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ADVANCEMENT FLAPS

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SUMMARY

  • Advancement flaps are among the most frequently performed flaps in dermatologic surgery.

  • These flaps may be conceptualized as a geometric variation of a linear closure, resulting in dog-ear redistribution and tension release.

image Beginner Tips

  • Advancement flaps may seem deceptively simple; handling of the displaced dog ears, however, requires a thorough appreciation of tissue dynamics.

  • As with all flaps, advancement flaps lead to a significantly extended suture line compared with a linear closure. Therefore, attention to detail in suturing techniques is of vital importance to camouflage the scar as effectively as possible.

image Expert Tips

  • Combining advancement flaps with suspension (tacking) sutures may be very useful around free margins.

  • Advancement flaps may be combined with other approaches such as grafts (typically Burow’s grafts harvested from the dog ears), partial closures, and SMAS plication.

  • Crescentic advancement flaps may obviate the need for secondary dog-ear removal.

image Don’t Forget!

  • Excessive undermining may be unnecessary and may increase the risk of tissue ischemia.

  • Always keep in mind the maximal flap length to pedicle width ratios when designing advancement flaps.

image Pitfalls and Cautions

  • Never force an advancement flap; while this design may seem most straightforward, some situations call for other approaches.

  • Always tailor flap design to the individual patient; flap elevation and undermining in patients on aspirin or anticoagulants may increase the risk of hematoma formation.

  • When in doubt, consider drain placement in these patients, even after meticulous hemostasis has been obtained.

image Patient Education Points

  • Patients should be warned prior to flap closure that they will have an incision stretching well beyond the initially visible defect.

  • Explaining that the additional scar length will likely heal with a minimally visible line may go a long way toward patient reassurance.

image Billing Pearls

  • Flap repair codes (140XX series) include the excision component, so it is not appropriate to bill both an excision and a flap repair code simultaneously.

  • Mohs codes may be submitted along with flap repair codes, though they may be subject to the multiple procedure reduction rule.

  • When coding a flap, medical necessity is the ultimate arbiter of appropriateness.

INTRODUCTION

Local random pattern flaps are workhorse reconstructive options for cutaneous defects. Advancement flaps are conceptually the simplest local flaps and fall within the group of sliding flaps, in which tissue is moved directly into the adjacent defect without lifting it over interposed tissue. Unlike rotation flaps, pure advancement flaps do not create significant secondary defects, and the leading edge of an advancement flap is not typically restricted significantly by pivotal restraint.

PRINCIPLES OF ADVANCEMENT FLAP DESIGN

Advancement flaps may be conceptualized as modified linear closures, with one or both apical standing cones (dog ears) moved laterally to facilitate aesthetic or functional closure. When a free margin such as the ...

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