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Introduction
CHAPTER 21 Advancement Flaps
Jeremy R. Etzkorn Michael P. Rabinowitz Ilya Lim Renelle Pointdujour-Lim Thuzar M. Shin Joseph F. Sobanko Christopher J. Miller
SUMMARY
Advancement flaps are among the most frequently performed flaps in
dermatologic surgery.
These flaps may be conceptualized as a geometric variation of a linear closure,
resulting in dog-ear redistribution and tension release.
Beginner Tips
Advancement flaps may seem deceptively simple; handling of the displaced dog ears,
however, requires a thorough appreciation of tissue dynamics.
As with all flaps, advancement flaps lead to a significantly extended suture line
compared with a linear closure. Therefore, attention to detail in suturing techniques is of vital importance to camouflage the scar as effectively as possible.
Expert Tips
Combining advancement flaps with suspension (tacking) sutures may be very useful
around free margins.
Advancement flaps may be combined with other approaches such as grafts (typically
Burowโs grafts harvested from the dog ears), partial closures, and SMAS plication.
Crescentic advancement flaps may obviate the need for secondary dog-ear removal.
Donโt Forget!
Excessive undermining may be unnecessary and may increase the risk of tissue
ischemia.
Always keep in mind the maximal flap length to pedicle width ratios when designing
advancement flaps.
Pitfalls and Cautions
Never force an advancement flap; while this design may seem most straightforward,
some situations call for other approaches.
Always tailor flap design to the individual patient; flap elevation and undermining in
patients on aspirin or anticoagulants may increase the risk of hematoma formation.
When in doubt, consider drain placement in these patients, even after meticulous
hemostasis has been obtained.
Patient Education Points
Patients should be warned prior to flap closure that they will have an incision
stretching well beyond the initially visible defect.
Explaining that the additional scar length will likely heal with a minimally visible line
may go a long way toward patient reassurance.
Billing Pearls
Flap repair codes (140XX series) include the excision component, so it is not
appropriate to bill both an excision and a flap repair code simultaneously.
Mohs codes may be submitted along with flap repair codes, though they may be subject
to the multiple procedure reduction rule.
When coding a flap, medical necessity is the ultimate arbiter of appropriateness.
CHAPTER 21 Advancement Flaps
INTRODUCTION
Local random pattern flaps are workhorse reconstructive options for cutaneous defects. Advancement flaps are conceptually the simplest local flaps and fall within the group of sliding flaps, in which tissue is moved directly into the adjacent defect without lifting it over interposed tissue. Unlike rotation flaps, pure advancement flaps do not create significant secondary defects, and the leading edge of an advancement flap is not typically restricted significantly by pivotal restraint.