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Advancement Flaps

  • Author: Anthony P Sclafani, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Feb 07, 2014
 

Background

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.

An image depicting advancement flaps can be seen below.

The photograph shows advancement flap incisions, w The photograph shows advancement flap incisions, with lesion to be excised. (The asterisk represents the distal end of the advancement flap; the double asterisk represents the proximal end of the advancement flap.)
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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.

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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.

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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.

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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.

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Contributor Information and Disclosures
Author

Anthony P Sclafani, MD Director of Facial Plastic Surgery and Surgeon Director, New York Eye and Ear Infirmary of Mt Sinai; Professor of Otolaryngology, Icahn School of Medicine at Mt Sinai

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, American College of Surgeons

Disclosure: Received salary from Aesthetic Factors, Inc. for consulting; Received consulting fee from Meditech Medical Enterprises for independent contractor; Received royalty from Thieme Medical Publishers for author; Received royalty from Jaypee Medical Publishers for author.

Coauthor(s)

Matthew W Shawl, MD, MD 

Matthew W Shawl, MD, 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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Stepnick, MD Associate Professor, Departments of Otolaryngology-Head & Neck Surgery and Plastic Surgery, Case Western Reserve University School of Medicine, MetroHealth 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 Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Paul S Nassif, MD FACS, Consulting Surgeon, Facial Plastic and Reconstructive Surgery, Spalding Drive Cosmetic Surgery and Dermatology

Paul S Nassif, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, California Medical Association, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Nothing to disclose.

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. 2005 May. 115(6):1582-90. [Medline].

  2. Baker SR. Reconstruction of facial defects. 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. 1998 Jan. 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. 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. 2005 Jul. 58(5):676-80. [Medline].

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

 
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The photograph shows advancement flap incisions, with lesion to be excised. (The asterisk represents the distal end of the advancement flap; the double asterisk represents the proximal end of the advancement flap.)
The photograph shows advancement flap incisions with skin defect. (The asterisk represents the distal end of the advancement flap; the double asterisk represents the proximal end of the advancement flap.)
The photograph shows a flap advanced with creation of "dog ears." (The asterisk represents the distal end of advancement flap; the double asterisk represents the proximal end of advancement flap; and the X represents the distal side of the dog ear.)
The photograph shows advancement flap with a dog-ear excised using Burow triangles. (The asterisk represents the distal end of the advancement flap; the double asterisk represents the proximal end of the advancement flap; and the X represents the distal side of the dog ear.)
The photograph shows the final appearance of advancement flap repair using Burow triangles to correct dog ears.
Drawing depicts a V-Y closure that converts the distal portion of the V-shaped distal defect into a straight-line closure. The V-shaped flap is advanced in the opposite direction and then closed.
 
 
 
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