The advancement flap known as the puzzle (jigsaw) flap was first designed and published by Goldberg et al. in 2005 for small defects of the nasal ala adjacent to the nasogenian fold, as an alternative to full-thickness skin grafts, classic subcutaneous island pedicle flaps, transposition flaps, and second-intention healing.1 The flap – resembling a “head-and-shoulders” advancement from the cheek – mimicked a jigsaw-puzzle piece. Although it crosses 2 cosmetic units, with potential effacement of sulci, the aesthetic outcome shown in the original report was more than acceptable due to similar skin texture between the regions and concealment of scars within the melolabial and melonasal sulci; however, trapdoor deformity was reported as a complication in 2 of the 5 patients.

Since then, use of this flap has extended not only to nasal subunits other than the ala but also to sites beyond the nasal pyramid. Evidence includes the 10 cases compiled by Padilla et al., who used this repair – sometimes adding advancement and rotation – in 2 patients with defects of the melolabial fold without apparent complications,2 and 5 cases documented by Dong et al. applying the flap to the auricular tragus, antitragus, and helix with good cosmetic and functional results.3

To characterize applications of this flap in Spain, we conducted a study analyzing a series of puzzle flaps performed by dermatologists nationwide.

We conducted a retrospective, multicenter observational study of surgical defects reconstructed with a puzzle flap. Cases were collected from March through April 2024 and included procedures performed from May 2005 through January 2024 by dermatologists from the Spanish Academy of Dermatology and Venereology (AEDV), following a call via the CLINI-AEDV platform, a multicenter case-collection tool developed by the AEDV Research Unit. CLINI-AEDV was approved by Hospital Universitario Puerta de Hierro Research Ethics Committee on Medicinal Products (Majadahonda, Madrid, Spain) (10/17/2022; minutes No. 18/2022). Informed consent was obtained for cases with iconography.

Variables recorded were patient age, sex, tumor histology, greatest defect diameter, anatomic location, immediate complications (≤1 month after surgery), late complications (>1 month), and weeks from surgery to last medical assessment.

Findings are shown in Table 1. A total of 17 practicing dermatologists in Spain contributed all of their cases.

In total, 35 patients were included (13 men, 22 women). Mean age was 77 years (SD, 11.2; range, 49–96).

Histology showed basal cell carcinoma in 33 cases (94%); there was 1 squamous cell carcinoma and 1 acantholytic actinic keratosis.

Regarding tumor location (Fig. 1), the nose predominated: 14 tip (40%), 7 ala (20%), and 2 sidewall (6%). In addition, 3 cases involved the nasogenian (nasolabial) fold (8%) (Fig. 2) and 2 the retroauricular area (6%); 1 case occurred in the malar region and 1 in the temple (3% each). Five cases (14%) were found at extrafacial sites.

Figure 1.

Left to right, schematic of the puzzle flap and locations of the 30 facial puzzle flaps in our series; the remaining 5 were extrafacial.

Figure 2.

Design (A), execution (B), immediate postoperative (C), and 6-week (D) views of a puzzle flap in the left nasogenian fold.

Source: courtesy of Dr. Enrique Rodríguez Lomba.

Greatest defect diameter ranged 6–22mm (mean, 14mm). Immediate complications were absent in 30/35 cases (88%); when present, the most common one was trapdoor deformity (3 cases; 8% overall), with 1 dehiscence and 1 partial necrosis (3% each). Late complications were absent in 33 cases (94%); 1 case each of bulging and paresthesias was recorded (3% each). No patient developed tumor recurrence; median follow-up was 8 weeks.

This series compiles 35 puzzle flap cases.

Mean patient age was in the 70s, and nearly two-thirds were women – likely a chance finding, as the most represented tumor, basal cell carcinoma, is generally more common in men.4

Although originally designed for alar defects, our study shows the flap was most often used elsewhere. In 2/5 of cases the lesion was on the nasal tip, and success at this site likely reflects skin mobilization from the dorsum, which helps avoid undesirable tip elevation. While 23/35 cases were nasal, one-third were non-nasal, including sites not previously reported – such as the central malar region (Fig. 3) and the temple – with good cosmetic results.

Figure 3.

Design (A), execution/immediate postoperative (B), and 2-week (C) views of a puzzle flap in the right malar region.

Source: courtesy of Dr. Jorge Romaní de Gabriel.

No complication occurred in roughly 9 of 10 cases. The principal complication in the original report – trapdoor deformity – was seen in only 3 of 35 patients. Given the study retrospective design, we could not verify whether a deep anchoring suture at the flap margins – thought to reduce this outcome – was used. Potential cosmetic impact from sulcal effacement was not recorded.

In conclusion, this retrospective study describes the largest puzzle flap case series to date, underscoring its usefulness on the nasal tip and adjacent areas and illustrating its application and validity at other facial sites, supporting its consideration within the dermatologist's current surgical armamentarium.

None declared.

None declared.