Overview of Advancement Flaps

When traditional ways of closing wounds aren’t feasible for cosmetic or functional reasons, extra steps have to be taken to rebuild the tissue area. This might involve the use of grafts, like skin or mouth tissue patches or flaps. Flaps are skin and tissue that retain their blood supply and are transported to cover a wound or defect. This makes them more likely to heal successfully. Some flaps have to be moved from far parts of the body to the wound area, which involves a process called microsurgical blood vessel anastomosis. This earns them the term ‘free’ flaps. ‘Regional’ flaps are tissue transferred from nearby, but not neighboring, areas of the body, while ‘local’ flaps come from tissue directly next to the wound. There are several types of local flaps including transposition, rotation, advancement, and interpolation.

Advancement flaps are some of the simplest local flaps, and along with rotation flaps, are often called ‘sliding’ flaps, because they are moved directly to the wound without having to move past or under normal tissue like some other types of flaps.

Local flap advancement is a go-to method in skin surgery for many reasons. They are simple to understand and apply, requiring less specific design than some other styles of flaps. They also have the advantage of not leaving secondary wounds that need healing at the original site of the flap, unlike some other types of flaps. Advancement flaps are useful for more than just wounds. For example, they can help lengthen the part of the nose in cases of cleft lip, reposition the lobe of the ear after face-lift surgery, correct partially joined toes, and releasing scar bands that alter the correct position of body structures like the eyelid. Furthermore, advancement flaps are important for cosmetic or gender-affirming surgeries like adjusting the hairline or forming the basis for facelift surgery.

Anatomy and Physiology of Advancement Flaps

Flap reconstruction is a procedure that demands careful planning, especially in knowing the unique characteristics of every part of the body that needs it. However, the most important factor in this procedure is ensuring a good blood supply to the affected area. This is often done by using “flaps” of skin that have their own supply of blood from a major blood vessel.

There are two major types of flaps: axial flaps and local flaps. Axial flaps are pieces of tissue that have a specific blood vessel attached. This blood vessel, often running the whole length of the flap, ensures that all parts of the flap get blood supply. This means when these flaps are designed, it is not necessary to strictly follow certain measurements, as long as all the tissue in the flap has enough blood supply from the blood vessel or vessels carrying blood to the flap. The most important thing is to ensure the blood vessel that attaches the flap to the body (called the “vascular pedicle”), remains healthy.

Local flaps, on the other hand, rely on a random blood supply from small caliber vessels lying just under the skin, which is less predictable. Therefore, careful planning is needed with local flaps. The rule of thumb is: on the face, the length should be no more than three times the width; while on the trunk and limbs, it should be two times at most. Any more than this risks poor blood supply and potential loss of tissue. People with poor circulation, such as smokers or those who have had radiotherapy, sometimes have better results with axial flaps.

When local flaps are used on the face, the surgeon takes care to hide scars as much as possible. This can often be done by placing incisions between different areas of the face. For instance, the nose, which is broken down into several subunits, can have incisions placed in between these subunits to effectively hide surgical scars. Scars can also be hidden in facial wrinkles, or “rhytides”, when present. Lines of wrinkles on the face often follow predictable patterns that run perpendicular to the direction of muscle contraction underneath them. Knowing these patterns is crucial in determining the most effective way to stretch a piece of skin for a flap.

Generally, the effect of stretching skin for reconstructions can be improved by using “stress relaxation” and “skin creep”. Stress relaxation is a condition where less tension is needed to stretch the skin the same length over time, and skin creep is the skin’s ability to lengthen under constant tension.

Why do People Need Advancement Flaps

Advancement flaps are a technique used during skin treatments to move pieces of skin and help close wounds. These flaps can also be used to tweak the arrangement of tissue, much like in facelifts and lowering of the hairline. They work by moving the skin’s upper layers to one side, rather than pulling them straight together. They’re especially useful in delicate or noticeable areas like the eyelid, lip, or the creases of the face.

By directing the cuts or surgical movements away from these areas, surgeons can ensure that natural boundaries of the face and body are respected. As a result, scars from the procedure can be more easily hidden. They’re often disguised along natural creases or boundaries between different areas of the skin. This technique is commonly used on areas like the upper and lower lip, the bridge of the nose, the cheek, the lower eyelid, the forehead, and the outer edge of the ear.

When a Person Should Avoid Advancement Flaps

When a patient has wounds that are too big to be closed by stitching the nearby skin together, doctors might need to use skin from other parts of the body. There are a few ways to do this, like skin grafts (where skin is taken from one area and moved to another), flaps (where skin is moved with its blood supply) and microvascular tissue transfer (which involves moving tissue, along with its blood vessels, from one area to another).

