Patient Presentation
This patient is a 55-year-old Caucasian male with a biopsy proven basal cell carcinoma (BCC) of the right shoulder area. Due to the ill-defined clinical borders of the tumor, as well as its large size, Mohs surgery was performed to ensure complete removal of the carcinoma.
After three stages of Mohs surgery, the margins were clear. The resulting defect measured over 4 cm in diameter.

The Surgical Answer
Turn to pages 24 and 25 for details and discussion about the surgical closure performed on this wound.

Surgery Discussion
Due to the large size of this defect, the options for repair were somewhat limited. We should always consider performing the simplest repair first, which would typically be a side-to-side closure. However in this situation, the large diameter (>4 cm), in an area of heavy movement and tension (the shoulder/neck), left limited options. It’s important to entertain the idea of using a flap to repair large defects in tension- bearing areas, even on the trunk, which is what was done in this case.

Using Multiple A to T flaps
The A to T flap is a type of bilateral advancement flap, in which a triangular shaped defect is closed by advancing flaps from opposite sides of the triangle. By creating three separate triangular defects around this very large circular defect, you can perform three separate A to T repairs, which can be joined at the center of the original defect (See Diagram 1 at left).
The advantage of this repair is that the vectors of force on the wound edges are distributed evenly in three separate directions, minimizing the tension on the wound margins that would ordinarily exist with a simple side-to-side closure for a defect of this size. The key sutures close the advancing edges of the two flaps of each A to T together. Then the three flaps are joined at the center of the original large circular defect. Some may interpret this as three separate “Burrow’s triangles” being removed from the periphery of the circular defect.

Minimizing Scarring and Easing Tension
The sutures or staples, which join the three flaps, bear the most tension(See Diagram 2 at right).
This creates an area where scarring may be a cosmetic issue. However, the area of unsightly scar tissue will be significantly smaller than what is seen with a side-to-side repair scar line, which in this case could be greater than 12 cm long. In order to avoid an unwanted scar at the central portion of this repair, suspension sutures may be placed, which tack the deep dermis to an underlying structure such as the deep fascia. This takes tension off of the tips of each A to T flap as well as the central joining point.
The disadvantage of this repair is that a significant amount of normal skin must be removed in order to create the three new triangular defects. Additionally, some may argue that instead of one scar line, three limbs to the scar are created. But again, a side-to-side repair could cause a 12-cm scar line.

In summary, consider multiple flap repairs when reconstructing large defects, which bear heavy tension or which are adjacent to vital structures. The use of bilateral advancement flaps and its variations, will often allow for a redistribution of tension on the wound, and a cosmetically pleasing outcome.