A Conceptual Approach to Designing Transposition Flaps

Jeffrey F. Scott, MD and Jeremy S. Bordeaux, MD, MPH*

BACKGROUND The large number of transposition flap geometries available for cutaneous reconstruction
often makes the design of these flaps difficult for less experienced dermatologic surgeons.

OBJECTIVE To present a conceptual approach to designing transposition flaps based on 2 elementary

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angles.

MATERIALS AND METHODS First, a simplified framework for designing transposition flaps is presented,
based on: (1) the takeoff point of the flap, (2) the angle between the primary limb and the primary defect (Angle
A), and (3) the angle between the secondary limb and the primary limb (Angle B). Next, a comprehensive
literature review highlights applications of the above conceptual approach in the design of z-plasties and
single-lobed and multi-lobed transposition flaps.

RESULTS Different types of transposition flaps all share the same key design elements, and modifications to
Angle A and Angle B predict flap biomechanics.

CONCLUSION The design of transposition flaps can be simplified by understanding how 2 elementary angles
influence the geometry and biomechanics of various transposition flaps.

The authors have indicated no significant interest with commercial supporters.

ransposition flaps are frequently used by

T dermatologic surgeons in cutaneous
Basic Definitions of Transposition Flaps

Single-lobed transposition flaps are characterized by a

reconstruction. One important advantage of
transposition flaps is the ability to alter tension vectors
of closure to avoid free margin distortion. However,
designing transposition flaps can often be difficult,
given the plethora of different flap geometries
available to the dermatologic surgeon. The authors’
goal is to present a conceptual framework for
understanding transposition flaps, highlighting how 2
elementary angles serve as the fundamental design
elements for all transposition flap geometries. The
design principles, execution, and site-specific
considerations of transposition flaps have been
previously reviewed in comprehensive detail and serve
as excellent resources for achieving successful
reconstructive outcomes.1–6
flap body and vascular pedicle defined by a primary
limb and secondary limb (Figure 1; See also Supple-
mental Digital Content 1, Video 1, http://links.lww.
com/DSS/A158). The flap’s primary limb originates
from the primary defect at a given Angle A (:A). The
flap’s secondary limb originates from the primary limb
at a given Angle B (:B). Movement of the flap’s body
into the primary defect is referred to as primary flap
movement. Primary flap movement results in the for-
mation of a standing cone deformity (SCD) at the base
of the primary defect, as well as a secondary defect at
the original location of the flap’s body.
The secondary defect bears the majority of closure
tension in single-lobed transposition flaps. Closure of

*All authors are affiliated with the Department of Dermatology, University Hospitals Cleveland Medical Center, Case
Western Reserve University, Cleveland, Ohio

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal’s Web site (www.dermatologicsurgery.org).

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2020;46:9–19 DOI: 10.1097/DSS.0000000000002011

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 TRANSPOSITION FLAPS SIMPLIFIED

Figure 1. Basic schematic of a transposition flap. As the body of the flap moves into the primary defect, a secondary defect
forms in its original location and a standing cone deformity develops at the base of the primary defect. The primary tension
vector is located at the secondary defect, and secondary flap movement occurs at both the primary and secondary defects
as a result of closure.

the secondary defect gives rise to the flap’s primary
tension vector, which can be oriented in any direction
relative to the primary defect. Transposition flaps
generate significantly less tension during closure of the
primary defect as compared to advancement or rota-
tion flaps, which are characterized by a primary ten-
sion vector located at the leading edge of the flap. Any
movement of skin unrelated to primary flap movement
and resulting from closure of the primary and sec-
ondary defects is referred to as secondary flap
movement.
cent tissue reservoirs for incorporation into the flap.
Carefully inspect and palpate for areas of tissue laxity
adjacent to the primary defect, and then design the
primary limb’s takeoff point to be in the same location
as tissue reservoirs.
Step 2: Choose :A
:A determines the orientation of the primary tension
vector and the degree of primary flap movement.
Transposition flap biomechanics are influenced by

Conceptual Approach to Designing

Transposition Flaps

The authors will now consider a round primary defect

designed to be reconstructed with a single-lobed
transposition flap, as there is a hypothetical free mar-
gin and inadequate tissue laxity adjacent to the defect
to allow for primary closure or use of a sliding flap.

