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Case Report/Case Series
Sept/Oct 2014

Modification of Burow’s Advancement FlapAvoiding the Secondary Triangle

Author Affiliations
  • 1Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • 2Section of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
JAMA Facial Plast Surg. 2014;16(5):364-366. doi:10.1001/jamafacial.2014.427
Abstract

Importance  Burow’s advancement flap is a frequently used and versatile flap in cutaneous surgery because it provides an excellent method for repair of large defects in proximity to free margins. Its execution typically requires excision of 2 standing cones, which increases scarring and flap size. We describe a modification of this flap achieved with a simple, reproducible suturing technique that eliminates one of the standing cones and both minimizes suture lines and optimizes cosmesis at a variety of surgical sites.

Observations  We describe 5 cases in which we successfully used our modified Burow’s advancement flap to repair Mohs surgical defects in various cosmetic subunits of the face.

Conclusions and Relevance  A simple suturing technique is proposed that can eliminate the need for a secondary triangle in Burow’s advancement flaps. By implementing the “rule of halves” in suturing wound edges of unequal length, one can evenly distribute redundant tissue along the length of the flap, which avoids additional incisions, minimizes scarring, and allows for repair within a single cosmetic subunit.

Level of Evidence  NA.

Introduction

Burow’s advancement flap is a frequently used and versatile reconstruction technique in cutaneous surgery1 because it provides an excellent method for repair of large defects in proximity to free margins, including the eyebrows, vermilion border of the lip, alar groove, preauricular cheek, and temple. In the execution of the classic Burow’s flap, the defect is first converted into a triangle, and an incision at the base of the triangle is extended to an adequate length, allowing mobilization of the flap to cover the surgical defect. The resulting tissue redundancy along the extended incision often forms a standing cone owing to wound edges of unequal lengths, and this cone is normally eliminated by harvesting an inverted secondary triangle, with the goal of final closure lines that lie flat (Figure 1). Unfortunately, this method requires unaffected skin to be sacrificed and additional incisions to be made. Furthermore, the defect from this secondary triangle cannot always be placed in natural skin creases or within a single cosmetic subunit. For these reasons, several modifications of Burow’s advancement flap have been proposed, with the common aim to counteract tissue redundancy and eliminate the need for a secondary triangle. Here, we review these methods and describe our simple, reproducible suturing technique that minimizes suture lines and optimizes cosmesis at a variety of surgical sites.

Figure 1.
Conventional Burow’s Advancement Flap
Conventional Burow’s Advancement Flap

A, Conversion of the Mohs defect into a primary triangle (solid line) and harvesting of a secondary triangle (dashed line). B, Final closure lines are hidden within the preexisting creases of the vermilion border and marionette lines. The arrowhead represents the direction of flap advancement.

The first modification, described by Moody and Sengelmann,2 avoids the secondary triangle by removing additional tissue via a curvilinear incision along one of the limbs of the flap. In this way, the shorter edge of the flap is effectively lengthened to create wound edges of similar lengths, thus avoiding the second standing cone. Although this modification produces excellent results, it may result in the distortion of free margins, such as the eyebrow or vermilion border of the lip.

A second modification, proposed by Kouba and Miller,3 uses a complicated suturing technique to distribute the redundant tissue equally along the length of the incision, thereby avoiding the need for a second Burow’s triangle. This “running pleated” technique involves creating many small Burow’s triangles along the length of the incision. However, sutures must be placed unequally in 2 dimensions along the incision, more widely set and more superficial on the side of the excess tissue but more narrowly set and deeper on the opposite side. The amount of incision to be pleated with each suture does not follow any mathematical rule and is entirely reliant on the discretion of the cutaneous surgeon, who must take into account factors that vary with each patient, anatomical site, and closure. Although the technique is elegant, the dynamic approach it requires is technically challenging.

Surgical Technique

We describe an alternative, simple modification to the conventional Burow’s flap that uses a well-known and reproducible suturing technique to avoid the need for a secondary triangle. By using simple interrupted sutures and the “rule of halves,” one can effectively eliminate the redundant tissue and thus avoid or significantly reduce standing cone formation. With this technique, a single deep interrupted suture is first used to bring together the short and long wound edges at their respective halfway points, dividing the excess tissue evenly between the halves. Subsequent deep interrupted sutures are then placed in the middle of each remaining half and the process is continued so that the excess tissue is evenly distributed along the length of the flap, without apparent inequality between wound edges (Figure 2). The placement of each suture is determined by this simple pattern and does not vary with the degree of redundancy, inherent tissue characteristics, or anatomical site.

