Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.     

Prefabricated sensate myocutaneous and osteomyocutaneous free flaps: an experimental model. Preliminary report

Principles of neovascularization have been reported for the successful creation of a variety of muscle and bone free flaps. This study demonstrates a simple and effective technique for construction of prefabricated sensate myocutaneous and osteomyocutaneous free flaps in a rat model. These experiments were carried out in 20 Sprague-Dawley male rats. In half the animals, a sensate myocutaneous flap was constructed by sandwiching the superficial inferior epigastric vessels between a laterally based external abdominal oblique muscle flap and a laterally based skin flap served by an identified cutaneous nerve. A similar preparation included a piece of iliac crest bone. Two to three weeks later, now neovascularized by the sandwiched vessels, the flaps were harvested and transferred as free flaps with high reliability. An increased number of potential donor sites, the versatility of design, and the ability to customize flaps to the specific recipient-site needs are proffered.     

Osteocutaneous flap prefabrication based on the principle of vascular induction: an experimental and clinical study

Conventional osteomyocutaneous flaps do not always meet the requirements of a composite defect. A prefabricated composite flap may then be indicated to custom create the flap as dictated by the complex geometry of the defect. The usual method to prefabricate an osteocutaneous flap is to harvest a nonvascularized bone graft and place it into a vascular territory of a soft tissue, such as skin, muscle, or omentum, before its transfer. The basic problem with this method is that the bone graft repair is dependent on the vascular carrier; the bone needs to be revascularized and regenerate. The bone graft may not be adequately perfused at all, even long after the transfer of the prefabricated flap. This study was designed to prefabricate an osteocutaneous flap where simply the bone nourishes the soft tissues, in contrast to the conventional technique in which the soft tissue supplies a bone graft. This technique is based on the principle of vascular induction, where a pedicled bone flap acts as the vascular carrier to neovascularize a skin segment before its transfer. Using a total of 40 New Zealand White rabbits, two groups were constructed as the experimental and control groups. In the experimental group, a pedicled scapular bone flap was induced to neovascularize the dorsal trunk skin by anchoring the bone flap to the partially elevated skin flap with sutures in the first stage. After a period of 4 weeks, the prefabricated composite flaps (n = 25) were harvested as island flaps pedicled on the axillary vessels. In the control group, nonvascularized scapular bone graft was implanted under the dorsal trunk skin with sutures; after 4 weeks, island composite flaps (n = 15) were harvested pedicled on the cutaneous branch of the thoracodorsal vessels. In both groups, viability of the bony and cutaneous components was evaluated by means of direct observation, bone scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results demonstrated that by direct observation on day 7, the skin island of all of the flaps in the experimental group was totally viable, like the standard axial-pattern flap in the control group. Bone scintigraphy revealed a normal to increased pattern of radionuclide uptake in the experimental group, whereas the bone graft in the control group showed a decreased to normal pattern of radioactivity uptake. The biodistribution studies revealed that the mean radionuclide uptake (percent injected dose of 99mTc methylene diphosphonate/gram tissue) was greater for the experimental group (0.49+/-0.17) than for the control group (0.29+/-0.15). The difference was statistically significant (p<0.01). By microangiography, the cutaneous component of the prefabricated flap of the experimental group was observed to be diffusely neovascularized. Histology demonstrated that although the bone was highly vascular and cellular in the experimental group, examination of the bone grafts in the control group revealed necrotic marrow, empty lacunae, and necrotic cellular debris. Circulation to the bone in the experimental group was also demonstrated by India ink injection studies, which revealed staining within the blood vessels in the bone marrow. Based on this experimental study, a clinical technique was developed in which a pedicled split-inner cortex iliac crest bone flap is elevated and implanted under the medial groin skin in the first stage. After a neovascularization period of 4 weeks, prefabricated composite flap is harvested based on the deep circumflex iliac vessels and transferred to the defect. Using this clinical technique, two cases are presented in which the composite bone and soft-tissue defects were reconstructed with the prefabricated iliac osteomyocutaneous flap. This technique offers the following advantages over the traditional method of osteocutaneous flap prefabrication. Rich vascularity of the bony component of the flap is preserved following transfer (i.e. (ABSTRACT     

An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction.