Sometimes, it’s harder for doctors to use these methods if the area around the wound is scarred, infected, inflamed or has been treated with radiation before. In these cases, doctors need to think about using a different kind of graft or flap that has its own blood supply.

It’s important to note that if a patient has been smoking recently, it can make these kinds of skin grafts and flaps less successful. Even though the tiny blood vessels in the skin can start working almost normally again just two weeks after a person stops smoking, doctors still need to be careful when doing these surgeries on people who usually smoke.

Equipment used for Advancement Flaps

Here are the items your doctor will be using during your surgery:

1. Local anesthetic (a numbing medicine that keeps you from feeling pain). A commonly used type is 1% lidocaine and 1:100,000 epinephrine. The doctors will inject this using a hypodermic syringe and needle.

2. Skin prep solution (a liquid medicine that kills bacteria on the skin to prevent infection). This could include 5-10% povidone-iodine, 4% chlorhexidine gluconate, or 70% isopropyl alcohol.

3. Skin marker and measuring tape, or calipers (used to mark and measure the area where the doctor will make the cut).

4. Scalpel: it’s a small, sharp knife used for surgical procedures. The specifics might be #15, #15c, or #11 blade, or #6700 beaver blade.

5. Various types of forceps: Adson-Brown or 0.5 mm Castroviejo. These are similar to tweezers, and are used to hold or move tissues during surgery.

6. Different styles of scissors used in surgery, such as Kaye blepharoplasty, iris, or Westcott. These will be used to cut tissue.

7. Needle drivers: Halsey or Castroviejo. These are used to hold the needle while sewing tissues together.

8. Hooks: Joseph or Guthrie double-prong. These are used to help expose the area being operated on.

9. An electrocautery forceps: These are tools that use heat to stop bleeding by sealing blood vessels.

10. Electrocautery pencil: A pen-shaped tool that uses electricity to cut tissues or stop bleeding.

11. Suture scissors: might be iris, tenotomy, or Mayo types. They’re used to cut thread-like material used to sew tissues together.

12. Skin sutures: a type of thread used to sew the wound closed. An example is 6-0 polypropylene.

13. Deep dermal suture: another type of thread, such as 5-0 poliglecaprone, that’s used to sew deeper layers of tissue together.

14. Topical antibiotic ointment (like bacitracin or mupirocin) will be applied to the wound to prevent infection.

15. Dressing supplies: These will be used to cover the wound after surgery is done.

Who is needed to perform Advancement Flaps?

Local flap advancement is a type of surgery often done with a local anesthetic, which means you’ll be awake but won’t feel anything in the area of the surgery. It’s typically done by a surgeon and an assistant. However, for more complex or larger scale surgeries, you might need general anesthesia. This is when a medical professional, called an anesthesia provider, gives you medicine to make you sleep during the operation.

This type of surgery is usually done in an operating room with a team of healthcare professionals. This team often includes a circulating nurse, who helps ensure the operation runs smoothly, and a surgical scrub technician, who assists the surgeon during the operation by handling the instruments and other equipment. They all work together to take the best care of you during your surgery.

Preparing for Advancement Flaps

Before the surgery, the doctor will clean the area where they are going to operate with a special solution. This helps to ensure that the area is as germ-free as possible to prevent any infections. Infections after skin surgery are quite rare, and even if the conditions are not completely sterile (free of all bacteria), as long as they are clean, the risk remains low.

Before any surgery, it’s important for patients to know what to expect. Doctors will explain what might occur during recovery and healing, like pain, infection, bruising, swelling, bleeding, scar formation, possible damage to nearby body parts, the need for extra procedures, and the possibility of not being happy with how the surgical area looks afterward.

This discussion is even more important in some situations. For instance, surgery involving the lower eyelid might cause prolonged swelling that could last for several months. Also, if the surgical wound is located along natural skin lines or creases, it can hide well over time, but it might be noticeable early after the surgery if the edges of the wound are turned outward. But, with patience and sometimes using special injections that help to reduce swelling and other minor irregularities after the procedure, these issues can be fixed.

How is Advancement Flaps performed

In most cases, local skin flaps, or certain types of surgical procedures for repairing wounds or reshaping areas of the body, are carefully lifted in the layer below the skin. This method takes care of the blood supply to ensure the flap remains healthy. This approach also reduces the excess tissue within the flap, making it easier to stretch and pivot if necessary. However, doctors may have different methods when working with the nose. Some may lift the skin just below the surface, while others may go deeper, especially when working near the tip of the nose. The decision between these methods depends on factors like the oily nature of the skin on the nose’s tip and wings. Even if repositioning muscle fibers might affect breathability, some doctors might choose a flap that contains muscle due to its copious blood supply.

