Overview of Rotation Flaps
A flap is a technique used in surgery to close a wound. It’s used when simpler approaches, like stitching the wound closed or letting it heal on its own, don’t provide a satisfactory outcome in terms of appearance or function. Flaps are especially useful as they allow the redirection of tension around a wound, which makes them crucial in healing a wound efficiently.
When using a flap, surgeons use tissue that’s nearby the wound. This ensures a good match in terms of the skin color, texture, and thickness. The concept behind a flap is using extra skin or tissue (also known as tissue laxity) to close a surgical wound (primary defect). A secondary defect is the name for the wound made when creating the flap.
Unlike other methods, flaps stay connected to a source of blood supply known as a pedicle, which helps them survive. Local flaps, which are created from tissue close to the primary wound, are categorized by their pattern of blood supply. Axial flaps receive blood from a named artery, while random pattern flaps get their supply from smaller, unnamed arteries.
Flaps can also be classified by their primary motion. There are three main types: transposition, advancement, and rotation. Transposition flaps involve swapping positions of two or more tissue areas to provide skin for a wound. An advancement flap works by pulling nearby tissue in a straight line to close the wound. Lastly, rotation flaps involve rotating skin around a point to close a wound, kind of like spinning skin into the wound area.
Anatomy and Physiology of Rotation Flaps
The process of moving a local skin flap, such as a ‘rotational flap’, during surgery requires the doctor to understand the anatomy of the skin particularly its blood supply. The skin gets its blood supply from a network of blood vessels just under the surface, which send tiny blood vessels upwards through the layers of the skin. These layers include the deeper ‘reticular dermis’ and closer to the surface, the ‘papillary dermis’. On top of these is the ‘epidermis’, which itself is made of different layers. If the blood supply network is damaged during surgery, the skin can die because it will be too thick to function properly.
When considering facial surgery, the surgeon also needs to keep in mind 3 main factors to ensure a good cosmetic result: relaxed skin tension lines, lines of maximum extensibility, and the different aesthetic subunits of the face. Relaxed skin tension lines are the lines that wrinkles often form along, and the skin stretches most easily along the lines of maximum extensibility. These factors will dictate how a skin flap is designed so that the surgical cuts lie along these lines or within the aesthetic boundaries and avoid twisting that may distort the look of sensitive structures such as the lips, eyebrows, and eyelids. The different aesthetic sections of the face include the forehead, areas around the eyes, nose, cheeks, the area around the mouth, and chin. Some of these like the nose and areas around the eyes are further split into smaller units. The lines that separate these units may also be used to hide surgical cuts.
Why do People Need Rotation Flaps
Rotation flaps are used in certain cosmetic surgeries, when simpler methods don’t provide satisfactory results in terms of function or appearance. They are essentially a technique used to close wounds or fill gaps after surgery, and can be utilized in various places on the body. They are most often recommended for use on the side of the face, cheeks, chin, and scalp.
Rotation flaps are especially beneficial when it comes to reducing tension around an open edge, to avoid any distortion or unevenness. This can be critical when reconstructing delicate features like eyebrows and lips.
There are different types of rotation flaps, such as Tenzel flaps and Mustardé flaps, which have specific uses depending on the situation at hand. These can be discussed further with your healthcare provider or surgeon to understand the best approach for your condition.
When a Person Should Avoid Rotation Flaps
Before creating a skin flap, a surgical technique to repair a wound, some factors need to be considered. If a patient has a cancer that has not been fully removed, skin flaps should not be used. The reason is that there may be hidden cancer cells, which could unfortunately grow unnoticed under the flap for years. This can cause further trouble as the cancer can also spread to the underlying skin layer.
Because of these concerns, skin flaps are usually created after a special kind of surgery, called Mohs micrographic surgery. This technique is really good at making sure all the cancer is removed. Also, doctors need to check if a patient has signs of cancer within or near the area where the skin flap is planned. The use of skin flaps can limit options for closing future wounds in the area, so other methods may need to be chosen.
It is also important that the doctor takes into account the patient’s overall health status and access to healthcare. This may require a different method for closing the wound. The health of the blood vessels in the skin flap and the strength of the skin flap can also be affected by individual health factors. For instance, if the skin flap is created from scarred skin or an area that has undergone radiation treatment, it might not have a healthy supply of blood. As a result, other ways to fix the wound should be considered.
There are other factors that might make the use of skin flaps less suitable. For example, a higher chance of bleeding and a patient’s smoking habit might be among these. Smokers generally have a higher risk of post-surgery complications. They particularly face a higher risk of skin flap failure due to poor blood supply. Hence, other wound closure methods might be a better choice. Smokers should be encouraged to either quit or reduce smoking before and after the surgery to increase the chances of the skin flap surviving. Patients who are on blood-thinning medications also have a higher risk of bleeding during and after the surgery, which can negatively affect the survival of the skin flap. However, they are still recommended to continue their medication for skin-related surgeries. In this scenario, a surgeon should carefully plan the wound closure to decrease the chance of complications.
