Chapter 9 - ADVANCEMENT FLAPS

Abstract

Advancement flaps have a linear configuration and are moved by sliding toward the defect. This involves stretching the skin of the flap. Thus advancement flaps work best in areas of greater skin elasticity. Most local cutaneous flaps used in the head and neck have some component of advancement during movement of the flap to the recipient site. Nevertheless, the term advancement flap usually refers to a flap created by incisions that allow for a “sliding” movement of the tissue. Tissue transfer is achieved by moving the flap and its pedicle in a single vector. The greatest wound closure tension is perpendicular to the distal border of the flap. Advancement flaps may be categorized as unipedicle, bipedicle, V-to-Y, Y-to-V, or subcutaneous tissue pedicled island flap. By necessity, all advancement flaps must be designed so that the advancing border of the flap also represents a margin of the cutaneous defect that the flap is designed to repair. Bipedicle advancement flaps are rarely used in facial reconstruction. Bilateral unipedicle advancement flaps are commonly combined to close various defects, resulting in an H-shaped wound closure line (H-plasty). T-plasty represents a modification of bilateral unipedicle advancement flaps. Instead of making two parallel incisions to create each of the flaps, only one incision on opposing sides of the defect is made. The two flaps are advanced and slightly pivoted toward each other to repair the defect. A standing cutaneous deformity develops at the defect site opposite the position of the two incisions. This deformity is excised and the wound repaired, giving the final suture line a T configuration. Like the T-plasty, V-to-Y and Y-to-V advancement flaps do not require two parallel incisions to create the flap. The V-to-Y advancement flap is unique in that the V-shaped flap is not stretched toward the recipient site but rather achieves its advancement by recoil or by being pushed forward. In contrast, the Y-to-V advancement flap is stretched or pulled toward a linear incision made at the apex of the triangular-shaped flap. The flap is advanced into the void and sutured in place. The wound closure suture line assumes a V configuration. The maximal wound closure tension is at the apex of the flap. The subcutaneous tissue pedicle island advancement flap is a unipedicle advancement flap without a cutaneous component to the pedicle. The pedicle of the flap consists only of subcutaneous tissue, which is usually fat. The flap depends on the sliding motion of its subcutaneous pedicle for advancement. Thus the flap can be most easily advanced in areas where there is an abundance of subcutaneous facial fat.