My Favorite Flap That Minimizes Scarring

As a surgical dermatology NP performing more than 11,000+ cutaneous surgeries at a Mohs practice, the one flap that has been my favorite is called - the O-T Advancement Flap. 

 

Design

The O-T wound repair is named because it involves two flaps that are advanced in opposite directions towards each other to repair an O-shaped defected creating a T-shaped configuration.  The horizontal incisions can usually be positioned in natural creases, resting skin tension lines (RSTLs), or at junctions of aesthetic regions. Ultimately, producing great aesthetic results that hides scars well! 

This flap can be universally used at various anatomic locations, and the most common areas I have utilized this repair on our Mohs patients are - the mid chest, chin, forehead, superior eyebrow, cutaneous lip, and cheek. 

Check out the following case studies where I was able to apply this flap so you, too, can start implementing it in your practice.  Also, continue reading to learn the steps. 

 

 

  Step-By-Step on How to Perform the O-T Flap (Cheek)

Looking at the above picture:

A. Left cheek Mohs defect

B. Bilateral horizontal incisions are made within the left orbital crease, creating the horizontal limbs of the O-T Flap. The border of the defect opposite of the horizontal incisions is excised towards the central cheek in a fusiform manner to remove a triangle of tissue (dog ear). This excision converts the round defect into a triangular defect (Note: Hiding the horizontal incisions in the orbital crease helps hide the scar once it heals. Also, removing the inferior dog ear in cheek RSTLs also helps hide the scar with time.  So, know where your RSTLs are).

C. Wide undermining of adjacent skin is performed to lessen wound closure tension (Note: Undermining is important to help minimize tension to the superficial wound and the incised wound edges. Less tension equates to less scarring).

D. The flaps are then elevated and advanced into the primary defect, being held by subcuticular and epidermal sutures (Note: Meticulous and correct placement of your subcuticular sutures is paramount.  Make sure when you place your deep sutures to position suture away from your incised wound edges and be mindful to not leaving excess suture to prevent suture reaction).

 

4 Months Postoperative Results With Minimal Scarring

 

 Suture Technique

In the above picture, you can see how the wound was closed after sutures placed.  The vertical limb was closed subcutaneously with 5-0 Vicryl using the SetBack Dermal suture technique. This technique allows maximum wound edge eversion, ultimately minimizing scarring with time.  Because this was a minimally tensioned wound and incised wound edges were well approximated once deep sutures placed, no epidermal sutures were placed. Instead, Glu-Stich was applied on the skin along the length of incision line, followed by steri-strips (pic not shown). 

For the horizontal limb at the orbital rim crease, the wound was closed subcutaneously with 5-0 Vicryl using the Simple Buried suture technique. This technique creates inversion, ultimately recreating the crease of the orbital rim.  For epidermal sutures, 6-0 Prolene was used followed by the Running Suture technique.

Four months later, patient healed with optimal results and, most importantly, the patient was happy! 

 

 Advance Your Skills

As dermatology NPs/PAs, I hope this article helped you better understand surgical pearls to be mindful of when performing surgery.  Also, techniques to use to achieve the best aesthetic results for your patient.

If you found this article helpful and want to dive deeper into building your confidence in your surgical skills, I created an advanced suturing course tailored specifically for dermatology NPs/PAs that will break down how to perform these suture techniques, step-by-step.  

The course will help you minimize scarring and improve your patients’ outcomes. If this sounds like a course that will help leverage your skills, click HERE to learn more!

Until next time...

Serving with GRATITUDE,

 

Theresa Talens DNP, FNP-C

P.U.L.S.E. Dermatology & Procedures, Inc.

Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.

Online suturing course re-opening up for 3 days only for a New Years Special on Jan. 1-3 ~$100 OFF!

 

This online, self-paced course is for dermatology NPs/PAs that perform or plan to perform excisions.  The course will help you master your technique, minimize scarring, and optimize your patient's outcomes. Enrollment is opened only for 3 days so don't wait (8 CMEs). Once you enroll, you get immediate access and can start learning at your own pace. Life-time access! Opens Jan 1-3.

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P.U.L.S.E. © will have a FULL DAY in-person suturing workshop coming soon on October 17, 2025 (7.5 CMEs)! 

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A workshop finally created and designed for dermatology NPs and PAs who perform or aspire to perform excisions and want to master their skills further.

There are only 10-20 seats available so join the waitlist for the workshop to guarantee your spot! 

Join Waitlist for In-Person Workshop Shop October 17, 2025

Only 10-20 seats available!

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