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Introduction
CHAPTER 22 Rotation Flaps
Luke Nicholas James Bota Mary E. Maloney Dori Goldberg
SUMMARY
Rotation flaps recruit tissue via rotational movement around a pivot point and
rely on tissue laxity adjacent to the surgical defect.
Tension vectors can be dispersed variably across the arcuate path of the flap,
and there are two areas where tissue redundancy becomes evidentโthe pivot point adjacent to the primary defect and the flap base at the end of the arcuate incision.
Beginner Pearls
Pivot point redundancy can be removed as a standing cone either before
(โtriangulatingโ the defect) or after inset of the flap; flap-base redundancy can be redistributed by meticulous rule-of-halves suturing or removed as a standing cone.
All rotation flaps are subject to rotational shortening and pivotal restraintโas the flap
tip rotates inward to fill the primary defect, the arc length of the flap decreases, which can be solved by oversizing the flap.
Expert Pearls
A backcut can further reduce pivotal restraint and assist in rotating the flap into place,
though it also reduces the width of the pedicle and may compromise flap perfusion.
Rotation flaps may be very useful on the nose; always keep in mind that the
undermining plane should be submuscular.
Donโt Forget!
A double rotation flap comprising two traditional rotation flaps taking off from the
opposite sides of the defect can be useful in areas of high tension.
The comet (or dog-ear rotation) flap combines a primary closure of one end of the
defect with the creation of a rotation flap from the tissue redundancy at the other end of the defect, and is particularly useful on the cheek.
Pitfalls and Cautions
Large cheek flaps may result in ectropion; this risk may be reduced by using
suspension sutures and oversizing the flap.
Other complications include persistent lower eyelid edema and textural mismatch.
The long secondary defects created by rotation flaps may lead to secondary tissue
movement and free-margin compromise.
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 22 Rotation Flaps
INTRODUCTION
Rotation flaps are local cutaneous flaps that rely on tissue laxity adjacent to the surgical defect in order to accomplish closure. By design, these flaps recruit tissue via rotational movement around a pivot point. Rotation flaps are overwhelmingly random pattern flaps deriving blood supply from the dermal and subdermal plexuses, although on occasion they may carry axial vessels within the flap body.
In its most basic form, a rotation flap is created by extending a curvilinear or arcuate incision from the defect around a central pivot point. Inherent in this design is the formation of a broad pedicle and a desirable length-to-width ratio. These features contribute to reliable vascularity, viability, and an overall robust flap.
Rotation flaps differ from primary repairs or advancement flaps by the orientation of tension vectors. In primary repairs or advancement flaps, the tension vectors generally are directed perpendicular to the long axis across the wound, whereas in a rotation flap, the tension vectors can be dispersed variably across the arcuate path of the flap.
Rotation flaps in dermatologic surgery were first described by Konz and colleagues in 1975 for the repair of facial defects, but the use of rotation flaps dates back to 1842 as reported by Pancoast in the early plastic surgery literature.1,2 Since then, rotation flaps have been widely used in reconstructive surgery, and have been used for a variety of disease processes including pilonidal sinuses, decubitus ulcers, and cicatricial alopecia.3โ5 In dermatologic surgery, rotation flaps have become a cornerstone of reconstruction, and their utility extends well beyond that of classically described rotation flaps with known eponyms.