This article presents an updated review of our experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in total auricular reconstructions. Our indications for use of the temporoparietal fascial flap are presented. Partial flap necrosis occurred in 5 cases, total necrosis in 2 of 14 microsurgically transplanted cases, cartilage infection in 2 cases, and paralysis of the frontal branch of facial nerve in 1 case. Prospective observations of vascular anatomy were carried out in the last 93 temporoparietal fascial flaps during flap elevations. Only 59 flaps (63.4 percent) showed a typical pattern, distributed mainly by the superficial temporal artery and vein. Others (36.6 percent) were distributed mainly by various combinations of the posterior auricular artery or vein, occipital artery or vein, diploic vein, and the superficial temporal artery or vein. At the upper margin of the imaginary reconstructed auricle, the mean diameters of the artery and vein were 1.7 mm and 2.2 mm, respectively. There were no significant differences of vascular patterns and their diameters between the temporoparietal fascial flap of microtia sides and of nonmicrotia sides (sides with acquired ear deformities or free-flap donor sides). We are presenting our technical evolution in using the temporoparietal fascial flap for total auricular reconstruction with the goal of reducing surgical complications and improving aesthetic results.     

The vascular anatomy of the galeal flap in the interparietal and midline regions.

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.     

Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.     

Maxillofacial reconstruction with prefabricated osseous free flaps: a 3-year experience with 24 patients

Between January of 1998 and May of 2002, 25 prefabricated osseous free flaps (23 fibula and two iliac crest flaps) were transferred in 24 patients to repair maxillary (six flaps) or mandibular (eight flaps) defects after tumor resection, severe maxillary (four flaps) or mandibular (one flap) atrophy (Cawood VI), maxillary (one flap) or mandibular (three flaps) defects after gunshot injury, and maxillary (two flaps) defects after traffic accidents. Prefabrication included insertion of dental implants, positioned with a drilling template in a preplanned position, and split-thickness grafting. Drilling template construction was based on the prosthetic planning. The template determined the position of the implants and the site and angulation of osteotomies, if necessary. The mean delay between prefabrication and flap transfer was 6 weeks (range, 4 to 8 weeks). While the flap was harvested, a bar construction with overdentures was mounted onto the implants. The overdentures were used as an occlusal key for exact three-dimensional positioning of the graft within the defect. The bar construction also helped to stabilize the horseshoe shape of the graft. The follow-up period ranged from 2 months to 4 years (mean, 21 months), during which time two total and three partial flap losses occurred. One total loss was due to thrombosis of the flap veins during the delay period, whereas the other total loss was caused by spasm of the peroneal artery. Two partial losses were due to oversegmentation of the flaps with necrosis of the distal fragment, whereas one partial loss was caused by disruption of the vessel from the distal part. Of the 90 implants that were inserted into the prefabricated flaps during the study period, 10 were lost in conjunction with flap failure; of the remaining 80 implants, four were lost during the observation period, for a success rate of 95 percent. Flap prefabrication based on prosthetic planning offers a powerful tool for various reconstructive problems in the maxillofacial area. Although it involves a two-stage procedure, the time for complete rehabilitation is shorter than with conventional procedures.     

Primary nonmicrosurgical reconstruction following ear avulsion using the temporoparietal fascial island flap

Primary ear reconstruction following avulsion using a temporoparietal fascial island flap based on the superficial temporal vessels is presented as a modification of an existing technique for the acute treatment of this difficult problem, offering a further alternative to established traditional nonmicrosurgical procedures.     

Easy tissue expansion of prelaminated mucosa-lined flaps for cheek reconstruction in a canine model

In head and neck reconstruction, there is sometimes the need for a skin flap lined with mucosa. The object of this study was to determine whether small pieces of mucosa grafted onto the undersurface of a skin flap can be expanded in a reasonable time to provide the material required to reconstruct a full-thickness cheek defect as a free flap. The study consisted of two phases: prelamination and expansion of the flap, and vascularized free-tissue transfer of the flap. Six adult mongrel dogs were used. First, a 5 x 10-cm flap based on the saphenous vessels was elevated on the lower leg, and then four 1 x 2-cm pieces of mucosa harvested from the tongue were grafted onto the undersurface of the flap. A tissue expander (5 x 10 cm) was then placed under the flap, and the incision was closed primarily. The expanders were initially filled with just enough normal saline to obliterate dead space immediately after surgery. The expansion was continued twice weekly for 3 weeks until sufficient expansion was obtained. Two of six flaps were followed for an additional 6 weeks after the 3-week expansion period to observe whether additional mucosa could be obtained. After measurement of the mucosal area, each flap was transferred as free flap to reconstruct an iatrogenic cheek defect. The increase of mucosal surface area was compared with the original graft, and differences were analyzed using the paired t test. All flaps were successfully expanded without any complications. Histologic evaluation revealed that grafted mucosa took well without evidence of graft necrosis, and the intergraft area was covered with histiocytes. Angiography revealed well-defined vascular structures covering the entire area of the flap. The new mucosal area (23.5 +/- 2.4 cm2) was significantly larger than the original mucosal graft (8.7 +/- 0.9 cm2) (p < 0.001). The net increase of the mucosal area was 172.9 +/- 32.4 percent. The increase of mucosal area in two flaps, following a 6-week consolidation period after 3 weeks of expansion, was only slightly greater (25.9 +/- 1.3 cm2) than those without the consolidation period (22.3 +/- 1.8 cm2). This increase of the mucosal area appears to be related to the amount of expansion, and not to the length of the consolidation period. The flaps were successfully transferred as free flaps to reconstruct the full-thickness cheek defects without major complications. Although a staged operation to allow flaps to mature is needed, the present procedure has the advantages of providing a mucosa-lined flap and allowing primary closure of the donor site. The authors conclude that expansion of this flap has great potential in reconstructive surgery.     