Equipment used for Rotation Flaps
The tools a doctor might use for a procedure called a rotational flap transfer can differ depending on the doctor’s preference. However, here are some examples of the kinds of tools they might use:
The first thing the doctor will need is a local anesthetic agent, like 1% lidocaine with 1:100,000 epinephrine, inside a hypodermic syringe. This is a drug that numbs a specific area of your body so you won’t feel any pain during the procedure.
The doctor will also need to clean your skin before beginning the procedure to prevent infection. They may use a skin cleanser like povidone-iodine, chlorhexidine, or isopropyl alcohol.
A fine-tip surgical marker will be used to make precise marks on your skin, and a scalpel, typically with a #15 blade or finer for small facial flaps, will be used to make cuts.
Adson-Brown or 0.5 mm Castroviejo forceps are kinds of tweezers that the doctor might use in your procedure. They may also use special kinds of scissors like Kaye blepharoplasty, iris, or Westcott scissors.
Halsey or Castroviejo needle drivers are used to hold the needle when the doctor is stitching a wound closed. Joseph and/or Guthrie two-pronged skin hooks might be used to help the doctor peel back your skin during surgery.
Bipolar electrocautery forceps and a fine-tip monopolar electrocautery pencil are tools that use electricity to control bleeding.
After making incisions, the doctor will need to stitch the wounds closed using suture scissors and skin sutures, possibly of a type called 6-0 polypropylene. They may also use a deep dermal suture like 5-0 poliglecaprone.
After your procedure, the doctor will probably use a topical antibiotic ointment, most likely bacitracin or mupirocin, to prevent infection. They’ll also use dressing supplies as needed to cover your wound.
Who is needed to perform Rotation Flaps?
Performing a procedure known as a rotational flap involves a team of professionals. This team includes a surgeon, who leads the procedure, and an assistant, who could be a nurse or a surgical tech (a person trained to prepare for and assist during a surgery). For bigger or more complex treatments, it’s helpful to have both a nurse and a surgical tech present. Sometimes, if the procedure is especially large or complicated, you might need to be put to sleep (sedation) or made completely unconscious (general anesthesia). If this is the case, an extra professional known as an anesthesia provider will join the team. This person’s job is to safely handle the anesthesia. All these professionals work together to ensure your procedure goes smoothly and safely.
Preparing for Rotation Flaps
In cases where reconstructive surgery is required, there are usually different methods or options available. Before any procedure, it’s recommended to have a discussion with the patient about these options to manage their expectations. If the patient is comfortable, showing them the affected area before reconstruction can give them an idea of what recovery and scarring might look like.
Before surgery, the area needing surgery is photographed for the patient’s medical records, and a ruler or measuring tape is often included in the photo to show the size of the area clearly.
In preparation for the surgery, the affected area and surrounding skin are numbed with a local anesthetic, which is a drug that blocks out pain in a small area of the body. A medicine called epinephrine is added to help control bleeding. Extra anesthetic is kept ready in case the patient feels any discomfort during the surgery.
The skin is then cleaned, either before or after the numbing medicine is injected, to make the area germ-free. When injecting the anesthetic, only a small amount is used to avoid altering the look of the skin around the affected area. The skin is cleaned with one of several substances, such as povidone iodine, chlorhexidine, or rubbing (isopropyl) alcohol, based on what the surgeon prefers. Surgeons may prefer to use colorless cleaning agents to make it easier to match the color and texture of the skin during surgery.
After the skin has been cleaned, the surgeon will mark out the planned area for the surgery. It’s crucial that this marking is done after the cleaning process, as the cleaning agent could cause any pre-marked indications to blur or disappear entirely.
How is Rotation Flaps performed
Rotation flaps are a type of skin flap used in surgeries to cover wounds or fill gaps in tissue. These flaps are named for the rotational movement used to move them into place. These flaps along with an advancement technique, where tissue is moved forward to close a wound, are especially helpful for closing triangular wounds. To use a single rotation flap for a circular wound, the wound is first reshaped into a triangular form aligning with the rotation of the tissue. The triangle’s apex, or highest point, should point towards the center of rotation with its base lining up with the arc of the flap. To avoid any unwanted skin protrusions near the pivot point of the flap, the wound should ideally be reshaped into an isosceles triangle (a triangle with two equal sides) before the flap is applied.