Likewise, when working with scalp flaps, the traditional approach involves lifting them within the muscle layer, a section with few blood vessels that allows for easy preparation. However, this layer includes the galea aponeurotica, a rigid layer that resists stretching. On the contrary, lifting the scalp below the skin’s surface may give the flap more elasticity for stretching and rotation, essential to fill injured areas.

Regardless, it is crucial to take care not to stretch or thin the flap excessively, as it can limit the blood supply. For flaps in the head and neck, it’s best to stick to a length-to-width ratio not more than 3:1, whereas flaps on the torso or limbs should keep a 2:1 ratio. Some additional adjustments around the tissue can reduce the need for excessive stretching. This is best achieved by gently separating the tissues in the same layer as the flap for 2 to 4 cm around the injured area. It’s important to note that undermining beyond this extent doesn’t reduce the closing tension further and might even make it worse.

To close the wound, the flap moves towards the injury, and the surrounding tissue moves towards the flap. This tension for wound closure doesn’t significantly change the force’s direction or magnitude compared to a linear closure in the same location for a similar injury. Occasionally, the doctor may use special stitches that anchor the flap to solid structures deep within, such as the rim of the eye socket. This can then redirect some of the tension from the wound closure.

The use of local flaps creates small areas of excess skin called standing cones. They are handled in different ways. The entire standing cone can be moved to a spot anywhere along the cut where the scar from its removal will be less visible, either in a relaxed skin tension line or along a natural edge, like the hairline. Alternatively, a small standing cone or a part of a large standing cone can be carefully distributed along the entire cut by closing the wound with interrupted stitches dividing the incision successively by halves until closure is complete.

When a skin defect appears after removing a tumor, especially after certain types of surgery, the surgeon might consider whether to increase the depth of the defect to a similar level to the layer of tissue used for easy separation underneath the skin. While it might seem strange to remove more tissue to facilitate closure, deepening the defect to the same layer as the tissue separation ensures that the advancing tissue matches the defect’s thickness, thereby preventing an irregular contour. Excising tissue between the surgical defect and a nearby crease or a natural line/seam may also be helpful. Drawing out incisions along these lines hides scars by keeping them in the shadows or creases.

The ability to stretch and move local flaps makes them versatile for various bodily areas. Intriguingly, local flap advancement is not exclusive to wound closure; for example, in facelift procedures, the development and rotation of facial flaps mirror the principles used in other kinds of advancement flaps for restorative purposes. Moreover, scalp advancement techniques are beneficial in cases such as lowering the hairline, particularly in gender affirmation surgery. However, different advancements cater to specific body areas, each with its unique considerations and applications.

When two flaps advance towards each other in the middle of a defect, each flap travels a smaller distance. An O to H flap closure technique transforms a circular defect into two parallel scars with a shorter perpendicular scar between them. The technique’s name comes from the resulting scars’ resemblance to the letter H. It is commonly used in the forehead and eyebrow region, leaving longer scars within forehead wrinkles while staying clear from any upward tension that might alter the eyebrow contour.

A technique like the O to H closure, called O to T flap reconstruction, uses a single releasing cut for each flap instead of two parallel ones. This method introduces a rotation element into the flap, similar to other regional flap closures. This technique is also called an A to T flap reconstruction if a triangle is removed from the wound.

A technique named V to Y advancement is unique because the advancing tissue is triangular rather than rectangular. Moreover, the tissue is pushed into place rather than pulled or stretched to close a tissue defect. The surgeon makes a V-shaped cut on the side of the tissue being moved, opposite the direction of the movement. Then, the V’s apex is sutured together in a line until the triangle of tissue has moved sufficiently. The V to Y advancement can be performed as a straightforward advancement flap or with the flap based upon a smaller layer below the surface that includes fatty tissue.

Possible Complications of Advancement Flaps

The main problem after local flap reconstructive surgery – a type of surgery that uses tissue from a patient’s body to cover wounds – is when a part or all of the “flap” of skin dies. This often leads to the surgical wound reopening. The main cause of flap loss is usually issues with the blood supply. Problems with veins, which carry blood back to the heart, are more common than issues with arteries, which supply fresh blood to the tissue.

Certain factors can increase the risk of flap loss, such as the flap being too narrow or stretched, or being too thin – this can disturb the tiny blood vessels in the skin. Pressure on the flap from swelling, blood clots or infections can also lead to problems with the blood supply. Early signs of these issues may be changes in color and feel of the flap: a dark and swollen flap could suggest vein insufficiency, while a pale and cool flap might indicate artery problems. However, issues with veins can eventually cause artery problems too.

