eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Rotation 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): Michael Fozo, MD, Staff Physician, Department of Otolaryngology, New York Eye and Ear Infirmary, New York Medical College
Contributor Information and Disclosures

Updated: Nov 5, 2008

Treatment

Surgical Therapy

The first step in designing a rotation flap is to outline an isosceles triangle around the defect. As a rule, the 2 sides of the triangle, which are equal in length, are longer than the third side, or defect base. This creates a narrow triangle with an acute angle opposite the defect's base. The long side of the triangle opposite the rotation flap corresponds to one of the borders of the flap after defect closure, so this should be oriented along relaxed skin tension lines or between aesthetic units when possible (see Image 1).

Next, the semicircular arc of the rotation flap is outlined by creating a half circle that incorporates the triangular defect at one end. The defect's base is oriented along the circumference of the arc. Obviously, narrower defects require less rotation from adjacent tissue. As a general rule, the length of the flap's perimeter should be at least 4 times the width of the defect. This accomplishes 2 goals: easier closure of the donor site and appropriate distribution of tension along the suture line.

Again, when possible, the incision for the arc should also be placed in a relaxed skin tension line and/or on an anatomic border. Undermining in the fat plane immediately beneath the dermis leaves the flap with an intact dermal plexus and avoids injury to the facial nerve or underlying muscles. After rotation of tissue into the defect, a standing cone is usually created at the distal end of the rotation flap. This deformity can often be managed with a back cut at the distal end (see Image 1). In cases in which a back cut does not remove the cone, a Burrow triangle is required. The flap's pivot point lies approximately midway between the apex of the defect and the end of the back cut.

Larrabee studied the biomechanics of rotation flaps.¹ Tension was measured for rotations of 0-180° around the circumference. Maximum tension after rotation and closure of the defect was 90-135°, or opposite the site of defect closure (see Image 2). Little mechanical benefit is gained in increasing flap length beyond 90°; however, cosmetic or functional reasons may exist for doing so. Increased undermining and increased arc radius have small beneficial effects on closing tension.

The triangular shape and flat tangential plane of the inner canthal region lends itself to angled defects that can be closed by a variety of local flaps, including rotational flaps. Medium-sized defects of the nose can be closed by rotation flaps with skin borrowed from the glabella, upper nasal dorsum, or nasolabial sulci.

The sliding nasolabial flap, frequently used for defects at the labial border of the nose, is especially advantageous for persons who are elderly and typically have excessive skin in this area. This flap is also useful for small defects involving the columella and infratip lobule and for women with short foreheads. Avoid these flaps in men to prevent transfer of hair-bearing skin to the nose. Sliding nasolabial flaps have certain drawbacks: they require a second-stage procedure, and they usually flatten the nasolabial fold.

Small-to-midsize cheek defects can be repaired with excellent results using simple rotation flaps that place incisions parallel to relaxed skin tension lines (see Images 3-4).

Larger skin defects involving the lower eyelid, cheek, and upper lip areas can be closed with a large cervical-facial rotation flap described in detail by Cook et al.² The flap is based inferiomediolaterally on the facial artery and vein. Outer margins are placed between aesthetic units whenever possible. The flap can be suspended superiorly up to 2-3 mm beneath the subciliary line and laterally to the preauricular crease. Ideal medial borders are the alar facial or nasofacial grooves. This flap affords an excellent match of skin color and texture and prevents ectropion of the lower eyelid and distortion of the upper lip. It can even be thinned selectively to match the thin skin beneath the eye. Use of this flap has no age limits in early childhood, and use of the same flap can be repeated if the defect (eg, hairy nevus) cannot be removed in the first procedure.

In contrast to the previously described flaps designed for medially based lesions, the cheek-neck rotation flap is designed to repair defects of the lateral aspect of the face (see Images 5-6). In this instance, the base of the triangular defect is placed laterally along a standard parotidectomy incision. Superiorly, the incision arches horizontally above the zygomatic arch. Inferiorly, it extends into the neck to the level of the cricoid cartilage. Another way in which this flap differs from other flaps is that the neck portion is not raised immediately beneath the dermis but rather deep to the platysma muscle, which places the marginal mandibular branch of the facial nerve at added risk. Surgeons can use this flap to close temporozygomatic wounds with excellent functional and cosmetic results.

Defects involving the lower third of the nose present technical and aesthetic challenges. Facial prominence, anatomic complexity, and structural dissimilarity to neighboring aesthetic subunits make reconstruction extremely difficult. The dorsal nasal flap, a rotation flap first described by Rieger in 1967, has undergone numerous modifications since its original description.³ Drawbacks include incisions extending into the radix of the nose between the eyebrows, thick glabellar skin being transferred to thin-skinned portions of the nose, iatrogenic epicanthal folds, trapdoor formation, and scarring. However, in carefully selected patients, results can be excellent (see Images 7-9).

Two relatively new flaps that improve upon some of the shortcomings of previous rotation flaps for the inferior third of the nose are the full nasal skin rotation flap and the island rotation flap (see Image 10). The full nasal skin rotation flap is not a random flap but rather an axial flap based on a branch of the angular artery. This flap is elevated in the submuscular plane above the nasal perichondrium. The full nasal skin flap avoids creating a scar at the radix of the nose and extending the dissection into the glabellar area.

The island rotation flap is a variant of the teardrop flap described by Staahl.⁴ It is based on an inferior pedicle that transfers tissue from the superior nasolabial region to the paramedian nose. Incisions are placed parallel to relaxed skin tension lines and between aesthetic subunits, resulting in superior results for defects measuring less than 2 cm along the alar-facial junction or nasolabial fold.

Complications

Rotation flaps can be compromised by any of the complications possible for other local flaps, including infection, hematoma, flap necrosis and sloughing, poor scarring, and distortion of neighboring landmarks. The excellent blood supply of the head and neck region affords good viability despite the flap's random blood supply, even for patients who smoke or those who have undergone radiation therapy.

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