eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery
Advancement Flaps
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.
Treatment
Intraoperative Details
Monopedicled, bipedicled, and V-Y flaps constitute the 3 types of advancement flaps. Undermine the donor site of an advancement flap at a level below the subdermal plexus. Preserve a minimal amount of adipose tissue on the flap undersurface to preserve the subdermal plexus. Advance the flap in a straight line to the defect.
When creating monopedicled or bipedicled flaps, redundant tissue at the flap base usually remains, which may be excised using Burrow's triangles. On the face and scalp, a length-to-width ratio as great as 3-4:1 may be achieved. The flap is typically advanced a distance equivalent to the width of the flap (see Images 1-5).
Monopedicled and bipedicled flaps are useful whenever defects lie near an area of skin laxity and incisions resulting from flap creation appear favorable. Exercise caution when pulling tissue from the donor site so that tension does not create a cosmetic deformity (eg, ectropion, distortion of the vermilion border). These flaps are typically used around the upper lip or forehead.
A V-Y advancement flap is created by making a V-shaped incision and advancing the broad base of the V into the defect.1 The resulting defect is closed primarily in a Y-shape. (see Image 6).
All advancement flaps should be under minimal tension. Further undermining may relieve excessive tension. Close incisions in multiple layers with interrupted stitches and absorbable sutures placed deep to the skin. Use nonabsorbable, nonreactive sutures for skin closure. Flaps may be revised later. If a long or tenuous flap is contemplated, surgeons may want to raise the flap in one procedure and wait 1-3 weeks before advancing the flap.
This action takes advantage of the delay phenomenon, which increases flap survival. The exact mechanism of the delay phenomenon is unknown, but it may work by opening choked vessels within the flap, thus increasing flap perfusion.
Postoperative Details
Sutures are removed 1 week after surgery. As with any near-circumferential scar, wound contract may cause flap pincushioning or a trapdoor deformity. Flaps that show signs of pincushioning may be treated with subdermal triamcinolone injection (Kenalog) in small amounts (10 mg/cc, 0.05-0.15 cc). Any scar widening can be treated with scar excision, additional undermining, and meticulous closure. Scar dermabrasion may be offered to patients generally no earlier than 6 weeks postoperatively. Persistent scar erythema or peri-cicatricial telangiectasias, if unresolved in 8-12 weeks, may be treated with an appropriate wavelength laser, such as a 1064 nm Nd-YAG.
Complications
In general, properly planned and executed advancement flaps are very reliable. Failure is generally unpredictable. Vascular insufficiency is the main cause of flap failure and may result from undermining in the wrong plane, excessive tension on the flap, hematoma, infection, or compression of the pedicle. Inadequate undermining or excessively larger defects may be associated with unacceptable wound tension and can lead to postoperative scar widening.
Outcome and Prognosis
The advancement flap is a valuable tool for the surgeon repairing skin defects in the head and neck region. Proper patient selection and planning are essential. Advancement flaps are desirable because skin advanced from adjacent areas is usually a good match for color, thickness, and texture. Incisions can be hidden well in relaxed skin-tension lines or in borders of facial aesthetic units.
Future and Controversies
The advancement flap is one of many techniques available to close skin defects of the head and neck. Often, a given defect may be closed in more than one way, and talented surgeons may disagree. Current research topics include the role of vasodilating agents, antiplatelet drugs, and hyperbaric oxygen. These research areas will probably improve techniques or provide agents to increase flap survival.
Multimedia
Media file 1: 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.)
Media file 2: 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.)
Media file 3: 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.)
Media file 4: 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.)
Media file 5: The photograph shows the final appearance of advancement flap repair using Burow triangles to correct dog ears.
Media file 6: 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.
References
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].
Baker SR. Reconstruction of facial defects. In: Otolaryngology: and Head and Neck Surgery. 1998:527-559.
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].
Connor CD, Fosko SW. Anatomy and Physiology of Local Skin Flaps. Facial Plast Surg Clin North Am. Nov 1996;4:447-454.
Fisher J. Basic principles of skin flaps. In: Essentials of Plastic, Maxillofacial and Reconstructive Surgery. Lippincott Williams & Wilkins; 1987:37-50.
Murakami CS, Nishioka GJ. Essential Concepts in the Design of Local Skin Flaps. Facial Plast Surg Clin North Am. Nov 1996;4:455-468.
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].
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].
Shumrick KA. Local skin flaps: anatomy, physiology, and general types. In: Head and Neck Surgery - Otolaryngology. Lippincott Williams & Wilkins; 1993:1913-1948.
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
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
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