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  • Understanding flap dynamics is a prerequisite for the performance of any flap procedures.

  • Advancement flaps can be conceptualized as geometric variations of linear repairs with dog-ear redistribution.

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

  • The ability of transposition flaps to push tissue into the defect by redirecting tension vectors perpendicular to the primary closure direction, coupled with their ability to close a defect using a smaller total surface area than sliding flaps (and the possible added benefit of a broken-up repair line), make these flaps particularly useful for larger defects.

image Beginner Tips

  • Understanding flap dynamics is predicated on an appreciation of the forces that oppose tissue movement.

  • Undermining mitigates most deep restraint, while horizontal restraint is addressed by using a sufficiently lengthy incision that recruits lax skin.

image Expert Tips

  • Horizontal, deep, and pivotal restraints must all be addressed for optimal flap outcomes.

  • Obstructive restraint can be addressed prior to flap movement.

  • On the face, the robust blood supply means that even random pattern flaps may behave more like axial flaps in terms of viability.

image Don’t Forget!

  • Undermining beyond 1 to 2 cm from the incision line may be counterproductive and lead to an increased risk of tissue ischemia.

  • Flap length:width ratios should ideally not be significantly greater than 3:1, at least when working in poorly perfused areas such as the legs. On the face, there is often a forgiving and robust blood supply.

image Pitfalls and Cautions

  • Failing to account for pivotal restraint is one of the most common flap design challenges. Appropriately oversizing rotation flaps and widely undermining the pivot point may go a long way to mitigating this problem.

  • Once relocated to the primary defect, flaps should be under minimal tension.

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.

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


Linear closures are the preferred technique to approach most defects given their reliability, predictability, and low rate of dehiscence or infection. At times, however, repairs performed by clinicians in the primary care or emergency room setting may necessitate more complex closures such as random pattern flaps.

These advanced techniques assume a higher level of familiarity with tissue movement, anatomy, and surgical technique than linear approaches to closure, but concomitantly permit ...

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