Advancement Flaps

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Local skin flaps provide a sophisticated approach to closing large skin defects produced by trauma or removal of skin lesions. The fusiform (elliptical) excision is the technique most commonly employed for simple lesion removal, but nearby structures (e.g., nose, ear, orifices) can preclude use of this technique by limiting the amount of undermining and loose skin that can be pulled to cover the defect. Nearby skin generally better approximates the needed color and texture to close a defect than skin brought in from a distant site (i.e., skin graft). Local skin flaps can provide excellent functional and cosmetic outcomes. 
Advancement flaps represent some of the simplest and most commonly used flap techniques. Advancement flaps move adjacent tissue to close a defect without rotation or lateral movement. The skin may be stretched unidirectionally (i.e., single advancement flap) or bidirectionally (i.e., bilateral advancement flap) to close the defect. Unidirectional pull on tissue can be useful when a certain type of skin is needed for closure. For instance, after removal of a tumor from the outer portion of the eyebrow, the defect should be replaced with hair-bearing skin of the medial eyebrow to prevent a shortened and cosmetically abnormal-appearing eyebrow. 
The blood supply for an advancement flap comes from the base of the flap. If a long advancement flap is needed to stretch skin for closure, the blood supply to the flap tip may be compromised. When closing a defect 1 inch in diameter on the face, the single advancement flap should be no longer than 3 inches. Single advancement flaps on less vascular areas of the body do better if limited to a length-to-width ratio of 2.5 to 1. One way to avoid long single advancement flaps is to pull skin from both directions; the bilateral advancement flap generally has less chance of flap tip necrosis. 
When removing skin cancer, it is best to ensure clear margins before performance of flap closure. Wide excision around a cancer may provide high rates of cure, but the excessive removal of tissue may limit the cosmetic outcome. Histologic confirmation by Mohs surgery or frozen sections is essential before closure when removing cancers at high risk for recurrence (e.g., morpheaform or sclerosing basal cell carcinomas). Lesions may also be left bandaged for several days pending confirmation of clear margins and closed later. 
Preventing complications is an important aspect of performing flap surgery. Strict sterile technique is necessary to avoid wound infections. Excessive stretching of skin should be avoided because necrosis will ensue. Wide undermining of the lateral tissue around a flap aids the closure. Do not pull on the skin edges with forceps because gentle handling prevents excessive scarring. Blood accumulations beneath flaps can interfere with oxygen delivery to the tissue, so excellent hemostasis is required. Bleeding vessels should be clamped or suture-ligated before the flap is sutured, and pressure bandaging is advocated following the procedure. 

Equipment

  • Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.

  • Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.

Indications

  • Closure of skin defects that require skin pull in line with the long axis of the lesion

  • Closure of eyebrow defects

  • Repair of defects of the temple area

  • Closure of forehead defects

  • Closure of cheek defects

  • Closure of upper arm defects

  • Closure of defects on the tip of the nose

  • Closure of defects on the trunk or abdomen

  • Closure of forehead skin defects

Relative Contraindications

  • Practitioner’s unfamiliarity or inexperience with techniques

  • Cellulitis in the tissues

  • Skin unable to be stretched to cover the defect

  • Chronic steroid use (and steroid skin effects)

The Procedure

Advancement Flaps

Step 1

Ideally, the long arms for single or bilateral advancement flaps should be placed to align the arms with the lines of least skin tension (see Appendix B, Lines of Lesser Skin Tension [Langer]). The flap placement must also take into account structures that will be distorted if the flap causes tension from this area (e.g., eyes and eyebrows) and structures that anchor the skin (e.g., ears and nose). 

Step 2

The advancement flap technique is performed after administration of anesthesia (e.g., field block; see Field Block Anesthesia). Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E, Skin Preparation Recommendations). The lesion is removed with a rim of normal- appearing skin. 
  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 3

The defect is squared. The flap arms are incised two to three times the original defect’s diameter. The flap and surrounding skin at the base of the flap are undermined with a horizontally held scalpel blade or iris scissors. 
  • PEARL: Some skin surgeons excise the original lesion in a square, which gives additional tissue in which to get clean margins. This is often easier if the long arms of the H-shape of the flaps are cut first and then the center cuts made connecting the two long arms. This greatly decreases the risk of positive margins.

Step 4

Attempt to slide the flap to cover the defect using skin hooks or fingertips. If the defect cannot be covered by the flap, the flap can be lengthened. Anchor the flap in place with one or two sutures. 
  • PITFALL: If there is tension on the flap, vertical mattress sutures can be placed instead of simple interrupted sutures to increase blood flow at the suture line (see Vertical Mattress Suture).

  • PITFALL: The skin often bunches up (i.e., dog ears) near the base of the flap. These dog ears are eliminated by excising triangular pieces of skin (i.e., Burrow triangles) (see Burrow’s Triangle (Dog Ear) Repair).

Step 5

After removal of any redundant tissue, the corners lie flat. Corner sutures (see Corner Suture) can be placed for the four corners, and interrupted suture is used to complete the flap. 

Advancement Flaps on the Brow

Step 1

This flap is also is useful in the brow region. After removal of a tumor in the lateral eyebrow, hair-bearing skin is used to close the defect with a single sided advancement flap. 

Step 2

A middle eyebrow or forehead defect can be closed using double advancement flaps. 

Step 3

A square defect is created around the tumor, and the flap arms incised to about 1.5 times the diameter of the defect. 

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. 

Postprocedure Instructions

Have the patient keep the bandage on and the wound dry for the first 24 hours. After that, it can be cleaned with hydrogen peroxide or gently washed it with soap and water as needed. An antibiotic ointment and bandage should be reapplied until the patient returns or for 2 weeks. Have the patient report signs of infection. Schedule a return appointment for sutures removal (see Appendix J, Recommended Suture Removal Times). 

Coding Information

These codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-Y-plasty, rotation flaps, advancement flaps, and double-pedicle flaps. When applied to traumatic wounds, the defect must be developed by the surgeon because the closure requires it, and these codes should not be used for direct closure of a defect that incidentally results in the configuration of one of the flaps or tissue rearrangements. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes (see Simple Interrupted Suture). The excision of benign lesions (CPT 11400–11446) and malignant lesions (CPT 11600–11646) may not be separately reported with codes 14000-14061. All of the following codes are for adjacent tissue transfer or rearrangement, and they refer to defects in the trunk or the following sites: scalp, arms, or legs (SAL); forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet (FCCMNAGHF); and eyelids, nose, ears, or lips (ENEL). 

Bibliography

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