Bilateral advancement flap, T-plasty (AT flap)

The standard bilateral T-plasty repair or AT (A to T) flap can be a great improvement

over the unilateral and bilateral rectangular advancement flaps in most facial locations.
In the AT repair, a linear repair of the operative wound is designed perpendicular to a
free margin or to a pre-existing cosmetic junction (Fig. 17.4). Instead of extending a
primary linear repair across a cosmetic boundary or free margin, incisions are designed
along the margin of the operative defect, a free margin, or a cosmetic boundary,
perpendicular to the linear repair axis. In this manner, one line of the repair is hidden in
a cosmetic junction or dynamic rhytid.

Closely related to the AT advancement flap is the OT rotation flap. Conceptually

similar, the flaps both create a T-shaped incision. Where the AT flap relies upon linear
tissue advancement, the OT flap relies upon flap rotation. The AT flap is useful for
perialar defects where the top of the T can be hidden in the alar crease and the vertical
limb of the T can be hidden in the nasolabial fold. Above the brow or on the forehead,
the base of an inverted T can be hidden either just above or just below the brow or
within a horizontal forehead rhytid. The vertical scar that results from this repair may be
somewhat visible, but it generally fades nicely over time if the flap is not closed under
tension. Although the classic AT flap is rather simplistic from a design perspective,
great care must be taken to align the advancing tissue edges. If the leading edges of the
advancement(s) traverse a great distance to close a large defect, distracting dog-ear
redundancies can be produced. Sometimes these tissue redundancies need to be excised
in the areas that the surgeon was initially reluctant to manipulate, so undermining flap
utility. Often, a single limb advancement flap will suffice to displace a dog ear far away
from a free margin into a natural crease. Whenever possible a single limb advancement
flap is favored because its inherent simplicity in design minimizes suture lines.
As with all facial flaps, advancement flaps are most useful when the incisions of the flap
can be hidden within cosmetic unit boundaries or along natural facial expression lines.

Commonly used sites for advancement flaps are the nasal sidewall superior to the alar
crease, the upper lateral lip superior to the vermilion border, and the supraorbital
forehead lateral to the midpupillary line. For defects in these areas, a vertical limb
extends superiorly from the operative defect and a horizontal or nearly horizontal limb
extends laterally along a free margin (the alar crease, vermilion border, brow, or
forehead furrow) (Figs 17.5 and 17.6). A dog ear is then removed laterally either within
the alar groove or nasal fold, the oral commissure, or the lateral canthus or crows feet.

This Burows-type advancement flap can be viewed simplistically as a flap that

displaces the inferior dog-ear redundancy that would have resulted from a linear closure
to an anatomic site from which it may be much more appropriately excised (Figs 17.6

and 17.7).29,30 A similar advancement modification, first described by Webster,31 is often

used along the nasofacial sulcus for operative defects of the lateral nasal sidewall and
cheek or for defects adjacent to the nasal ala. In this case, a superior dog ear is removed
nearly vertically along the nasofacial sulcus while the inferior limb of the flap curves
around the ala as a crescent. A crescent of redundant tissue is removed inferiorly to
allow proper tissue advancement (Fig. 17.7). The concept of the crescentic advancement
flap may be extended to other common defects. This technique obviates the need for
dog-ear resection because this is accounted for in flap design with a crescent of excess
skin to be excised. Removing this crescent of tissue prevents unsightly tissue protrusion
in the area of flap harvesting.

Island pedicle flap

The island pedicle flap is a specialized advancement flap. The island pedicle flap differs
from other traditional advancement flaps in that most of its vascular supply derives from
a subcutaneous pedicle. Additionally, all dermal margins of the flap are severed as the
flap is advanced (hence the appropriate island nomenclature). The first island pedicle
flap was described by Celsus, but the first modern use of the island pedicle flap was by
Esser in 1917.32 Since the 1940s, many types of island pedicle flaps have been
described, the most common of which is a triangular flap that derives its blood supply
from a deep and mobile subcutaneous or muscular pedicle, which remains attached to
the central portion of the flap.33,34 In the plastic surgery literature, this traditional island
pedicle flap is frequently referred to as a V to Y advancement flap.35
The island pedicle flap is remarkable because the flap can be advanced as far as the
motion of the deep pedicle allows. This mobility is frequently much greater than a
similarly designed flap would advance if dermal margins that restrain flap motion were
retained at the peripheral margins of the flap (Fig. 17.8). In addition, the island pedicle
has a rich blood supply from underlying vessels and musculature and is not forced to

rely solely upon the anastomotic vascular network of the dermis for perfusion. As such,
the island pedicle flap is remarkably impervious to ischemia, even when the flap is
inserted under considerable wound closure tension.

