Rotation Flap

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Rotation Flap

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Introduction

Rotation flaps are local flaps that use adjacent tissue rotated in an arc to close skin defects. They are composed of skin and associated subcutaneous tissue devoid of segmental vessels. They ultimately rely on arterial perforators that course superficially to supply blood via the dermal and subdermal plexuses. Rotation flaps should be designed to place closure lines parallel to the lines of least skin tension (see Appendix B) and take advantage of adjacent areas of skin laxity or redundancy. 
Rotation flaps provide the ability to recruit large areas of tissue with a wide vascular base for defect closure. This flap can be thought of as the closure of a triangular defect by rotating adjacent skin around a rotation point into the defect. The biggest advantage of these flaps over other flaps is that they have a particularly wide base and resulting excellent blood supply. Their primary disadvantage is that they require extensive cutting beyond the primary defect to develop the flap, increasing the length of the scar and the risk of nerve damage or bleeding. 
Rotation flaps are well suited to closing defects on the nose, glabella, upper nasal dorsum, or nasolabial sulci. Small to midsize cheek defects can also easily be repaired using simple rotation flaps. Two simultaneous rotation flaps can be created when extra tissue is required. The bilateral rotation flap can be made with two mirror image rotation flaps that meet at the defect. This flap is similar to the A-to-T-plasty and the O-to-Z-plasty. 

Equipment

  • Surgical 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 minimum skin removal, or where skin may be under tension from a variety of directions.

  • This flap work best for partial-thickness defects of the face, neck, and back.

Contraindications (Relative)

  • Areas with poor blood flow.

  • Uncooperative patient.

  • Wounds best closed by other methods.

  • Presence of cellulitis, bacteremia, or active infection.

  • Heavy smokers and insulin-dependent diabetics present an increased risk of complications.

The Procedure

Step 1

The rotation flap can be visualized as starting with an isosceles triangular defect to remove a lesion. The two sides of the triangle, which are equal in length, are longer than the third side, or defect base. This creates a narrow triangle with an acute angle opposite the defect’s base. The long side of the triangle opposite the rotation flap will become one of the borders of the flap after defect closure. 

Step 2

The base of the triangle is incorporated into a semicircular arc, which will be rotated to close the defect. Larger defects require more rotation from adjacent tissue. Generally, the length of the flap’s border should be three to four times the length of the base of the triangle defect. Make the incision for the arc so that the final closure line is as parallel as possible to the lines of least skin tension and/or on an anatomic border. 

Step 3

Perform a field block that extends well past the edges of the incisions and the entire flap. Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E: Skin Preparation Recommendations). 
  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 4

Excise the lesion with the triangle of tissue and cut the arcing incision. It may be tempting to excise the lesion in a circle of the recommended margin (see Appendix D) and then trim out the triangle, but by removing the lesion with the triangle, the provider minimizes the risk of a positive margin with the extra tissue in the points. 
  • PEARL: Surgical defects are typically round. A larger round defect may be closed without the creation of a triangle defect by undermining the flap and cutting the point of the flap off in a curve to match the edge of the defect.

Step 5

Undermine in the fat plane immediately beneath the dermis. This gives the flap an intact dermal plexus and avoids injury to the underlying muscles or nerves. Attention to hemostasis is important because the rotation flap is large relative to the size of the defect and development of a hematoma threatens the survival of the flap. 
  • PEARL: The flap pedicle should be placed inferiorly so that gravity aids in lymphatic and venous drainage.

Step 6

Now rotate the flap into place to assess the sufficiency of its size and the optimal flap placement. The leading outside edge of the flap is rotated into the triangular defect. The flap’s pivot point lies approximately midway between the apex of the defect and the end of the back cut. 
  • PEARL: A tacking suture (to be removed later) can be placed to assess flap motion and placement.

Step 7

Place a corner suture to attach the tip of the flap to the corner of the defect. See Corner Suture

Step 8

Use simple interrupted sutures to approximate the rest of the closure. See Simple Interrupted Suture
  • PEARL: If tension is present in the flap, consider placing buried sutures to reduce the tension.

Step 9

After rotation and suturing of tissue into the defect, a standing cone is often created at the distal end of the rotation flap. This deformity can often be managed with a Burow triangle repair (see Burow Triangle (Dog Ear) Repair). Apply antibacterial ointment and a pressure bandage. 
  • PEARL: Little mechanical benefit is gained in increasing flap length beyond a 90-degree arc. Increased undermining and increased arc radius gives small benefits on closing tension.

  • PITFALL: The Burow triangle should not be taken into the pedicle of the flap itself because this diminishes the blood supply; rather, it should be moved away from the flap.

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

  • Tissue sloughing (usually due to excess tension or the blood supply being disrupted by undermining)

  • Sensory changes (often subside with time)

  • Flap necrosis and sloughing

  • Distortion of neighboring landmarks

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or 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 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 suture removal (see Appendix J). 

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 plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes. 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

Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial skin defect reconstructions. Arch Otolaryngol Head Neck Surg .  1998;124(1):60–66. [View Abstract]
Cook TA, Israel JM, Wang TD, et al. Cervical rotation flaps for midface resurfacing. Arch Otolaryngol Head Neck Surg .  1991;117(1):77–82. [View Abstract]
Green RK, Angelats J. A full nasal skin rotation flap for closure of soft-tissue defects in the lower one-third of the nose. Plast Reconstr Surg.  1996;98(1):163–166. [View Abstract]
Jackson IT. Local flap reconstruction of defects after excision of nonmelanoma skin cancer. Clin Plast Surg.  1997;24(4):747–767. [View Abstract]
Larrabee WF Jr, Sutton D. The biomechanics of advancement and rotation flaps. Laryngoscope .  1981;91(5):726–734. [View Abstract]
Millman B, Klingensmith M. The island rotation flap: a better alternative for nasal tip repair. Plast Reconstr Surg .  1996;98(7):1293–1297. [View Abstract]
Murtagh J. The rotation flap. Aust Fam Physician .  2001;30(10):973. [View Abstract]
Myers B, Donovan W. The location of the blood supply in random flaps. Plast Reconstr Surg .  1976;58(3):314–316. [View Abstract]
Patterson HC, Anonsen C, Weymuller EA, et al. The cheek-neck rotation flap for closure of temporozygomatic-cheek wounds. Arch Otolaryngol .  1984;110(6):388–393. [View Abstract]
Schrudde J, Beinhoff U. Reconstruction of the face by means of the angle-rotation flap. Aesthetic Plast Surg .  1987;11(1):15–22. [View Abstract]
Spector JG. Surgical management of cutaneous carcinomas at the inner canthus. Laryngoscope .  1985;95(5):601–607. [View Abstract]
Whitaker DC. Random-pattern flaps. In: Wheeland RG. Cutaneous Surgery . Philadelphia: WB Saunders;  1994.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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