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COMPLICATIONS AND MANAGEMENT
COMPLICATIONS AND MANAGEMENT
Rotation flaps are susceptible to many of the same pitfalls that affect other types of flaps. The potential for postoperative bleeding is ever present in dermatologic surgery. A thorough preoperative evaluation to include the patientโs use of anticoagulants is critical in identifying those at risk for this complication. Careful attention to intraoperative hemostasis, especially beneath the flap, is of the utmost importance, as a newly inset flap forms a potential space for hematoma formation. Bulky pressure dressings are another key component of preventing bleeding in the postoperative period.
Should persistent bleeding continue beneath the flap during the postoperative period, a true hematoma may develop. Within the first 24 to 48 hours following surgery, hematomas should be evacuated to ensure the greatest chance for flap survival. If the hematoma is not yet organized, attempts can be made to remove the blood with a syringe and 18-gauge needle. However, it is likely that the sutures will need to be removed and the hematoma physically evacuated while also irrigating the wound. This additionally offers the opportunity to visualize and address the source of bleeding, a critical step if the hematoma seems to be increasing in size. Once the wound bed and base of the flap
are clean and dry, the flap may be resutured in place. Outside of the first 2 days postoperatively, hematomas are more likely to be organized and less amenable to evacuation. Not only do hematomas create pressure that may compromise flap perfusion, they also significantly increase the risk of wound infections that may adversely affect flap viability. Thus regardless of the time following surgery, the presence of a hematoma is an indication for prophylactic antibiotics, as hematomas serve as a nidus of infection.
Complications that are unique to rotation flaps derive from the design and tissue movement of these flaps. As stated previously, rotational shortening is inherent in the expected movement of rotation flaps. When unaccounted for, rotational shortening can produce excessive tension on the leading edge of the flap. This may result in dehiscence of the wound or flap ischemia and necrosis along this edge. Unnecessarily high tension due to rotational shortening may be combated by increasing the length of the leading edge of the rotation flap beyond the defect. Also, wide undermining of the flap and the surrounding tissues further minimizes this risk.
In most cases, the geometric design of rotation flaps helps to ensure robust perfusion. One instance in which this blood supply may be compromised is with the use of a backcut to relieve pivotal restraint. When performing a backcut, the dermatologic surgeon must take care not to overly narrow the pedicle. Maintaining a length-to-width ratio of no more than 3:1 mitigates this risk.
Finally, rotation flap may also be complicated by altering the position of free margins. The long arcuate incisions often created by these flaps result in long secondary defects. It is important to be cognizant of the course of these secondary defects, especially when in close proximity to free margins. To varying degrees, there will always be secondary movement of the surrounding tissue to close the secondary defect. While it is true that increasing the length of the arc of rotation will decrease tension across the secondary defect, this must be weighed against extending the secondary defect to an anatomic location where a given amount of secondary tissue movement is unacceptable.
CONCLUSIONS
The rotation flap is a workhorse in the reconstructive toolbox of the dermatologic surgeon, and can be employed in a wide range of anatomic locations. As with many other random pattern flaps, the rotation flap has the advantage of good local tissue match with regard to texture, thickness and presence of adnexa. It is a reliably robust flap owing to its broad pedicle inherent in its basic design. Generally, this flap is conceptually and technically simple to execute when proper planning and design considerations are accounted for. The modern dermatologic surgeon must be prepared to
approach every surgical defect as unique. There is not a single โcookie-cutterโ repair that is appropriate for all wounds of a given location. Often, an innovative combination closure is required incorporating a blend of flaps, grafts, primary closure, or second intention healing.