The following framework will enable the dermato-

logic surgeon to design a transposition flap with any
geometry for reconstruction of any primary defect
(Figure 2).

Step 1: Determine the Takeoff Point of the

Primary Limb
There are an infinite number of possible primary limb
takeoff points for a given primary defect. The choice of
takeoff point will depend on the availability of adja-
Figure 2. Conceptual approach to designing transposition
flaps. Step 1: determine the takeoff point of the primary
limb. Step 2: choose :A between the primary limb and the
primary defect. Step 3: choose :B between the primary
and secondary limbs.

10 DERMATOLOGIC SURGERY

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

increasing or decreasing :A (See Supplemental Digi-
tal Contents 2 and 3, Video 2 and Figure S1, http://
links.lww.com/DSS/A159 and http://links.lww.
com/DSS/A160). First, orient the primary tension
vector away from any free margins associated with the
primary defect. Tension is completely directed away
from a given free margin when the flap’s primary limb
is perpendicular to the free margin, and thus the pri-
mary tension vector is parallel to the free margin
(:A = 90°). As shown in Figure 3A, the takeoff point
of the primary limb (:A = 90°) ensures that the pri-
mary tension vector is parallel to the free margins
associated with the upper and lower eyelids (Figure
3B). This orientation may not always be feasible,
however, as tissue laxity may be lacking or the flap’s
design may cross cosmetic subunit boundaries. When
:A is less than or greater than 90°, secondary flap
movement develops at the primary defect because a
component of the primary tension vector is now ori-
ented in the direction of the free margin. As :A
approaches 0 or 180°, the primary tension vector
becomes perpendicular to the free margin and all the
closure tension is transmitted to the free margin.
Pivotal restraint also influences the amount of sec-
ondary flap movement and the size of the SCD
occurring at the primary defect. Increases in :A result
in increased primary flap movement and greater piv-
otal restraint, which causes the flap’s leading edge to
lose height as it moves into the primary defect.7
Increasing :A above 90° is generally not advisable
Figure 3. (A) Orientating the takeoff point of the primary limb and :A perpendicular to adjacent free margins ensures that
the (B) resulting primary tension vector is parallel to the at-risk free margins.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SCOTT AND BORDEAUX
as a large amount of secondary flap movement devel-
ops at the primary defect due to the combination of the
primary tension vector’s orientation, and significant
pivotal restraint from the large amount of primary flap
movement.
In addition, the size and orientation of the SCD that
develops at the base of the primary defect must be
carefully considered during the design of transposition
flaps, as it may narrow the vascular pedicle, cross
cosmetic subunit boundaries, or have an unfavorable
orientation that may lead to free margin distortion
when closed primarily. The SCD increases in size as the
primary flap movement increases. The orientation of
the SCD can typically be adjusted by altering where the
flap’s body is sutured into the primary defect. Thus, the
orientation of the SCD can often be strategically
placed away from the vascular pedicle or within cos-
metic subunit boundaries, so as to limit its overall
impact on the reconstructive outcome of the trans-
position flap.
Step 3: Choose :B
The size of the flap is determined by both :B and the
length of the flap’s primary and secondary limbs. For
example, a large flap can be designed with a small :B
and longer primary and secondary limbs, and a small
flap can be designed with a larger :B and shorter
primary and secondary limbs. However, blood supply
to the flap becomes increasingly tenuous as :B
decreases and the vascular pedicle narrows.
46:1:JANUARY 2020 11
 TRANSPOSITION FLAPS SIMPLIFIED
Transposition flap biomechanics are also influenced
by increasing or decreasing :B (See Supplemental
Digital Contents 4 and 5, Video 3 and Figure S2, http://
links.lww.com/DSS/A161 and http://links.lww.
com/DSS/A162). The size of the flap influences flap
biomechanics in 3 important ways. First, the second-
ary defect becomes more difficult to close primarily as
the flap’s size increases. As such, the magnitude of the
primary tension vector increases and secondary flap
movement increases at the secondary defect. Second,
the size of the SCD at the base of the primary defect
increases as the flap’s size increases. Third, the flap’s
size influences the amount of secondary flap move-
ment at the primary defect, as an undersized flap will
require additional secondary flap movement for clo-
sure of the primary defect. Thus, the ideal size of the
flap is determined by the amount of secondary flap
movement that can be tolerated at the primary and
secondary defects. A smaller flap is chosen when little
or no secondary flap movement is permitted at the
secondary defect, and a larger flap is chosen when little
or no secondary flap movement is permitted at the
primary defect. As depicted in Figure 4A, the takeoff
point of the primary limb (:A = 90°) ensures that the
primary tension vector is parallel to the free margin
associated with the eyebrow. In addition, an under-
sized flap is designed with a smaller :B to facilitate
closure of the secondary defect. In this example,
additional secondary flap movement is tolerated at the
primary defect because it is parallel to the eyebrow
Figure 4. (A) Undersizing the transposition flap by making :B smaller facilitates closure of the secondary defect but (B)
increases secondary flap movement at the primary defect.
12 DERMATOLOGIC SURGERY
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(Figure 4B). By contrast, as shown in Figure 5A, an
oversized flap is designed with a larger :B to ensure
that little to no secondary flap movement occurs at the
primary defect, as this movement is perpendicular to
the free margin and may distort the eyebrow (Figure
5B).
As transposition flaps are commonly used to reorient
tension vectors away from free margins associated
with the primary defect, the secondary defect should
generally assume as much closure tension as possible
without unnecessarily compromising free margins
associated with the secondary defect. The allocation of
closure tension is a careful balancing act, and any
tension not assigned to the secondary defect will be
transmitted to the primary defect. The precise alloca-
tion of closure tension between the primary and sec-
ondary defects will also depend on the size and
location of the primary defect, available tissue reser-
voirs, elastic and sebaceous quality of the skin, and
biomechanical properties of associated free margins.1–
6
If little tissue laxity is present, :B may need to be
reduced to facilitate primary closure of the secondary
defect in exchange for increased secondary flap
movement at the primary defect.
In summary, any transposition flap geometry can be
rationally designed by first determining the takeoff
point of the primary limb, and then choosing appro-
priate sizes for :A and :B that result in a favorable
 SCOTT AND BORDEAUX

