Skip to Main Content


This chapter presents a basic overview of the approach to reconstruction of cutaneous facial defects with local skin flaps. Emphasis is placed on the understanding of the anatomy, evaluation of a defect, and design of an appropriate local skin flap.


Essentials of Diagnosis


For successful local flap reconstruction of facial defects, the surgeon must have a thorough understanding of thefollowing.


  • Biomechanics of soft tissues
  • Vascular supply to the face and given skin flap
  • Aesthetic subunits and the relaxed skin tension lines of the face (RSTL)
  • Dimensions and depth of the defect
  • Inherent structural characteristics of the native skin in the area of the defect (ie, thickness and sebaceous character).


Successful reconstruction of facial defects requires a thorough understanding of skin anatomy and physiology, careful analysis of the defect, and meticulous soft tissue techniques. Options for reconstruction should generally proceed from least invasive to most invasive in terms of morbidity. This approach is termed the “reconstructive ladder.” Most facial defects that are too large for primary closure are amenable to local flaps. When planned and executed properly, local flaps allow for rapid reconstruction with a reliable blood supply, minimal morbidity, and excellent cosmesis. This chapter reviews the classification of commonly used local skin flaps and outlines the use of local flaps for facial reconstruction. In considering the appropriate surgical approach for a given defect, the surgeon should not forget that secondary intention healing is a viable option for concave areas of the face.


When possible, local flaps should be designed in the same aesthetic unit as the initial defect. Lines of excision should usually be made parallel to relaxed skin tension lines (RSTL) or along aesthetic borders to optimize scar camouflage. If the defect involves multiple aesthetic subunits, it may be necessary to use a separate flap for each subunit. If more than 50% of a subunit is involved, the defect may be enlarged to reconstruct the entire unit with a flap. Placing incisions parallel to RSTLs reduces tension on wound closure by placing maximal tension into lines of maximal extensibility (LME). Skin tension and its distribution are important to avoid distortion of key facial landmarks such as the eyelid, lip, and the nasal ala.

Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:329–347. (Classic article describing the subunits of the nose.)
Zitelli JA. Secondary intention healing: an alternative to surgical repair. Clin Dermatol. 1984;2:92–106. (This paper describes secondary intention healing and the areas of the face that are most amenable to this technique.)


Local skin flaps can be classified either by their blood supply or by the method of transfer. (Table 77–1)

Table Graphic Jump Location
Table 77–1. Classification of Local Flaps by Tissue Movement.

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.