Because the traditional island pedicle flap has a conspicuous kite-shaped outline, its
greatest use is in locations where one or two of the margins of the flap can be hidden
within a contour line or aesthetic unit boundary. Surgical defects on the upper lip near
the noselipcheek junction and on the lateral nasal sidewall are particularly well suited
for repair with an island pedicle flap (Figs 17.9 and 17.10). Additionally, the island
pedicle flap is useful in the reconstruction of the eyebrow, where the flap can advance
the remaining brow medially to recreate brow continuity and central facial symmetry.
Certain defects of the temple and forehead are likewise amenable to closure with either
a single or bipedicle island flap repair; however, in many of these cases, alternative
flaps that produce less conspicuous scars than the triangular-shaped scars of the island
pedicle flap are available.

In designing and executing the island pedicle flap, it is essential to predict the amount of
mobility that will be achieved when all peripheral margins of the flap have been
severed. Two centimeters in diameter or even larger wounds of the perinasal area of the
upper lip can be repaired with an island pedicle flap, but in general, defects on the nose
amenable to island pedicle flap repairs tend to be smaller (given the poor compliance of
stiff nasal skin and the inability to rely on secondary motion at the flaps insertion point
without producing distracting nasal asymmetry). The island pedicle flap is particularly
well suited to deeper operative wounds because it carries all tissue layers with it,
including skin, subcutaneous tissue, and some skeletal muscle. Additionally, the flaps
rich vascular supply makes it appropriate for repairs in areas of compromised skin
vascularity (such as areas of chronic radiation damage).
Proper design and execution of an island pedicle flap are necessary for an aesthetic
repair. Because the flap has a thick base, it is particularly subject to developing a
protuberant appearance (the pin-cushioned or trapdoor deformity) during the early
postoperative period. The development of the trapdoor deformity with this flap is
common when the flap is used to repair wounds on the medial cheek and lip, and this
globular appearance may be permanent. One solution may be to design a flap that has a
smaller breadth than the diameter of the primary surgical defect and will still generally
allow for closure of the operative wound by relying upon secondary motion of the skin
edge of the wound. This slight undersizing of the flap places modest wound tension on
the lateral aspects of the island pedicle flap, which theoretically diminishes
postoperative contraction of the flap and the risk of developing a subsequent trapdoor
deformation.36 The flap is incised with either strictly vertical incisions or with slightly
outwardly beveled incisions that include the adjacent deep subcutaneous fat or
underlying muscle. The peripheral margins of the flaps incisions are widely
undermined, as is the primary defect. The tapering tail (approximately the distal third)
of the flap must be freed completely from any lateral or deep restraint, either by blunt or
sharp undermining. This tethering of the tail of the flap is usually the primary area of
restraint that inhibits the flaps mobility.

Because the flap must be deeply undermined vertically but not across its base to allow
proper flap mobility, a thorough knowledge of the underlying anatomy is required. This
undermining is generally carried out just over the superficial fascia. In addition to
freeing the flaps tail, the surgeon may need to undermine the leading edge of the island
pedicle flap to some extent (rarely more than 1 cm) to allow the flap to advance with
minimal wound closure tension and to prevent inversion as a result of tethering of the
leading edge. Failure to minimize the flap tension can result in unanticipated and
undesirable secondary motion near the flaps insertion point. In critical areas, such as
along the free margin of the eyelid, this secondary motion can produce aesthetically
significant distortion (an ectropion, for example).
The flap itself should be inset slightly into the operative defect and secured with several
deep sutures, and a flap that is initially slightly concave will eventually heal as a flap
that is appropriately flush with the surrounding skin. This flap recession can be
routinely achieved, as mentioned above, by slightly undersizing the flap and by suturing
the flap under slightly increased wound tension.
In addition to the traditional design, many variants of the island pedicle flap have been
discussed in the reconstructive literature. Curved island pedicle flaps can be particularly
useful on the nose, where the incision lines can be placed along the alar groove.37 Deepithelialized flaps or even flaps that have the entire pedicle buried in a subcutaneous
tunnel can occasionally be quite useful in the repair of deep nasal or medial canthal
wounds.38,39 Regardless of the design nuances, all island pedicle flaps have as their chief
advantage a healthy and protected vascular supply.

