Summary: Rotation Flaps

•A rotation flap is a random pattern flap. The primary movement of a rotation flap is the sliding of tissue about a pivot point into a defect, redistributing wound tension as well as tissue redundancy. There are several variations including single and bilateral rotation flaps and dorsal nasal flaps.

33.5Rotation Flaps

In a rotation flap, skin moves into the defect by rotating around a pivot point (Fig. 33.9). This is classically used to close relatively large defects on the cheek, temple, or scalp. The design of the traditional rotation flap uses a curvilinear incision along an arc adjacent to the primary defect. Adjacent lax tissue is recruited while the closure tension is redirected in multiple directions away from the primary defect. The flap is designed with attention to its length and curvature [16]. Rotation flaps often require long incision lines, as a larger arc of the rotation vector allows closure with minimal tension on the flap’s tip while simultaneously decreasing the width of the secondary defect. The ideal arc of a rotation flap extends up to five times the width of the defect and makes up approximately one-quarter of the circumference of a circle.

As the flap is raised and undermined, the adjacent tissue laxity allows the flap to rotate into the primary defect. The stiffness about the pivot point may hinder the flap’s movement [16], and undermining the area of pivotal restraint improves flap mobility. If restraint of motion keeps the tip from moving into the distal defect, a back-cut can increase tissue movement in areas of limited tissue laxity, such as the nose. The back-cut cannot extend so far across the base of the flap that it interferes with blood flow into the flap.

33.5.1 Dorsal Nasal Rotation

Also known as the Rieger flap, this flap is employed to repair nasal defects involving the nasal dorsum or tip [17]. The tissue reservoir of the nasal root and glabella allows for the movement of the dorsal nasal skin

superior to the defect. A long, sweeping arc is created that extends into the nasofacial sulcus and terminates in the glabella. A back-cut in the glabella improves the rotational mobility of this flap and is termed a hatchet flap (Fig. 33.10). If the arc of this flap is not long enough or there is too much tension on the leading edge of the flap, elevation of the nasal tip will result. Wide undermining at the level of the perichondrium is required.

33.5.2 Bilateral Rotation

At times, the size of the defect or the tension on the flap mandates a bilateral rotation flap, in which tissue is rotated into a defect from two opposite sides. The vectors of rotation may be mirror images of each other, recapitulating the premise of the A–T advancement flap. This may be utilized for large defects on the scalp and larger defects on the lower mucosal lip (Fig. 33.11). The vectors of movement may also be in opposition, creating an O–Z flap, often used for large defects of the scalp.

Summary: Transposition Flaps

•A transposition flap is a random pattern flap. The primary movement of a transposition flap is not merely sliding but rather the lifting of the flap over intervening tissue, redistributing tension vectors. There are several variations of the rhombic, banner, and bilobed flaps.

33.6Transposition Flaps

A transposition flap is a random pattern flap that borrows skin laxity from an adjacent area in order to fill a defect in an area with little or no skin laxity. In its migration from the donor site to the recipient site, the flap is lifted over, or “transposed” with, a segment of intervening tissue. When the secondary defect is closed, the transposition flap pushes tissue into a defect rather than pulling it, as with the advancement and rotation flaps. The flap is rotated as it is transposed, and it must be designed so that it is not forced to rotate to such a degree that will result in too much tension/ torsion on its pedicle.