One important detail to note about rotation flaps is a particular limitation known as pivotal restraint, which can prevent the flap from fully covering a wound. It occurs at the farthest point of the curved incision from the wound that acts as the pivot. This tissue restraint can be mitigated by carefully separating the skin layers around the pivot point (termed undermining) to give the flap more mobility. However, over-undoing this process can disconnect the blood supply to the flap, so it must be done with caution.
Rotation flaps need to be carefully designed to fully cover a wound. To reduce pivotal restraint, the arc’s radius (the distance from the center of the circle to the circle’s edge) should be bigger than the wound’s length. Additionally, the flap could be adjusted to move more horizontally, bringing more tension. Lastly, a back cut, which is an extension cut at the far end of the incision, could be done. This brings the pivot point closer to the wound and thus decreases pivotal restraint. However, this might compromise blood supply as it narrows the tissue carrying the blood vessels to the flap (the pedicle).
Rotation flaps should have an arc angle of more than 90 degrees for even tension distribution. An angle below 90 degrees could cause high tension at closure, causing the wound to reopen. A higher angle, over 180 degrees, redirects the tension which might have been helpful in primary wound closure. It’s important to strike a balance in the arc angle to reduce unwanted tension while closing the wound.
Rotation flaps are typically used for closing larger wounds but might cause some skin protrusions due to tension. They typically result in a standing cutaneous deformity or a standing cone at the end of the rotation arc. These can be corrected through a few techniques such as taking a Burow’s triangle which is a triangle shaped piece of skin usually on the end of the incision, or using sutures to compress and distribute the excess tissue over the wound’s length.
In the case of larger wounds, double rotation flaps may be employed. They involve two flaps that simultaneously move in opposite directions to meet in the middle and close the defect. Another variation of double rotation flaps is O to Z flaps, usually used on the scalp or large lesions on the trunk, where two flaps rotate in opposite directions from opposite ends of the wound to close the defect. Utilizing both these methods allows for the closure of larger wounds that single rotation flaps may not cover.
Possible Complications of Rotation Flaps
If someone gets a type of skin repair surgery called a rotational flap transfer, there can be a few complications, though good planning and careful technique can often prevent them. Here’s what could happen:
1. Excessive tension on the skin, either during or after the surgery, can distort the tissue around the operated area. If the rotated skin flap doesn’t balance the skin tension properly, it can distort delicate areas like the eyelids or lips.
2. The relocated flap can cause two different cosmetic issues if not sized or placed correctly. A “trapdoor deformity” is a depression in the skin because the flap wasn’t thick enough or didn’t have enough support underneath. A “pincushion deformity,” on the other hand, is a raised area of skin. This happens when the flap is too thick or too big for the area, and it wasn’t trimmed down enough to fit properly.
3. Flap necrosis is a condition where the flapped skin dies due to lack of blood flow. It can happen if the base of the flap (the pedicle) is too narrow to support it or if the flap is too thin and doesn’t get enough blood. This condition could leave a dark, hard scab (eschar) on the skin. It isn’t always easy to tell how much of the skin flap is still alive underneath the scab, but it’s essential to avoid peeling (debriding) the scab until the area underneath has healed. Sometimes, the top layer of skin (epidermis) peels off, but the tissue underneath can still heal. Even if the whole flap dies, the scab that forms can help protect the area underneath as it heals.
4. An infection at the surgical site is another possible complication. If a doctor suspects an infection, they will make a culture from the wound and may prescribe antibiotics that work against a common skin bacterium (staphylococcus) until the bacteria causing the infection can be identified. If there’s a lot of pus, the skin might need to be opened again, cleaned, and any foreign materials like stitches must be removed.
5. Dehiscence is when the healed skin splits open again. This can happen because of too much tension on the skin or an infection. If the split happens within 24 hours after surgery, it can be closed again, but doing so later might increase the risk of infection. Usually, these reopenings are left to heal on their own.
6. Bleeding is a potential complication, though most cases can be managed by applying continuous, firm pressure to the wound. Sometimes the wound might need to be reopened to stop the bleeding. This bleeding might also cause a build-up of blood (hematoma) under the skin. Hematomas can either be drained or left to reabsorb with time. However, they might create an environment for an infection, in which case antibiotics may be needed. If a hematoma grows, it needs to be removed by reopening the wound, which can also stop any bleeding and prevent pressure on the skin flap that could reduce its blood supply.
What Else Should I Know About Rotation Flaps?
Rotation flaps are a kind of surgical treatment that, when done properly, can offer many useful solutions. They’re particularly good for fixing small to medium-sized issues with soft tissues, like muscles or ligaments. The procedure can provide excellent results functionally and cosmetically. That means it not only helps the body work better, but it also improves the look of the affected area. Proper planning and execution are vital to ensure successful outcomes.
