Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Single Advancement Flap Technique
• Sliding the Flap over the Defect
• Suturing the Corners and the Sides
• Application of Single Advancement Flap
• Bilateral Advancement Flap
• Joining the Centers and Corners of the Flaps
• Application of Bilateral Advancement Flap

• Local skin flaps provide a sophisticated approach to closing large skin defects. Advancement flaps represent some of the simplest and most commonly used flap techniques. Advancement flaps move adjacent tissue to close a defect without rotation or lateral movement.
• The blood supply for a single advancement flap comes from the base of the flap. If a long advancement flap is needed to stretch the skin for closure, the blood supply may be compromised to the flap tip. When closing a 1-in. in diameter defect on the face, single advancement flap should be no longer than 3 in. Single advancement flaps on less vascular areas of the body do better if limited to a length-to-width ratio of 2.5 to 1.
• 1 way to avoid long single advancement flaps is to pull skin from both directions; a bilateral advancement flap generally has less chance of flap tip necrosis. Long arms for single or bilateral advancement flaps are designed to align with the lines of least skin tension to improve the final cosmetic result.
• Preventing complications is an important aspect of performing flap surgery. Strict sterile technique is necessary to avoid wound infections. Avoid excessive stretching of the skin because necrosis will ensue. Wide undermining of the lateral tissue around the flap aids closure. Do not pull on the skin edges with forceps because careful handling prevents excessive scarring. Bleeding vessels should be clamped or suture-ligated before the flap is sutured, and pressure bandaging is advocated after the procedure.

Single Advancement Flap

• Closure of lateral eyebrow defects
• Repair of defects of temple area
• Closure of forehead defects
• Closure of cheek defects
• Closure of upper arm defects
• Closure of defects on tip of nose

Bilateral Advancement Flap

• Closure of defects on trunk or abdomen
• Closure of middle eyebrow defect
• Closure of forehead skin defects

Relative Contraindications

• Practitioner's unfamiliarity or inexperience with techniques
• Cellulitis in tissues
• Skin unable to be stretched to cover defect
• Chronic steroid use (and steroid skin effects)

• The single advancement flap technique is performed after administration of anesthesia (e.g., field block).
  • The lesion is removed with a rim of normal-appearing skin, and the defect is squared (Fig. 26-1A). The flap arms are incised, paralleling the lines of least skin tension, approximately 2 times the original defect's diameter (Fig. 26-1B). The flap and surrounding skin are undermined with a horizontally held scalpel blade (Fig. 26-1C).
  • Attempt to slide the flap to cover the defect using skin hooks on the flap. If the defect cannot be covered by the flap, the flap can be lengthened. Anchor the flap in place with 1–2 sutures (Fig. 2A). If there is tension on the sutures, vertical mattress sutures can be placed (see Chap. 16, Vertical Mattress Suture Placement).
  • Notice that skin bunches up (i.e., dog ears) near the base of the flap when the flap is moved. These dog ears are eliminated by excising triangular pieces of skin (i.e., Burrow's triangles) (Fig. 26-2B).
  • After removal of redundant tissue, the corners lie flat. Corner sutures can be placed for the 4 corners, and an interrupted suture is used to complete the flap (Fig. 26-3).
• After removal of a tumor in the lateral eyebrow, hair-bearing skin is used to close the defect (Fig. 26-4A). After removal of a tumor in the temple, hair-bearing skin is brought down from the scalp to close the defect (Fig. 26-4B).
  • A square defect is created around the tumor, and the flap arms are incised to about 1.5 times the diameter of defect (Fig. 26-5).
  • The centers of the flaps are joined with anchoring sutures, and the corner sutures are used to join the flap corners (Fig. 26-6A). Dog ears formed are smaller with bilateral advancement flaps and sometimes may not require excision. Smaller triangles are excised (Fig. 26-6B), and the completed flap is illustrated in Fig. 26-6C). A pressure bandage can be applied using gauze and elastic tape.
  • The middle eyebrow (Fig. 26-7A) and forehead (Fig. 26-7B) can be closed using this technique.

• Codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-Y plasty, rotation flaps, advancement flaps, and double-pedicle flaps.
• When applied to laceration repair, the defect must be developed by the surgeon, and these codes should not be used for direct closure of a defect that incidentally results in configuration of 1 of the flaps or plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes (see Chap. 14, Simple, Interrupted Skin Suture Placement).
• All of the following codes are for adjacent tissue transfer or rearrangement, and they refer to defects in trunk or the following sites: scalp, arms, or legs (SAL); forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet (FCCMNAGHF); and eyelids, nose, ears, or lips (ENEL).

CPT code	Description	2002 average 50th percentile fee (US$)
14000	Trunk 10 cm2	963
14001	Trunk 10.1–30.0 cm2	1,276
14020	SAL 10 cm2	1,231
14021	SAL 10.1–30.02	1,559
14040	FCCMNAGHF 10 cm2	1,400
14041	FCCMNAGHF 10.1–30.0 cm2	1,800
14060	ENEL 10 cm2	1,696
14061	ENEL 10.1–30.0 cm2	2,410
14300	Any unusual or complicated area >30 cm2	2,515

CPT is a trademark of the American Medical Association.