Overview
Definition:
A rotation flap is a surgical technique used in reconstructive surgery to cover tissue defects by mobilizing adjacent tissue on a vascular pedicle
The flap is designed to pivot or rotate into the defect area.
Epidemiology:
Not applicable as it is a surgical technique rather than a disease
Its use is widespread across various surgical specialties including plastic, reconstructive, head and neck, and limb salvage surgery.
Clinical Significance:
Rotation flaps are fundamental for reconstructing defects where primary closure is not feasible or would result in unacceptable tension or distortion
They allow for the transfer of well-vascularized tissue to cover exposed vital structures, restore contour, and improve aesthetic outcomes, thereby enhancing patient quality of life.
Indications
Defect Size And Shape:
Large or complex defects that cannot be closed primarily without tension
Defects with irregular shapes that can be accommodated by the arc of rotation of the flap.
Tissue Loss:
Loss of skin and subcutaneous tissue due to trauma, excision of tumors (e.g., basal cell carcinoma, squamous cell carcinoma), burns, or infections.
Anatomical Location:
Areas where adjacent healthy tissue is available for mobilization, such as the scalp, face, neck, chest, and extremities.
Coverage Needs:
Requirement for covering exposed bone, cartilage, tendons, nerves, or vessels where healthy, well-vascularized tissue is paramount.
Flap Design Principles
Base Width Ratio:
The base of the flap should generally be wider than its distal end to ensure adequate blood supply
A common ratio is 1:1 or 1:2 (distal:base), though this can vary based on flap type and location.
Arc Of Rotation:
The flap must be designed to reach the defect without excessive tension
The pivot point (center of rotation) is critical in determining the arc the flap can cover.
Pedicle Length:
The pedicle length should be sufficient to allow rotation into the defect but not so long that it compromises vascularity or creates excessive drag.
Donor Site Considerations:
The donor site should ideally be closed primarily, or if large, may require secondary closure, grafting, or another flap
Aesthetic and functional outcome at the donor site are crucial.
Tissue Type:
Selection of flap tissue based on the recipient site requirements for thickness, pliability, hair-bearing characteristics, and color match.
Preoperative Planning
Patient Assessment:
Evaluation of patient's overall health, comorbidities, nutritional status, and smoking history, which can impact healing and flap viability.
Defect Analysis:
Precise measurement of the defect size, depth, and shape
Assessment of surrounding tissue quality and laxity.
Vascular Supply Considerations:
Identifying major vessels in the vicinity that could potentially supply the flap or need to be preserved.
Marking The Flap:
Careful preoperative marking of the flap boundaries, base, pivot point, and planned incision lines on the skin.
Flap Inset
Mobilization:
Careful dissection of the flap from its bed, preserving the subdermal vascular plexus and the pedicle
Dissection plane is typically superficial to the muscle fascia.
Anchoring Sutures:
Securing the flap edges to the recipient site bed with fine sutures to prevent shearing forces and ensure good tissue contact.
Tension Management:
Achieving a tension-free closure of the flap at the recipient site
This may involve undermining recipient tissues or careful positioning.
Donor Site Closure:
Primary closure of the donor site when possible
If primary closure is not feasible, consideration for skin grafting or secondary healing.
Dressing:
Application of a non-adherent dressing over the flap and a bolster or compressive dressing to minimize hematoma formation and maintain flap integrity.
Complications
Flap Necrosis:
Partial or complete loss of the flap due to inadequate vascular supply, hematoma, infection, or excessive tension
Can be caused by kinking or torsion of the pedicle.
Hematoma Seroma:
Accumulation of blood or serous fluid under the flap, which can compromise vascularity and increase infection risk
Requires prompt drainage.
Infection:
Bacterial contamination of the wound or flap, potentially leading to delayed healing or flap loss.
Granulation Tissue Formation:
Excessive granulation tissue at the flap edge, which can hinder closure and may require debridement.
Poor Aesthetic Outcome:
Mismatch in color, texture, or contour
scarring
distortion of surrounding structures
or hair growth in an undesirable area.
Key Points
Exam Focus:
Understand the basic principles of flap design: base width, pivot point, arc of rotation, and pedicle length
Recall indications for use and common complications
Differentiate from other flap types.
Clinical Pearls:
Always err on the side of a wider base and shorter pedicle to ensure vascularity
Gentle handling of flap tissues is paramount
Meticulous hemostasis is critical during dissection
Consider patient's ability to tolerate surgery and potential donor site morbidity.
Common Mistakes:
Designing a flap that is too narrow or too long
Failing to adequately assess the vascular supply
Excessive tension on the flap during inset
Inadequate closure of the donor site
Poor postoperative monitoring for signs of compromised flap viability.