Figure 5. (A) Oversizing the transposition flap by making :B larger increases the magnitude of the primary tension vector
but (B) ensures that little to no secondary movement occurs at the primary defect.

orientation of the primary tension vector, acceptable
degree of secondary flap movement at the primary and
secondary defects, and reasonable size of the SCD
(Table 1). The authors will now illustrate how :A and
:B are the fundamental design elements of all trans-
position flaps and how they impact the biomechanics
of each specific type of flap.
Applications of the Conceptual Framework
Z-Plasty
Z-plasty is the fundamental building block of all
transposition flaps.1,2 A z-plasty is a double trans-
position flap used for lengthening contracted scars,
reorienting scars to align within relaxed skin tension
lines or cosmetic subunit boundaries, and breaking up
linear scars into irregular broken segments to improve
their aesthetic appearance.8 When no primary defect is
present, :A dictates the final size and biomechanics of
the z-plasty. Z-plasties are designed with a central limb
and 2 primary limbs branching off at 2 separate angles
(:A1 and :A2) forming the shape of a “Z” (Figure 6).
After double transposition of the 2 flap bodies, the flap’s
central limb is reoriented and increased in length.9
If :A1 = :A2 = 60°, the central limb of the z-plasty
reorients 90° from its original position and increases in
length by approximately 75%. If :A1 and :A2
decrease to 45°, the central limb now reorients 60°
from its original position and increases in length by
approximately 50%. Angles less than 30° should be
used with caution in z-plasties because of the small
vascular pedicle resulting from the acute angle. If :A1
and :A2 increase to 75°, the central limb now reor-
ients 120° from its original position and increases in
length by approximately 100%. Notably, angles
greater than 75° will typically result in the develop-
ment of SCD after double transposition. Although

