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Introduction
CHAPTER 25 Island Pedicle Flaps
H. William Higgins Samuel Book
SUMMARY
The V-Y island pedicle flap permits a triangular island of tissue to be advanced
into a defect.
The flap relies on a robust vascular pedicle, and when properly designed is an
effective technique for numerous defects.
The chief disadvantage of this approach is the increased risk for trapdooring and
resultant undesirable scarring.
Beginner Tips
Island pedicle flaps are frequently used on the lip, as their triangular scar line may be
camouflaged within cosmetic subunit boundaries.
The fully circumferential suture lines and increased risk of trapdoor phenomenon mean
that attention to detail in suturing techniques is of vital importance to camouflage the scar as effectively as possible.
Expert Tips
Basting sutures at the base of the flap may help mitigate the risk of the trapdoor
phenomenon, though care should be taken to avoid restricting blood flow to the pedicle.
In general, island pedicle flaps should be undersized relative to the defect size.
Donโt Forget!
Undersizing island pedicle flaps means that there may be a significant component of
secondary motion. This needs to be accounted for in order to avoid tissue distortion.
Island pedicle flaps are not purely advancement flaps; they may be rotated or
transposed into place as well.
Pitfalls and Cautions
Even though island pedicle flaps benefit from a robust vascular pedicle, they should be
used with caution in smokers, who may have an increased risk of necrosis.
Always tailor flap design to the individual patient; flap elevation and undermining in
patients on aspirin or other anticoagulants may increase the risk of hematoma formation.
Patient Education Points
Patients should be warned prior to flap closure that they will have an incision
stretching well beyond the initially visible defect.
Always advise patients that they may have a multistage procedure, and that trapdooring
is likely to occur. Patients will be much more understanding regarding the need for intralesional steroid injection or other intervention if they were prewarned that this may occur.
Billing Pearls
Flap repair codes (14040 and 14060 series) should be used for V-Y island pedicle
flaps, and include the excision component, so it is not appropriate to bill both an excision and a flap repair code simultaneously.
Island pedicle flaps should not be coded with 15740, as this requires identification
and dissection of a named axial vessel.
CHAPTER 25 Island Pedicle Flaps
INTRODUCTION
Defects on cosmetically sensitive locations of the head and neck require delicate reconstruction to preserve anatomic function while also providing satisfying cosmesis to the patient.1โ3 Options for repair range from second intention healing to complex surgical reconstruction. When chosen appropriately, flaps can provide excellent cosmesis and outcomes.4โ6
Prior to flap repair, the surgeon should ensure that the tumor has been resected completely with clear histologic margins. Using flaps to repair the defect rearranges surrounding tissues, making it difficult to locate tumors if they recur. An incompletely excised recurrent tumor may be disguised by the flap, delaying appropriate diagnosis, which may result in increased morbidity. The rearranged tissue planes produced by the flap can also make tumor extirpation more challenging, leading to more complex surgery to remove the remaining tumor.
Once the tumor has been removed with clear histologic margins, the surgeon can consider a range of reconstructive options. A well-designed and properly executed flap provides reconstructive advantages, providing a viable vascular supply to the defect while maintaining function with minimal morbidity. The variability in skin flaps available for each type of defect requires an experienced surgeon to possess an extensive knowledge of facial anatomy, tissue motion, and reconstructive options offering the best soft tissue repair.7