Figure 2.
Schematic Demonstrating the “Rule of Halves” Suturing Technique
Schematic Demonstrating the “Rule of Halves” Suturing Technique

A, Modified Burow’s advancement flap without the secondary triangle (row I). Wound edges of unequal length, short (dashed line) and long (solid line) (row II), are equally divided by a single deep interrupted suture (row III). Subsequent sutures bisect each remaining half (row IV). The process is continued so that excess tissue is evenly distributed between halving sutures. B, Anatomical depiction. Arrowheads represent the direction of flap advancement.

Figure 3 illustrates the use of our modified Burow’s advancement flap in the repair of several Mohs defects in a variety of anatomical locations. Columns A, B, and C show the initial defect, reconstruction, and 3-month follow-up, respectively. In each reconstruction the need for a secondary triangle is eliminated by the rule of halves suturing technique, which evenly distributes excess tissue along the length of the flap. This modification minimizes additional incisions and scarring that may extend across more than one cosmetic subunit.

Figure 3.
Modified Burow’s Advancement Flap in the Repair of Mohs Defects
Modified Burow’s Advancement Flap in the Repair of Mohs Defects

Columns A, B, and C show the initial Mohs defect, reconstruction, and 3-month follow-up, respectively. The rows show the use of our modified flap in several anatomical locations: the temple (row I), lateral brow (row II), cutaneous upper lip (row III), preauricular cheek (row IV), and nasal bridge (row V). Use of the “rule of halves” suturing technique evenly distributes excess tissue along the length of the flap. Elimination of the secondary triangle reduces suture lines and maintains repairs within a single cosmetic subunit.

Discussion

Similar to other Burow’s advancement flap modifications, our technique minimizes scarring by eliminating the need for a secondary triangle, allowing the repair to be accomplished within a single cosmetic unit. However, our technique offers several advantages over those previously proposed. Our suturing method is technically more straightforward and easier to execute. By following a simple mathematical rule, it enables reproducible and cosmetically appealing results. Unlike the modification by Moody and Sengelmann,2 which requires an additional curvilinear incision, our technique maintains the original incision lines, keeping the force vector of the flap parallel to its advancement and avoiding the potential for elevation or depression of a nearby free margin. Moreover, it is simpler to execute than the running pleated technique by Kouba and Miller.3 We have used our technique to create advancement flaps in a variety of anatomical locations, with exceptional cosmetic outcomes.

Conclusions

In summary, we propose a simple suturing technique that can eliminate the need for a secondary triangle in Burow’s advancement flaps. By implementing the rule of halves in suturing wound edges of unequal length, one can evenly distribute redundant tissue along the length of the flap. This avoids additional incisions, minimizes scarring, and allows for repair within a single cosmetic subunit. Given its versatility and practicality, this technique should be recognized as a straightforward and highly effective alternative to the conventional Burow’s advancement flap.

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Article Information

Accepted for Publication: April 18, 2014.

Corresponding Author: Faramarz H. Samie, MD, PhD, Section of Dermatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766 (faramarz.h.samie@hitchcock.org).

Published Online: July 31, 2014. doi:10.1001/jamafacial.2014.427.

Author Contributions: Drs Quatrano and Samie had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Quatrano, Samie.

Acquisition, analysis, or interpretation of data: Samie.

Drafting of the manuscript: Quatrano, Samie.

Critical revision of the manuscript for important intellectual content: Quatrano, Samie.

Study supervision: Samie.

Conflict of Interest Disclosures: None reported.

References
1.
Tromovitch  TA, Stegman  SJ, Glogau  RG. Flaps and Grafts in Dermatologic Surgery. Chicago, IL: Year Book Medical Publishers; 1989.
2.
Moody  BR, Sengelmann  RD.  Standing cone avoidance via advancement flap modification. Dermatol Surg. 2002;28(7):632-635.
PubMed
3.
Kouba  DJ, Miller  SJ.  “Running pleated” suture technique opposes wound edges of unequal lengths. Dermatol Surg. 2006;32(3):411-414.
PubMed
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