Versatility and reliability of combined flaps of the subscapular system

One-stage reconstructions of complex or unusually large defects frequently require composite tissue transfers. The various components of these "chimeric" flaps facilitate three-dimensional reconstructions or the coverage of large surface defects. Data from 36 combined flaps from the subscapular arterial system are demonstrated in this series. Defect locations were evenly distributed between the upper and lower extremities. Eighty-three percent were two-component flaps, and 17 percent contained three or more various tissue components. Overall flap survival was 97 percent. Major complications included vascular revisions in four patients and seven secondary skin transplantations. Five cases contained osseous components. The independent mobility of skin, muscle, and bone proved to be a major advantage in the reconstruction of compound defects. Donor-site morbidity was acceptable; the most frequent donor-site complication was persistent seroma in 9 of 36 patients (25 percent). Patient satisfaction was high. Ninety-one percent were satisfied with the operative result and would undergo the operation again. Eighty-six percent accepted the aesthetic appearance of the donor site. The data demonstrate that these complex flap procedures are extremely reliable and versatile, thus avoiding multiple reconstructive procedures and achieving excellent reconstructive results with acceptable donor-site morbidity.     

The versatility of pericranial flaps

The pericranium is the source of multiple, dependable, well-vascularized flaps which are of use to the plastic and reconstructive surgeon for multiple defects of the face and skull. Based anteriorly, the flap can cover the entire central third of the face or be transposed intracranially to correct abnormalities of the cribriform plate and dura. Based laterally on the temporalis muscle, the flap can be turned to multiple arcs for reconstruction of the face, ear, and intracranial defects. Donor-site morbidity and complications have been minimal.     

Flap prefabrication in the head and neck: a 10-year experience

Tissue neovascularized by implanting a vascular pedicle can be transferred as a "prefabricated flap" based on the blood flow through the implanted pedicle. This technique potentially allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. During the past 10 years, 17 flaps were prefabricated and 15 flaps were transferred successfully in 12 patients. Tissue expanders were used as an aid in 11 flaps. Seven flaps were prefabricated at a distant site and later transferred using microsurgical techniques. Ten flaps were prefabricated near the recipient site by either transposition of a local vascular pedicle or the microvascular transfer of a distant vascular pedicle. The prefabricated flaps were subsequently transferred as island pedicle flaps. These local vascular pedicles can be re-used to transfer additional neovascularized tissues. Common pedicles used for neovascularization included the descending branch of the lateral femoral circumflex, superficial temporal, radial, and thoracodorsal pedicles. Most flaps developed transient venous congestion that resolved in 36 to 48 hours. Venous congestion could be reduced by incorporating a native superficial vein into the design of the flap or by extending the prefabrication time from 6 weeks to several months. Placing a Gore-Tex sleeve around the proximal pedicle allowed for much easier pedicle dissection at the time of transfer. Prefabricated flaps allow the transfer of moderate-sized units of thin tissue to recipient sites throughout the body. They have been particularly useful in patients recovering from extensive burn injury on whom thin donor sites are limited.     

