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  • Rotation flaps recruit tissue via rotational movement around a pivot point and rely on tissue laxity adjacent to the surgical defect.

  • Tension vectors can be dispersed variably across the arcuate path of the flap, and there are two areas where tissue redundancy becomes evident—the pivot point adjacent to the primary defect and the flap base at the end of the arcuate incision.

image Beginner Pearls

  • Pivot point redundancy can be removed as a standing cone either before (“triangulating” the defect) or after inset of the flap; flap-base redundancy can be redistributed by meticulous rule-of-halves suturing or removed as a standing cone.

  • All rotation flaps are subject to rotational shortening and pivotal restraint—as the flap tip rotates inward to fill the primary defect, the arc length of the flap decreases, which can be solved by oversizing the flap.

image Expert Pearls

  • A backcut can further reduce pivotal restraint and assist in rotating the flap into place, though it also reduces the width of the pedicle and may compromise flap perfusion.

  • Rotation flaps may be very useful on the nose; always keep in mind that the undermining plane should be submuscular.

image Don’t Forget!

  • A double rotation flap comprising two traditional rotation flaps taking off from the opposite sides of the defect can be useful in areas of high tension.

  • The comet (or dog-ear rotation) flap combines a primary closure of one end of the defect with the creation of a rotation flap from the tissue redundancy at the other end of the defect, and is particularly useful on the cheek.

image Pitfalls and Cautions

  • Large cheek flaps may result in ectropion; this risk may be reduced by using suspension sutures and oversizing the flap.

  • Other complications include persistent lower eyelid edema and textural mismatch.

  • The long secondary defects created by rotation flaps may lead to secondary tissue movement and free-margin compromise.

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.


Rotation flaps are local cutaneous flaps that rely on tissue laxity adjacent to the surgical defect in order to accomplish closure. By design, these flaps recruit tissue via rotational movement around a pivot point. Rotation flaps are overwhelmingly random pattern flaps deriving blood supply ...

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