Fortunately, if these problems are noticed early enough, they may be managed by releasing some of the stitches to reduce tension on the flap. Additionally, draining blood clots underneath the flap can help improve the circulation. Treatments for infection would include draining the infected area, cleaning and applying antibiotics. Another treatment option might be nitroglycerin paste. Leeches can be used too, as they directly remove congested blood and naturally promote circulation, but antibiotics need to be given alongside leech therapy to prevent any risk of additional infection.

Besides flap loss, infection is the next most frequent issue after local flap transfer surgery. Often, infection happens at the site of flap loss. Another common issue is bleeding, which can lead to blood clot formation. However, this is a rare complication, as long as the bleeding is controlled well during the operation. Excessive use of devices for controlling bleeding, such as electrocautery, can also add to flap loss. Additionally, designs of local flap transfers that put too much strain on freely movable structures like eyelids or lips, have predictable outcomes, like improper positioning of these structures. To avoid this, surgeons ensure that the main direction of closure is parallel to these structures, and not directly against them.

If scarring leads to undesirable appearances, corticosteroid injections – a type of anti-inflammatory medicine – might be used during the initial few weeks after surgery. If that doesn’t work, skin resurfacing treatments like dermabrasion or laser treatments can be considered. A final option could be revising the surgery.

What Else Should I Know About Advancement Flaps?

Local flap advancement refers to a specific method used in reconstructive surgery, particularly when dealing with large wounds that can’t simply be stitched up. It involves shifting some of your own skin from one area to another to help close a bigger wound. This type of surgery is great because it ensures the treated area matches well with the skin color and texture around it.

To ensure the best results, it’s crucial that the surgeon pays great attention to the design of the flap of skin that’s being moved. This attention to detail helps to limit any possible visible signs, like scarring, from the surgery. By carefully planning the surgery, scars can be hidden within the natural lines and contours of the skin.

The surgeon considers several things for the best results with this procedure. These include the direction of the primary tension (how the skin will be pulled), placement of any skin deformities, how the surgery will affect nearby body parts, the blood supply to the flap, and the shape of the wound. Considering these factors helps ensure that the surgery is effective and gives the best aesthetic results.

Frequently asked questions

1. How will the advancement flap procedure be performed? 2. What are the potential risks and complications associated with advancement flaps? 3. How long is the recovery period after advancement flap surgery? 4. Will I have any visible scars after the procedure? How can they be minimized? 5. Are there any specific post-operative care instructions or precautions I should follow?

Advancement flaps may be needed when a patient has wounds that are too large to be closed by stitching the nearby skin together. In cases where the area around the wound is scarred, infected, inflamed, or has been treated with radiation before, advancement flaps with their own blood supply may be necessary. Additionally, if a patient has been smoking recently, it can make other types of grafts and flaps less successful, so advancement flaps may be a preferred option.

You should not get Advancement Flaps if the area around the wound is scarred, infected, inflamed, or has been treated with radiation before. Additionally, if you have been smoking recently, it can make the procedure less successful.

To prepare for Advancement Flaps, the patient should have a thorough understanding of the procedure and its potential risks and complications. It is important to have a discussion with the doctor about what to expect during the recovery and healing process, including pain, infection, swelling, and scarring. Additionally, the patient should follow any pre-operative instructions given by the doctor, such as stopping smoking to improve the success of the procedure.

The complications of Advancement Flaps include flap loss, infection, bleeding, improper positioning of movable structures, and scarring. Flap loss is often caused by issues with the blood supply, such as problems with veins. Factors that increase the risk of flap loss include a narrow or stretched flap, a thin flap, and pressure on the flap from swelling, blood clots, or infections. Infection can occur at the site of flap loss. Bleeding can lead to blood clot formation, but this is rare if bleeding is controlled well during the operation. Improper positioning of movable structures like eyelids or lips can occur if the design of the local flap transfer puts too much strain on them. Scarring can be treated with corticosteroid injections, skin resurfacing treatments, or revising the surgery.

There are no specific symptoms mentioned in the text that would require Advancement Flaps. Advancement flaps are a technique used during skin treatments to move pieces of skin and help close wounds, especially in delicate or noticeable areas like the eyelid, lip, or the creases of the face. They are used to ensure that natural boundaries of the face and body are respected and scars from the procedure can be more easily hidden.

There is no specific information provided in the text about the safety of advancement flaps in pregnancy. It is recommended to consult with a healthcare professional for personalized advice regarding surgical procedures during pregnancy.

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