These vessels ascend into the deep reticular and papillary dermis to supply deep and superficial microcirculatory plexus. Rich anastomoses of vessels within these plexus allow for blood flow into the most distant flap portion. Modification of Esser's design has led to improved cosmetic results. In modified designs, the lobes are not identical in size. Width of the larger flap is slightly smaller than the defect it has to fill, and width of the second flap is half that of the larger flap.
Lengths are identical.
The second flap often is designed with an elliptical tip to facilitate closure of its resulting defect. Wide undermining is used to reduce tension and pin-cushioning. Raise the flap just deep to the subdermal plexus, leaving a small amount of subdermal fat on the undersurface of the flap. Position flaps in areas of increased tissue laxity. Remove permanent cutaneous sutures 5-7 days following surgery.