eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Advancement Flaps

Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Coauthor(s): Matthew W Shawl, MD, Fellow, Buckhead Facial Plastic Surgery
Contributor Information and Disclosures

Updated: Oct 17, 2008

Introduction

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 Procedure

Celsus, 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.

Indications

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 Anatomy

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.

Contraindications

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.

More on Advancement Flaps

Overview: Advancement Flaps
Treatment: Advancement Flaps
Follow-up: Advancement Flaps
Multimedia: Advancement Flaps
References
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References

  1. Andrades PR, Calderon W, Leniz P, et al. Geometric analysis of the V-Y advancement flap and its clinical applications. Plast Reconstr Surg. May 2005;115(6):1582-90. [Medline].

  2. Baker SR. Reconstruction of facial defects. In: Otolaryngology: and Head and Neck Surgery. 1998:527-559.

  3. Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial skin defect reconstructions. Arch Otolaryngol Head Neck Surg. Jan 1998;124(1):60-6. [Medline].

  4. Connor CD, Fosko SW. Anatomy and Physiology of Local Skin Flaps. Facial Plast Surg Clin North Am. Nov 1996;4:447-454.

  5. Fisher J. Basic principles of skin flaps. In: Essentials of Plastic, Maxillofacial and Reconstructive Surgery. Lippincott Williams & Wilkins; 1987:37-50.

  6. Murakami CS, Nishioka GJ. Essential Concepts in the Design of Local Skin Flaps. Facial Plast Surg Clin North Am. Nov 1996;4:455-468.

  7. Onishi K, Maruyama Y, Hayashi A, et al. Repair of scalp defect using a superficial temporal fascia pedicle VY advancement scalp flap. Br J Plast Surg. Jul 2005;58(5):676-80. [Medline].

  8. Sabit I, Schaefer SD, Couldwell WT. Extradural extranasal combined transmaxillary transsphenoidal approach to the cavernous sinus: a minimally invasive microsurgical model. Laryngoscope. Feb 2000;110(2 Pt 1):286-91. [Medline].

  9. Shumrick KA. Local skin flaps: anatomy, physiology, and general types. In: Head and Neck Surgery - Otolaryngology. Lippincott Williams & Wilkins; 1993:1913-1948.

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Further Reading

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Keywords

advancement flaps, skin flaps, skin flap, vy advancement flaps, local skin flap, rotation flap, skin defects, monopedicled flap, bipedicled flap, V-Y flap, delay phenomenon, random flap

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Contributor Information and Disclosures

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, MD 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
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Contura Grant/research funds Independent contractor; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership

Coauthor(s)

Matthew W Shawl, MD, Fellow, Buckhead Facial Plastic Surgery
Matthew W Shawl, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Paul S Nassif, MD, FACS, Consulting Surgeon, Facial Plastic and Reconstructive Surgery, Spalding Drive Cosmetic Surgery and Dermatology
Paul S Nassif, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and California Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA 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 Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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