• The V–Y island flap is named because of the type of incisions made. First, an incision is made in the shape of a V near the wound. (Fig. 1a) The tissue is moved into place to fill the wound. (Fig. 2a) That V is then extended from the bottom so it looks more like a Y, or a kite tail. That kite tail is like a zipper that helps push the fat in place and closes everything up. (Fig. 3a)
• In Himmel’s case, he was under monitored anesthesia care (MAC), which keeps the patient in a deep sleep. Dr. Sidle marked Himmel’s smile lines before he was completely asleep in an effort to get as much of the scar line—the kite tail—to fall along the relaxed skin tension lines (RSTL). This was difficult to do with Himmel because he didn’t have many RSTL on the high cheek—often the case with younger patients lacking wrinkles. Because there were no RSTL to follow, Dr. Sidle took extra caution to be sure he did not displace the eyelid.
• A local anesthetic is administered, which includes lidocaine and epinephrine. The lidocaine numbs and the epinephrine causes the blood vessels to clamp down so there’s less cautery and less bruising. Once the anesthetic has taken effect, the procedure is executed following the lines drawn by the doctor. When the tissue is replaced, the wound is stitched up and the patient is sent to recovery. Swelling and tenderness do occur. (Fig 4a)