Table 1. The Impact of Angle A and Angle B on the Geometry and Biomechanics of Transposition Flaps

1° Tension Vector 1° Tension Vector 2° Flap Movement at 2° Flap Movement at Size of

Orientation Magnitude 1° Defect 2° Defect SCD
:A

:B

1°, primary; 2°, secondary; SCD, standing cone deformity.

46:1:JANUARY 2020 13

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 TRANSPOSITION FLAPS SIMPLIFIED
Figure 6. The design of z-plasties with (A) :A1 and :A2 equal to 60°, (B) :A1 and :A2 equal to 45°, and (C) :A1 and :A2
equal to 75°.
traditionally designed with primary limbs and angles
of equal sizes, Z-plasties can be designed with primary
limbs of unequal sizes and originating at unequal
angles from the central limb. The purpose of this
design modification is to transpose a more acutely
angled flap to a more favorable location.
Rhombic Transposition Flaps
The classic rhombic transposition flap (Limberg flap)
is designed to recruit adjacent reservoirs of tissue to
repair rhombic-shaped primary defects with internal
angles equal to 60 and 120° (Figure 7).10–13 If the
primary defect is not rhomboid in shape, normal skin
can be removed to create a rhombus for design of the
flap.14 The takeoff point of the primary limb is
designed off the short axis of the defect, with :A =
120°, :B = 60°, and the primary and secondary limbs
14 DERMATOLOGIC SURGERY
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of the flap equal in length. The primary tension vector
is now parallel to the long axis of the defect. Secondary
flap movement and a moderately sized SCD com-
monly develop at the primary defect as a result of
pivotal restraint from the relatively large degree of
primary flap movement.7
Dufourmentel modified the Limberg flap to increase its
versatility in reconstructing rhombic-shaped primary
defects with internal angles of any size.15–17 By
decreasing :A from 120 to 90°, the Dufourmentel
modification results in less primary flap movement,
less secondary flap movement at the primary defect,
and a smaller SCD.16 The Dufourmentel modification
is useful for repairs in which very little secondary flap
movement is permitted at the primary defect or when
the size of the SCD must be minimized.