Oromandibular reconstruction with the radial-forearm osteocutaneous flap: experience with 60 consecutive cases

One of the more difficult problems in reconstructive surgery of the head and neck is replacement of bone and soft tissue lost because of injury, osteomyelitis, or malignancy. The radial-forearm osteocutaneous flap is an accepted choice for oromandibular reconstruction. This study was undertaken to review one center's experience with 60 consecutive cases of oromandibular reconstruction with the radial-forearm osteocutaneous flap. Records of the 38 men and 22 women (mean age, 60 years; range, 26 to 86 years) were reviewed for tumor location, defect and bone length, flap failure rate, recipient- and donor-site complications, length of surgery, and hospital stay. Cancer resection was the reason for 97 percent of reconstructions; 33 percent of flaps were used to reconstruct a lateral defect of the mandible, 40 percent a lateral-central defect, and 27 percent a lateral-central-lateral defect. Mean skin flap size was 55 cm2 (range, 15 to 117 cm2) and mean bone length, 9.4 cm (range, 5 to 14 cm). The microvascular success rate was 98.3 percent. Complications included fracture of the donor radius (15 percent), nonunion of the mandible (5 percent), and hematoma (8.3 percent). These results are comparable to results reported in the literature with other radial forearm flaps. The free radial osteocutaneous flap is a safe and reliable choice for mandibular reconstruction. It offers sufficient bone to reconstruct large defects and can provide adequate pedicle length for vessel anastomosis to the contralateral side of the neck. The above attributes make the radial forearm osteocutaneous flap one of the "first line" flap choices for oromandibular reconstruction.     

The free latissimus dorsi flap revisited: a primary option for coverage of wide recurrent lumbosacral defects

In comparison with other regions of the trunk, defects located in the lumbosacral region are infrequent. However, these particular lesions sometimes present difficulties in reconstruction, arising from the quality of the surrounding tissue and the width of the defects. In this area, the skin adheres strongly to subcutaneous tissue and is difficult to mobilize. Attempts to perform local or regional flaps for covering defects of this area often end in necrosis of the flaps, with subsequent risk of infection and unstable wounds. The consequence is larger defects and the need for a wide, tension-free coverage, which can be performed after a wide debridement. The authors report on 10 patients presenting with wide, recurrent (and in some cases, infected) defects of the lumbosacral region, after already having undergone several reconstructive local or regional operations. In all cases, the authors harvested a free latissimus dorsi flap, lengthening the pedicle by means of an arteriovenous suralis loop connected to the thoracodorsal vessels (lumbar defect) or the femoral vessels (sacral defect). The procedure, already described in the past by others, has been revisited by the authors' group and used as the technique of choice in selected cases, that is, in the presence of wide, recurrent, and infected lesions; radiation; and scarring injuries. The authors thus obtained stable coverage with well-vascularized tissue and were able to save the patients any further operations. The authors suggest, therefore, that this procedure can be used in cases of wide and recurrent defects where other conventional procedures have failed. Advantages, disadvantages, and technical features of the method used are discussed in this article.     

Prefabricated superficial temporal fascia flap combined with a submental flap in noma surgery

The authors report their experience with a new procedure: the combination of a prefabricated superficial temporal fascia flap and a submental flap performed in an African hospital on five patients with cheek deformities caused by noma. The prefabricated superficial temporal fascia flap makes the inner lining of the cheek, which is anchored on the peripheral scar tissue. The submental flap is released during the second operation and makes the outer lining. The main advantages are the excellent aesthetic color of this last flap and the short distance between the donor site and the recipient site. Moreover, the submental flap is positioned in a single operation (when the outer-lining reconstruction is performed with a deltopectoralis flap, a third operation is necessary to cut the pedicle). None of the flaps failed, and the functional results were good. The prefabricated superficial temporal fascia flap and submental flap are versatile and reliable flaps, with reasonably long vascular pedicles, that can be used successfully, even under suboptimal conditions in weak patients with huge defects of the face.     

Clinical applications of the subgaleal fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.     

The thigh flap: an osteomyocutaneous free-flap model in the rat

A new experimental model for free-flap transfer has been developed in the rat. This "thigh flap" is an osteomyocutaneous free flap of bone (femur), muscle (thigh), and skin (groin) based on the femoral vessels. The flap is harvested from the left groin and thigh of an inbred female rat and is transferred to a subcutaneous pocket in the left groin of a male rat of the same inbred strain. The femoral vessels supplying the flap are anastomosed end-to-end with the femoral vessels of the recipient. Thirty flaps have been transferred, with 5 technical failures. Three of the remaining 25 flaps developed necrosis within 24 hours. The other 22 flaps remained viable until the rat was sacrificed at 7 days. The survival rate of the thigh flap was thus 88 percent. The model is suitable for use in metabolic, vascular, and immunologic studies of composite free flaps.     

Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.     

The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.