second line originates from the free end of the first line and is drawn parallel to the long axis of the rhombus. This second line’s orientation results in a slightly widened pedicle, a decrease in the tip volume, and a decrease in the degree of rotation necessary to execute the flap. The tissue redundancy at the base of the leading edge of the flap can be removed by taking a slightly larger Burrow’s triangle.

33.6.1.2 Thirty-Degree Angle Webster Flap

The 30° angle Webster modification of the classic rhombic flap utilizes a more acute angle than other rhombic transposition flaps allowing for even greater tension sharing between the primary and secondary defects. A Webster 30° angle flap is planned similarly to the Dufourmental flap; however, its distal tip angle is designed to be 30° (Fig. 33.15). This gives the flap a slimmer design and narrower pedicle. The flap area is only 50% of the area of the primary defect; therefore, it only relieves half of the tension from the primary defect. This modification is used in situations where a fair amount of laxity exists in the horizontal axis of the rhombic-shaped defect. Since this design places more tension on the primary defect, care must be taken not to close with too much lateral tension or distort adjacent anatomic structures.

Rhombic transposition flaps are very versatile and may be used to reconstruct a variety of defects. Transposition flaps are generally used when there is insufficient laxity in the immediate surrounding area of closure and or the tension vectors need to be redirected. This is particularly important when repairing defects near free margins such as the eyelids and the

nose. The most common areas where they are employed include the nasal dorsum, nasal sidewall, medial and lateral canthus, lateral forehead, temple, cheek, perioral region, inferior chin, and the dorsal hand.

33.6.2 The Banner Flap

Banner-type flaps are random pattern finger-shaped cutaneous flaps that, like other transposition flaps, tap into adjacent skin to borrow laxity and fill a defect [20]. This flap is most commonly planned as a melolabial transposition to repair defects of the nasal ala or from the preor postauricular area to close defects on the ear. For an optimal cosmetic result, the scar is generally placed at the junction of two cosmetic units, providing excellent camouflage (in the nasolabial fold or preauricular sulcus).

The fundamental design of the banner flaps consist of a finger-shaped flap drawn with a width that is equal to the width of the defect and a length equal to the distance from the pivot point to the far edge of the defect. The flap is transposed and rotated in an arc around the pivot point to fill the defect. Since this is a long random pattern flap with a narrow pedicle, the risk of vascular compromise may be high if the entire length of the flap is used and its pedicle originates from an area of minimal vascularity. To minimize risk of vascular compromise, the flap is typically designed to rotate through an angle of 60–120° instead of the originally described 180°. Typical locations for use of Banner-type flaps include the nasal ala, the superior helix of the ear, and the medial anterior ear.