You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Advancement FlapsArticle Last Updated: Aug 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College Anthony P Sclafani is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons Coauthor(s): Matthew W Shawl, MD, Fellow, Buckhead Facial Plastic Surgery Editors: Paul S Nassif, MD, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Southern California at Los Angeles, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine; Vice President, University Otolaryngology-Head and Neck Surgery, Inc; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: advancement flaps, local skin flap, rotation flap, skin defects, monopedicled flap, bipedicled flap, V-Y flap, delay phenomenon, random flap INTRODUCTIONSection 2 of 11
  Skin defects created by trauma or excision of benign or malignant lesions may be repaired by numerous methods. Techniques include healing by secondary intention, full or partial-thickness skin grafts, or local skin flaps (ie, rotation, advancement flaps). More substantial defects, or those that also involve soft tissue, bone, and nerve, are usually repaired with axial pattern flaps, regional flaps, or revascularized free flaps. Many variables determine the type of repair chosen. Variables include defect size, functional deficit, anatomic location, donor site morbidity, likelihood of infection (particularly in human and animal bites), need for tumor surveillance, overall patient health, and surgeon experience and preference. Advancement flaps are used when the patient is in overall good health and the defect is free of tumor and obvious infection. Flaps should match thickness, color, and texture of excised skin. Resultant scars should fall in relaxed skin-tension lines. History of the ProcedureCelsus, of ancient Rome, is the first person credited with using advancement flaps to close skin defects. In the early 1800s, French surgeons described and advocated advancement flaps under the term "lambeau par glissement" (sliding flaps). Today, advancement flaps are widely used to close skin defects of the face, scalp, and neck. INDICATIONSSection 3 of 11
Advancement flaps are indicated when the skin defect lies next to an area of skin laxity, and prospects for a favorable resultant scar appear strong. Favorable scars respect anatomical subunits of the face and lie in relaxed skin-tension lines. Advancement flaps are typically used in forehead, scalp, eyelid, and upper lip areas. RELEVANT ANATOMYSection 4 of 11
Any viable flap must have an adequate blood supply. Blood flow of 1-2 mL/min/100 g of tissue is adequate. Circulation to the skin starts with large, named, segmental vessels branching from the aorta. Segmental vessels branch to give rise to perforating arteries that run through overlying muscles. Perforating arteries arrive at the skin either by direct cutaneous arteries (the basis for axial pattern flaps) or by anastomosis with the subdermal or dermal plexus. Advancement flaps are based on a random pattern blood supply, which comes from the anastomoses within the subdermal or dermal plexus. The perfusion pressure of feeding vessels and intravascular resistance determines the viable length of an advancement flap. These flaps in the head and neck region may achieve a length-to-width ratio of 4:1. The sympathetic nervous system, with control over arteriovenous (A-V) shunts in the subdermal plexus, regulates arterial resistance. Local skin flap failure may be due to preferential blood flow through A-V shunts. CONTRAINDICATIONSSection 5 of 11
Advancement flaps are contraindicated by poor patient health (eg, uncontrolled diabetes, extensive smoking history, bleeding disorder), concurrent wound infection, or the need for postoperative tumor surveillance. Other forms of reconstruction may be more favorable because of better cosmesis. TREATMENTSection 6 of 11
Intraoperative detailsMonopedicled, bipedicled, and V-Y flaps constitute the 3 types of advancement flaps. Undermine the donor site of an advancement flap at a level below the subdermal plexus. Preserve a minimal amount of adipose tissue on the flap undersurface to preserve the subdermal plexus. Advance the flap in a straight line to the defect. When creating monopedicled or bipedicled flaps, redundant tissue at the flap base usually remains, which may be excised using Burow triangles. On the face and scalp, a length-to-width ratio as great as 3-4:1 may be achieved. The flap is typically advanced a distance equivalent to the width of the flap (see Images 1-5). Monopedicled and bipedicled flaps are useful whenever defects lie near an area of skin laxity and incisions resulting from flap creation appear favorable. Exercise caution when pulling tissue from the donor site so that tension does not create a cosmetic deformity (eg, ectropion, distortion of the vermilion border). These flaps are typically used around the upper lip or forehead. A V-Y advancement flap is created by making a V-shaped incision and advancing the broad base of the V into the defect. The resulting defect is closed primarily in a Y-shape. (see Image 6). All advancement flaps should be under minimal tension. Further undermining may relieve excessive tension. Close incisions in multiple layers with interrupted stitches and absorbable sutures placed deep to the skin. Use nonabsorbable, nonreactive sutures for skin closure. Flaps may be revised later. If a long or tenuous flap is contemplated, surgeons may want to raise the flap in one procedure and wait 1-3 weeks before advancing the flap. This action takes advantage of the delay phenomenon, which increases flap survival. The exact mechanism of the delay phenomenon is unknown, but it may work by opening choked vessels within the flap, thus increasing flap perfusion. Postoperative detailsSutures are removed 1 week after surgery. Scar dermabrasion may be offered to patients generally no earlier than 6 weeks postoperatively. COMPLICATIONSSection 7 of 11
In general, properly planned and executed advancement flaps are very reliable. Failure is generally unpredictable. Vascular insufficiency is the main cause of flap failure and may result from undermining in the wrong plane, excessive tension on the flap, hematoma, infection, or compression of the pedicle. OUTCOME AND PROGNOSISSection 8 of 11
The advancement flap is a valuable tool for the surgeon repairing skin defects in the head and neck region. Proper patient selection and planning are essential. Advancement flaps are desirable because skin advanced from adjacent areas is usually a good match for color, thickness, and texture. Incisions can be hidden well in relaxed skin-tension lines or in borders of facial aesthetic units. FUTURE AND CONTROVERSIESSection 9 of 11
The advancement flap is one of many techniques available to close skin defects of the head and neck. Often, a given defect may be closed in more than one way, and talented surgeons may disagree. Current research topics include the role of vasodilating agents, antiplatelet drugs, and hyperbaric oxygen. These research areas will probably improve techniques or provide agents to increase flap survival. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: Aug 30, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||