Mucosal advancement flap

For operative wounds restricted to the glabrous portion of the pink lip, repair choices
are often limited. Partial-thickness wounds that do not cross the vermilion border can be
allowed to heal by second intention with minimal scarring. For broader wounds, an
advancement flap from the remaining intraoral mucosa is often an appropriate repair.
The mucosal advancement flap is designed so that the incision line traverses the entire
horizontal length of the border between the cutaneous and the mucosal portions of the
lip. The flap is incised, and undermined between the plane of the minor salivary glands
and the underlying orbicularis oris musculature.40 This undermining plane protects the
perfusion of the flap while preserving the function of the underlying muscle. The flap is
sharply undermined from anterior to posterior, following the natural curvature of the lip.
Extensive undermining may be necessary into the intraoral mucosa to achieve proper
flap mobility; undermining is generally extended to the area where the mucosa reflects
onto the mandible. Using the principles of simple tissue advancement, the generously
liberated flap can then be advanced to cover even broad wounds on the lower lip.
Because the actual length of tissue advancement is relatively small and because the
mucosa is quite forgiving, dog-ear redundancies that result from tissue advancement are
not typically significant enough to require complete removal. Although the incision scar
of the mucosal advancement flap is often quite subtle, the modest tension required to
advance the flap typically results in a slightly flattened appearance of the lower lip.

Alternatively, an island pedicle flap can be designed by advancing mucosal skin

anteriorly to fill full-thickness defects of the pink lip that do not cross the vermilion
border. Advancement must proceed with minimal tension in the direction of primary
movement or lip distortion ensues. One adverse effect of moving mucosal lip onto the
exposed pink portion of the lip is long-term peeling of this new lip skin as a result of
metaplasia.

Bipedicle advancement flap

The bipedicle flap is a variant of a linear closure technique that also relies upon local
tissue advancement. The flap has its greatest use on the upper forehead41 and temple,
where a simple linear repair of a large defect may be associated with unacceptably high
wound closure tension or with the production of lateral canthal distortion. The flap is
constructed as a rectangular advancement of tissue that basically shares the diameter of
the original surgical defect equally between primary and secondary defects.
To design the flap, the surgical defect is envisioned as an elliptical side-to-side closure.
To minimize the tension that would be required to close the wound, a parallel incision of
equal length is placed several centimeters lateral or superior to the primary defect.
When both incisions have been made, a bipedicled, easily mobile flap is created (Fig.
17.11). The pedicled portion of skin between the defect and parallel incision is not
undermined such that it maintains a rich blood supply. The other aspects of the defect
and incision, however, are undermined to allow tissue advancement and closure with
minimal tension. Therefore, the diameter of the primary defect is effectively shared with
the secondary defect, and secondary motion around the original wound is minimized.
The scars that result from the construction of the flap consist of two fine parallel lines.

Rotation flaps
Many surgical wounds that cannot be closed side-to-side or with local tissue
advancement may be repaired by recruiting adjacent tissue laxity while directing wound

closure tension vectors away from the primary surgical defect. This redirection of
wound closure tension is the primary purpose of a rotation flap.
The design of a traditional rotation flap uses a curvilinear incision along an arc adjacent
to the primary surgical defect. As a rotation flap is created, the direction of wound
closure tension is effectively changed (Fig. 17.12). This allows a rotation flap to use
abundant donor tissue located a considerable distance from the primary defect to close
wounds in areas in which tissue availability is minimal. In addition to reorienting
tension vectors, rotation flaps also frequently allow for displacement of dog ears to
more favorable locations. If well designed, rotation flaps create scar lines that are
hidden along facial boundaries or within relaxed skin tension lines or are camouflaged
within hair-bearing skin (Figs 17.13 and 17.14).

As the rotation flap is raised and undermined, the laxity of the adjacent tissue allows the
flap to be rotated into the primary defect. Like all flaps, rotation flaps are hindered in
their movements by the inherent stiffness of the tissue, especially at the flaps pivot
point. Because of this pivotal restraint, the tip of the rotation flap will not extend to the
distal margin of the operative defect unless the tip of the flap is also advanced under
some tension and/or the recipient edge is mobilized toward the flap tip (secondary
motion). To compensate for pivotal restraint, minimize tension on the flap, and
eliminate the need for secondary motion around the operative defect, the arc of the
rotation can be oversized and offset so that it extends vertically beyond the distal extent
of the operative defect42 (Fig. 17.15). When the flaps rotation is subsequently executed,
the extended tip of the flap then rests without tension where it meets the distant point of
the primary defect. A rotation flap can often be closed without undermining beneath the
point of pivotal restraint; however, for optimal flap motion, this area of restraint should
be undermined (Fig. 17.16). This is particularly important with the dorsal nasal flap,
where maximal rotation is required to close a defect in the inelastic skin of the distal
nose.

Occasionally, a backcut into the rotation flaps body can improve flap mobility (Fig.
17.17), particularly on relatively immobile skin such as the scalp. This must be done
conservatively because cutting too far into the pedicle base may interfere with blood
supply to the flap. In addition to reorienting tension vectors, rotation flaps serve to
exchange primary defects for displaced secondary defects.