Reconstruction
Flaps & Grafts
Understanding Your Reconstruction Options
After Mohs surgery, the method used to close the wound depends on the size, depth, and location of the defect — as well as the overall health and tissue quality of the patient. Dr. Skinner will always choose the simplest effective technique, reserving more complex approaches for larger or more challenging wounds.
Skin Flaps
A flap is tissue — skin and its underlying fat, and sometimes muscle — that is moved from an adjacent or nearby area while maintaining its own blood supply. Because the tissue retains its circulation, flaps are more reliable than grafts and generally produce better cosmetic results with superior color and texture match.
Advancement Flap
Tissue directly adjacent to the wound is stretched (advanced) forward in a straight line to cover the defect. Useful for defects on the forehead, scalp, lip, and temple where tissue can be recruited from one direction. The primary tension is managed with small back-cuts or the removal of Burow's triangles.
Rotation Flap
A semicircular arc of tissue is rotated around a pivot point to fill the wound. The large radius of the flap distributes tension widely, making this technique useful for scalp, cheek, and forehead wounds. The pivot point and arc can be designed to hide the donor scar along natural landmarks.
Transposition Flap
Tissue is moved laterally — lifted, pivoted, and placed into the defect at an angle. The classic rhombic (Limberg) flap and its variants are transposition flaps. The banner flap, bilobed flap, and nasolabial flap are also transposition designs. These are among the most commonly used flaps in facial reconstruction.
Interpolation Flap
For large or complex defects where no adjacent tissue can reach, interpolation flaps use a pedicle (a stalk of skin and subcutaneous tissue containing a blood vessel) to carry tissue from a nearby — but not immediately adjacent — donor site. The pedicle bridges normal skin, which is preserved. After 3–4 weeks, the reconstructed tissue has established its own blood supply, and the pedicle is divided in a second procedure.
Common examples:
Paramedian forehead flap — for large nasal defects; pedicle based on supratrochlear artery
Abbe flap — transfers a segment of one lip to reconstruct the other; pedicle divided at 2–3 weeks
Nasolabial interpolation flap — for alar reconstruction; pedicle based in the nasolabial fold
Bilobed Flap
A double-transposition flap with two lobes — the primary lobe fills the main defect, and the smaller secondary lobe fills the donor site of the primary lobe. This design distributes the tissue movement and significantly reduces pin-cushion deformity. The bilobed flap is one of the most elegantly designed flaps in facial surgery and is especially well-suited for the nasal tip and ala.
Island (Subcutaneous Pedicle) Flap
An island of skin is elevated on its underlying subcutaneous fat — which acts as the pedicle — and tunneled or advanced into the defect. The surface skin over the pedicle is not disturbed. This produces a single-scar closure and is particularly useful on the cheek and temple.
Skin Grafts
A skin graft involves removing skin from one area of the body (the donor site) and transplanting it to cover the wound. Unlike a flap, a graft has no attached blood supply — it must establish a new blood supply by growing into the wound bed. Grafts require a well-vascularized wound base and careful postoperative care.
Full-Thickness Skin Graft (FTSG)
Harvests the full thickness of the epidermis and dermis from the donor site. FTSGs produce better cosmetic outcomes than split-thickness grafts — less contraction, better color match, more normal texture.
Common donor sites:
Preauricular (in front of the ear) — excellent match for facial wounds
Postauricular (behind the ear) — thin, smooth skin; ideal for the ear and nose
Supraclavicular (above the collar bone) — good match for facial skin in some patients
Inner arm — used for larger grafts
Split-Thickness Skin Graft (STSG)
Harvests only a portion of the dermis. STSGs are more reliable (higher take rate) than FTSGs but produce more contraction and a less cosmetically ideal result. Used for large scalp wounds, lower extremity wounds, and other situations where FTSG is not appropriate.
How Dr. Skinner Chooses
The hierarchy of reconstruction — from simplest to most complex — is listed below. Dr. Skinner always starts with the simplest technique that will produce an excellent result for that specific location. A larger procedure is only chosen when it will produce a meaningfully better outcome.
Schedule a Consultation
Questions about your reconstruction options? Call our Alcoa office.
(865) 268-4444