Rotation Flaps Procedures 

Rotation flaps provide the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. The name rotation flap refers to the vector of motion of the flap, which is curved or rotational, and the procedure involving these flaps can be thought of as the closure of a triangular defect by rotating adjacent skin around a rotation point (or fulcrum) into the defect (see image below).

Rotation flaps are particularly useful when the proposed donor site of the flap is the lateral aspect of the face. These flaps are advantageous because they have a particularly wide base and thus an excellent blood supply. Their disadvantage is that they require relatively extensive cutting beyond the defect to develop the flap, thus increasing the risk of nerve damage or bleeding.^{[1, 2]}

• After excisional surgery, 4 basic options for wound management are possible: (1) the wound can be left open to heal by second intention, (2) the wound can be closed side to side and heal by primary intention, (3) a skin graft can be placed, or (4) a local or distant flap can be used.
• When a flap is chosen, the cutaneous surgeon most often uses an adjacent local flap in a single-stage procedure. Flaps used in such procedures are typically random pattern flaps, that is, the flap is not based on a named arterial blood supply, but rather, the orientation of the flap is dictated by the wound and the availability of adjacent tissue to serve as a donor site. Thus, the blood supply is essentially random. Flaps allow the cutaneous surgeon to mobilize excess tissue at some distance from the wound and to redirect tension away from the wound and to a more advantageous location.

