Turning over a new leaf

Contour restoration can prove difficult when trying to fill the concavity remaining from resected skin, subcutaneous tissue and sometimes even muscle. Joel Cook, M.D., associate professor of dermatology and otolaryngology, Medical University of South Carolina, department of dermatology, Charleston, S.C., speaks on turnover flaps (also referred to as hinge or foldover flaps), their importance, and how and when to execute this essential yet sometimes tricky surgical procedure when repairing deeper central facial defects.

Contour the key

Deeper facial defects should not just be covered with a flap or graft, but should be filled with adequate volume of tissue consisting of subcutaneous fat and sometimes muscle (depending on the depth of the defect), thereby restoring complex facial topography to its original state. Turnover flaps consisting of adipose or muscular tissues serve as a simple, effective and versatile addition to Burow's grafts or local flaps. The most profitable anatomic locations in which to use this procedure include the alar-cheek junction, nasal sidewall and medial canthus, nasal tip and soft triangle, and the infraorbital cheek region.

"In some cases, the turnover flap represents a feasible alternative to a more complex, two-staged flap. This turnover flap possesses a unique motion whereby a flap of tissue folds over on its pedicle like a page of a book in order to fill the depth of a defect," Dr. Cook tells Dermatology Times.

"After the epithelial-free turnover flap is inset to fill the wound's base, cutaneous coverage is provided by a separate graft or flap. The use of the turnover flap restores the natural contour by introducing a volume of tissue for repair that a graft alone or a single flap cannot provide. While this hinged flap could potentially be used in many locations, we find it to be most helpful for defects involving the nose."

The surgeon explains that the hinge flap should only be employed in defects in which all surgical margins have been confirmed to be clear of tumor (ideally, using the Mohs technique); defects located in the central facial region ranging from 1 cm to 3 cm in size; and defects judged to be too deep for effective repair with a simple flap or graft.

Making of a successful flap

The first step in the turnover flap procedure is to plan and mark the tricone.

Subsequently, the skin overlying the proposed flap is then removed to the superficial dermis. A U-shaped flap slightly smaller than the dimensions of the defect to be repaired is incised and elevated. It is crucial that the estimated volume of the deficient tissue in the original wound matches the thickness of the elevated flap. The flap is then further elevated, allowing it to fold over into the defect on a hinge (typically only several millimeters wide) adjacent to the surgical wound.

The surgeon can then simply fold over the flap into the original defect and suture it into place with several buried stitches. Subsequently, the donor site is electrocoagulated as necessary and is typically closed with a linear repair or additional local flap.

Dr. Cook explains that very little, if any, contour deficiency is produced by the flap's harvest, as the donor site is usually placed in an area of relative fullness of subcutaneous tissue.

Dr. Cook firmly believes that adipose and muscular turnover flaps are invaluable when dealing with deeper defects of the central face. He says turnover flaps have several advantages when compared with other repair possibilities.

Turnover advantages

"Turnover flaps can safely and effectively restore contour to a deeper defect," Dr. Cook says.