may extend beyond the 

insertion of the ear lobe for maximum mobility of 

the flap. Draw a triangle where the standing cone 

deformity will be located medial to the defect and 

oriented obliquely across the temple. 

Alternatively draw a line from the inferolateral 

border of the defect, around the orbital rim to the 

crows feet at the lateral canthus. Draw a triangle 

where the standing-cone deformity will be 

located, lateral to the defect and up into the hair 

line. 

Incise the fl ap and undermine in the 

subcutaneous plane. 

4 

5 

6 

7 

8 


sutures to advance the fl ap superiorly over the 

defect. 

Excise the standing cone deformity and 

approximate the edges with deep absorbable 

sutures. 

If the line in the preauricular fold, or along the 

orbital ring, can be closed by the rule of halves 

principle, it should be. Sometimes for large 

defects a Burow’s triangle will need to be removed 

from beneath the ear lobe or in the crow’s feet. 

A few absorbable sutures may be placed along the 

fl ap edges. 


Courtesy of Dr Chris Kearney 

A 

B 

C 

Figure 9.6 A Burow’s exchange advancement fl ap around the orbital rim to the crow’s feet


ROATION FLAP continued 

TRIPOLAR (MERCEDES) ADVANCEMENT FLAP 

ADVANTAGES 

• Suitable for closure of medium-sized defects 

• A portion of the scar can hide within the horizontal 

rhytides 

DISADVANTAGES 

• Possible eyebrow or eyelid distortion 

• A portion of the scar is noticeable 

TECHNIQUE 1 

1 

2 

3 

Undermine widely around the defect. 

Using skin hooks, pull defect edges together in 

multiple directions to gauge the directions of 

greatest movement. Most laxity will always be 

found to be inferior to the defect. Use the skin 

marker to outline the potential triangular cones 

of redundant skin. 

Place a buried purse-string type suture connecting 

the center of all three sides of the outlined 

4 

5 

6 

triangles then confi rm or remark the redundant 

cones. 

Incise and remove these triangles. 

After hemostasis is achieved, place several 

absorbable sutures with the fi rst suture closing the 

vertical line then other deep sutures to fully close 

the defect. 


Figure 9.7 Tripolar advancement fl ap 

A 

B 

Figure 9.8 Tripolar advancement fl ap


UNILATERAL TWO-SIDED ADVANCEMENT FLAP (O-TO-U FLAP) 

ADVANTAGES 

• Utilizes skin laxity from beneath the defect 


which are more square in shape 

DISADVANTAGES 

• Anterior vertical line may be visible 

TECHNIQUE 

1 

Outline the fl ap by drawing vertical lines down 

from the inferolateral corner of the defect in 

the hairline and from the inferomedial corner 

down to the crow’s feet adjacent to the lateral 

canthus. Draw triangles where the standing cone 

deformities will be located in the crow’s feet 

medially and in the sideburn region laterally. 

The fl ap should be broader at its base than at the 

leading edge. 

3 

4 

5 


sutures to advance the fl ap superiorly over the 

defect. 

Excise the standing cone deformities and 

approximate the edges with deep absorbable 

sutures. 

A few absorbable sutures may be placed along the 

fl ap edges. 

2 

Incise the fl ap and undermine in the 

subcutaneous plane. 

6 


A 

B 

Figure 9.9 Design of the unilateral two-sided advancement fl ap for a square-shaped medium to large defect on the 

temple. This fl ap is not commonly used and is best considered when the medial vertical edge of the defect is too long 

for an M-plasty or rotation-pucker repair as part of a unilateral advancement fl ap or rotation fl ap.


SKIN GRAFTS 

PARTIAL CLOSURE PLUS BUROW’S FULL-THICKNESS SKIN GRAFT 

As part of a combined repair, excised standing cones from a partial side-to-side closure or a fl ap repair, such as a 

tripolar advancement fl ap, may be used as full-thickness skin grafts to fi ll the residual defect. 

ADVANTAGES 

• Closure of the donor site reduces the defect size 

• No need for separate donor site repair 

• Good color, texture, and contour match. Some 

defatting of the grafts is still necessary and grafts 

are cut to fit, and sutured in position in the standard 

manner. 

DISADVANTAGES 

• Grafts are more obvious scars than fl aps but 

smaller grafts are preferable to larger grafts 

A 

B 

C 

Figure 9.10 Side-to-side closure with M-plasty and 

Burow’s graft to the residual central defect


FULL-THICKNESS SKIN GRAFT 

ADVANTAGES 

• Closure stays within the surgical area 

• No brow elevation or other distortion of anatomy 

• More rapid healing and less wound care than 

second intention 

DISADVANTAGES 

• Obvious scar 

• Color and texture mismatch 

• Separate donor site repair needed 

TECHNIQUE 

Refer to the technique for full-thickness skin grafts in Chapter 1 Nasal tip (page 25). 

SPLIT-THICKNESS SKIN GRAFT 

ADVANTAGES 

• Suitable for closure of very large defects 

• Closure stays within the surgical area 

• More rapid wound healing and less wound care 

than second intention 

DISADVANTAGES 

• Secondary donor site often painful and less 

cosmetically acceptable 

• Often produces inferior cosmetic results to a fullthickness 

skin graft 

A 

B 

C 

Fiogure 9.11 A split-thickness skin graft has been manually fenestrated to allow for greater coverage of a very large 

temple defect


SECOND INTENTION 

ADVANTAGES 

• No suturing required 

• Scarring confined to defect area 

• Scar will decrease in size as it heals (contracting 

approximately 30%) 

• Can be combined with side-to-side or fl ap repairs 

for larger defects. Hypertrophic scars are rare on 

concave areas 

• Unlikely to distort eyebrow, lateral canthus or 

hairline 

• Less undermining with lower risk of hematoma, 

infection, and nerve damage 

DISADVANTAGES 

• Best for shallow defects 

• Open wound for approximately six weeks 

• Daily wound care required 

• Scar is often hypopigmented and a different color 

from the surrounding skin 

• Scar may become indented, thickened or stellate in 

appearance 

TECHNIQUE 

1 

2 

3 

4 

Partially close the defect in the simplest manner 

to minimize the size of the residual defect. 

After the wound has been cleansed and 

hemostasis achieved, apply antibiotic or plain 

ointment to the wound. 

• Do not leave any form of hemostatic bandage 

(gel foam or calcium alginates) on the wound. 

Apply a nonstick dressing with a gentle pressure 

dressing on top for the fi rst 24 to 48 hours. 

After this, the patient is instructed to cleanse the 

wound twice daily and apply petrolatum with or 

without a dressing. 

5 

6 

A wound check one week postoperatively should 

be offered to all patients; otherwise follow up 

approximately six weeks postoperatively. 

Hydrocolloid dressings can be used after one to 

two weeks to speed up healing and improve the 

appearance for the patient. 

See Figs. 31.7 and 31.8 on pages 350 and 351 for 

examples of second intention healing. 

Reference 

1. Hunt, M.J. “The Mercedes closure.” Proceedings of the 37th Annual Scientific Meeting of the Australasian College of Dermatologists, 

Sydney, 2004.

139

advancement flap - McGraw-Hill Education Australia & New Zealand

Create successful ePaper yourself

Delete template?

Save as template?