eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Advancement Flaps: Treatment

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

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.

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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