Figure 7. The design of rhombic transposition flaps using :A and :B, including (A) the classic design (Limberg flap), (B)
the Dufourmentel modification, and (C) the Webster 30° modification.
Finally, Webster further modified the Limberg flap to
facilitate closure of the secondary defect.18 The Web-
ster 30° modification decreases :A from 120 to 90°,
but also decreases :B from 60 to 30°, which results
in a smaller flap, decreased magnitude of the primary
tension vector, and reduced secondary movement at
the secondary defect. However, secondary flap
movement increases at the primary defect as a result of
the flap’s reduced size. The Webster 30° modification
is useful for repairs in which there is minimal skin
laxity available for closure of the secondary defect,
and when secondary flap movement at the primary
defect can be tolerated. In addition, the Webster 30°
modification can be useful when secondary flap
movement is desired at the primary defect, such as in
elderly patients with nasal tip ptosis.1
Subsequent modifications of the rhombic trans-
position flap expanded its versatility to repair circular
defects, in which the flap’s primary limb originates
from the midline of a round defect or the short axis of
an oval defect.19–22 Moreover, rhombic transposition
flaps have been described for the repair of various
others primary defect geometries, including trapezoids
and diamonds.23,24 Finally, multiple rhombic trans-
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SCOTT AND BORDEAUX
position flaps can be combined in a similar fashion as
bilateral rotation flaps (O-to-Z), with up to 4 flaps
designed around a single primary defect.25–29
Banner and Note Transposition Flaps
Banner and note transposition flaps differ from
rhombic transposition flaps in that the flap’s primary
limb originates tangentially from a round defect, and
the flap’s primary and secondary limbs are unequal in
length.30,31 The banner transposition flap, named for
its triangular shape resembling a banner or pennant, is
designed with :A approximately equal to 30°, and
the flap’s primary limb significantly longer than the
primary defect (Figure 8).32–38 The flap’s secondary
limb does not extend past the distal edge of the primary
defect, which results in a long narrow flap with :B
approximately equal to 30°. The design of the banner
transposition flap allows for relatively easy closure of
the secondary defect, and therefore a lack of secondary
flap movement at the secondary defect. However, the
orientation of the primary tension vector and the rel-
atively small size of the flap result in secondary flap
movement at the primary defect and a moderately
sized SCD. Notably, early descriptions of the banner
46:1:JANUARY 2020 15
 TRANSPOSITION FLAPS SIMPLIFIED
Figure 8. The design of the (A) banner transposition flap and (B) note transposition flap using :A and :B.
transposition flap reports its utility in repairing defects
on the nasal dorsum of elderly patients with nasal
ptosis, where free margin distortion and elevation of
the nasal tip was considered a favorable cosmetic
outcome.30
The note transposition flap, named for its resemblance
to a musical note, differs slightly from the banner
transposition flap in that the flap’s secondary limb is
much shorter and :B is larger and approximately equal
to 50 or 60°.31 The note transposition flap is smaller and
has a wider vascular pedicle compared with the banner
transposition flap. The note transposition flap suffers the
same limitations as the banner transposition flap, namely
the suboptimal orientation of the primary tension vector
and small size of the flap, resulting in secondary flap
movement at the primary defect and a moderately sized
SCD. Moreover, the larger size of :B increases the
magnitude of the primary tension vector and further
increases secondary flap movement.
Bilobed and Trilobed Transposition Flaps
The same designs considerations for :A and :B also
apply to multilobed flaps, including bilobed and tri-
lobed transposition flaps. In multilobed flaps,
however, a different :A will exist for each lobe of the
flap (:A1, :A2, etc.), and :B refers only to the angle
between the 2 limbs of the terminal defect where the
primary tension vector will be located. A bilobed
transposition flap consists of a primary lobe posi-
tioned immediately adjacent to the primary defect,
16 DERMATOLOGIC SURGERY
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which is typically designed to be the same size as the
primary defect.39–44 :A1 and :A2 orient the primary
and secondary lobes, respectively. The design of :A2
is particularly important, as it will dictate the orien-
tation of the primary tension vector resulting from
closure of the terminal defect.45,46 Similar to single-
lobed transposition flaps, :B determines the size of
the terminal flap lobe, the magnitude of the primary
tension vector, and the degree of secondary flap
movement at the terminal defect.
The classic bilobed transposition flap, originally described
by Esser, is designed with primary and secondary lobes
each moving through 90° (:A1 = :A2 = 90°), for 180° of
total primary flap movement (Figure 9).47–49 :B is
designed between 30 and 45°, and the primary tension
vector is ideally oriented parallel to any free margins
associated with the primary defect. In this classic design,
primary flap movement through 180° results in a large
SCD developing at the primary defect.50–52 Moreover, the
primary lobe’s leading edge loses height due to pivotal
restraint as it moves through 90°, commonly leading to
secondary flap movement at the primary defect.7,50,51
To address these limitations, Zitelli53 modified the design
of the classic bilobed transposition flap and decreased
primary flap movement of the primary and secondary
lobes from 90° to 45° (:A1 = :A2 = 45°), for approx-
imately 90° of total primary flap movement. Zitelli’s
design results in a smaller SCD, which can be more
favorably oriented and is less likely to compromise the
vascular pedicle.50,51 Secondary flap movement may still