• Tissue can move into an adjacent defect in 2 directions. It can advance in a straight line (ie, advancement flap), or the tissue can rotate into the defect (ie, rotation flap). The distinction between the two is not always clear, and one type of motion blends into the other (see image below). Furthermore, a single flap can have both straight (advancement) movement and rotational (rotation) movement. Movement of the flap into adjacent tissue.
• The procedure involving the classic rotation flap can be thought of as closure of a triangular defect. The defect can be visualized as a portion of a much larger circle. By cutting along the arc of the circle, tissue is freed to rotate into the defect. In the image below, point A moves to point B with rotational motion. The closure of point C has a component of advancement motion, but little if any pucker develops. Classic rotation flap.
• In clinical practice, surgical defects are typically round or oval; therefore, some adjustments in the basic outline are necessary. Imagining that the circular defect lies inside a larger triangle is useful, but the creation of a triangular defect is not necessary. This procedure would only enlarge the wound unnecessarily.
• In developing a rotation flap, begin the incision at the top of the circular defect, because this point touches the outside of the imaginary triangle (see image below). The length of the circular cut depends on the laxity of the donor site, but, in general, the flap itself has 3-4 times the area of the defect. The flap can always be enlarged if sufficient motion is not possible without significant loss of blood supply; this ability is an advantage of this repair. Developing a rotation flap. A circular defect can be imagined as lying within a triangular defect, without the actual creation of a triangular defect. Point A of the triangle will be sutured to point B. Thus, the leading edge of the flap (shaded area) is started above the midpoint of the circular defect, then rotated beyond the defect, and ultimately sacrificed.
• After the circular incision is made, the flap is undermined within the fat. Extensive undermining can be performed while still maintaining the broad attachment and thus good blood supply of the flap. Attention to hemostasis is important at this point because the rotation flap is large relative to the size of the defect and the rather extensive cutting performed.
• The surgeon can now rotate the flap into place to assess the optimal placement and the sufficiency of its size. The leading outside edge of the flap is rotated beyond the circular defect to fill the upper corner of the imaginary triangle, as shown in the image below. A tacking suture to be removed later can be placed to assess flap motion and placement. The use of a tacking suture is usually a good idea because this first stitch sets everything that is to follow and allows the surgeon to better visualize flap placement without unduly traumatizing the most vulnerable part of any flap, that is, the advancing edge. Developing a rotation flap. A circular defect can be imagined as lying within a triangular defect, without the actual creation of a triangular defect. Point A of the triangle will be sutured to point B. Thus, the leading edge of the flap (shaded area) is started above the midpoint of the circular defect, then rotated beyond the defect, and ultimately sacrificed.
• Once the optimal location of the flap is decided, the flap itself is sutured in place. Generally, some tension is present; therefore, the placement of buried sutures, followed by use of interrupted cuticular sutures, is recommended. The leading tip of the flap that advanced beyond the circular defect is excised last because this step is irreversible.
• Two areas that require revision are created: (1) a dog ear, that is, the lower portion of the circular defect, is created at point C as shown in the image below, and (2) an inequity in length is created along the circular incision of the flap itself. Excising the dog ear after the flap is in place is best because this approach allows better assessment of its size. The dog ear can be excised and sutured as one would do in a side-to-side closure. Developing a rotation flap. A circular defect can be imagined as lying within a triangular defect, without the actual creation of a triangular defect. Point A of the triangle will be sutured to point B. Thus, the leading edge of the flap (shaded area) is started above the midpoint of the circular defect, then rotated beyond the defect, and ultimately sacrificed.
• A secondary defect is also created in the flap donor area. All flaps involve some compromise; therefore, a secondary defect is created at the donor site of the flap. In the case of a rotation flap, the releasing circular incision now has 2 sides of unequal length: the inner side represents the flap itself, and it is now shorter than the outside edge, which did not move. In most cases, this inequity can be simply sewn out by following the rule of halves. The procedure begins by sewing the 2 sides together in the middle of the defect. Sewing is then continued in the middle of the remaining open areas to equally distribute the inequity along the length of the wound.
• If this sewing procedure is not possible, a Burow triangle can be removed anywhere along the length of the longer side, generally away from the defect in an area where it can be hidden. 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.
• If the surgeon finds that the flap does not cover the defect, 2 strategies can be pursued. First, the surgeon can simply lengthen the arc of the flap, undermine more, and increase the size of the flap. If this approach is not possible, a back cut into the pedicle of the flap can be made (see image below). This cut frees the flap to rotate and advance more but at a cost. The pedicle supplies the flap with blood, and when the pedicle is cut, the blood supply decreases, and the likelihood of flap necrosis increases. The distal edge of the flap that lies in the original surgical defect is farthest from the blood supply, and thus, it is the most vulnerable part of the flap. Excess tension or strangulation with sutures that are too tight also increases the risk of necrosis in the distal edge. Rotation flap with back cut. The back cut allows greater rotation, but this cut involves the pedicle of the flap and thus diminishes its blood supply.
• Two simultaneous rotation flaps can be created when extra tissue is required. A bilateral rotation flap can be made with the 2 rotation flaps oriented in the mirror image of each other (see the first image below). This flap is analogous to the A-to-T flap, which is a similarly oriented double advancement flap. Another variation of a double rotation flap is the O-to-Z flap. In this case, the 2 rotation flaps are inverted relative to each another. When completed, this flap produces a scar that is roughly shaped like the letter Z (see the second image below). This flap is particularly helpful in scalp defects. Double rotation flap. Bilateral rotation flap. Double rotation flap. O-to-Z flap.
• Fan et al reported on a "flying wings" design of scalp flap that can be used for large scalp defects (up to 50% scalp loss) in children, stating the repair technique is "simple, safe, and efficient."^[3]
• Jung et al describe a cutaneous alar rotation flap. Used to correct severe alar retraction, it reportedly has the advantage of being performed in a single stage, with further attributes of an easy design, tissue matching, and a robust blood supply. Inconspicuous scarring is achieved by placing the incision within the junction of the ala and the nasal dorsum in a precise manner.^[4] Neltner et al discuss alar rotation flaps for small defects in the ala.^[5]
• Further, Neu described a technique to help preserve the anatomy upper lateral cartilages in dorsal reduction surgery, thereby addressing the relationship between the upper lateral cartilages and the septum.^[6]

A disadvantage of rotation flaps is the extensive cutting and undermining necessary to develop the flap, thereby increasing the risk of bleeding and nerve damage.