Figure 9. The design of multilobed transposition flaps using :A and :B, including the (A) classic bilobed design, (B) Zitelli
modification of the bilobed design, and (C) classic trilobed design.
develop at the primary defect, and this is particularly
pronounced if the primary lobe is undersized relative to
the primary defect.50,51,54 As such, various modifications
to Zitelli’s design have been proposed to address pivotal
restraint, including increasing the size of the primary lobe
relative to the primary defect.55,56
Closure of the tertiary defect also plays an important role
in dictating secondary flap movement.45,46,50,51 Second-
ary flap movement may occur at the primary defect if
some component of the primary tension vector is ori-
ented perpendicular to a free margin. Alternatively, sec-
ondary flap movement can occur on closure of the
tertiary defect if the magnitude of the primary tension
vector is too large, such as when the tertiary lobe’s size is
increased (increasing :B). Interestingly, Zimany49
originally advocated for the secondary lobe to be
undersized relative to the primary lobe, thereby reducing
the magnitude of the primary tension vector and limiting
secondary flap movement at the tertiary defect.
By extension, the trilobed transposition flap builds on
Zitelli’s bilobed modifications and uses 3 flap lobes, each
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SCOTT AND BORDEAUX
moving through 45° (:A1 = :A2 = :A3 = 45°), for
approximately 135° of total primary flap movement.57–
62
The trilobed design maintains the same biomechanical
advantages of Zitelli’s bilobed design, including mini-
mizing pivotal restraint and size of the SCD. The prin-
ciple advantage of the trilobed design is that the flap
possesses greater length, and is therefore capable of
reaching remote reservoirs of tissue laxity distal to the
primary defect.1,57 The trilobed design also allows for
easier orientation of the primary tension vector com-
pletely parallel to any at-risk free margins, and increases
the width of the vascular pedicle, which can compensate
for suboptimal orientation of the SCD. In general, a tri-
lobed transposition flap should be considered when the
primary tension vector cannot be oriented parallel to an
at-risk free margin, or when a bilobed design cannot
effectively recruit available tissue reservoirs.
Conclusion
In summary, the large number of transposition flap
geometries available for cutaneous reconstruction
makes the selection and design of these flaps often
46:1:JANUARY 2020 17
 TRANSPOSITION FLAPS SIMPLIFIED
difficult for less experienced dermatologic surgeons.
However, the design of transposition flaps can be
greatly simplified by using a conceptual approach
based on 2 elementary angles and how these angles
influence the geometry and biomechanics of trans-
position flaps. Moreover, this framework illustrates
the rationale for various modifications to the classic
designs of transposition flaps, including the Dufour-
mentel and Webster modifications of the rhombic
transposition flap, and the Zitelli modification of the
bilobed transposition flap.
Ultimately, successfully executing transposition
flaps and achieving optimal reconstructive out-
comes requires consideration of a number of factors
in addition to appropriately designing :A and :B,
including the site and size of the primary defect, the
location of tissue reservoirs and free margins, and
the elastic and sebaceous quality of the skin. How-
ever, the authors’ hope is that this conceptual
approach may serve as a reconstructive palette, to be
used by dermatologic surgeons to design a limitless
number of transposition flap geometries for repair
of different surgical defects arising in skin with
varying biomechanical properties and at-risk free
margins.
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Address correspondence and reprint requests to: Jeffrey F.
Scott, MD, Lakeside 3100, 11100 Euclid Avenue,
Cleveland OH, 44106, or e-mail:
jeffrey.scott@uhhospitals.org
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