Variables for using flaps

May 1, 2007

The science of flap procedures has been refined by many leading dermatologic surgeons, but each surgeon prefers his or her methods when approaching a flap surgery. One expert details his particular techniques and explains when and why he uses them.

Key Points

Pittsburgh - Most dermatologic surgeons implement their own special methods when approaching a surgical procedure.

According to one specialist, the execution of a successful flap procedure in dermatologic surgery highly depends on the detailed planning of the procedure, as well as a complete understanding of the dynamics of the tissues.

"When I approach a flap procedure, I always first define the 'what' and the 'how' of what needs to be done. I define the 'what' as the three D's - meaning, defect, donor pool and directive," says David G. Brodland, M.D., assistant professor of the departments of dermatology and otolaryngology at the University of Pittsburgh.

"The discussion of options with the patient will often help you choose the best closure," Dr. Brodland tells Dermatology Times.

Mix of approaches

Dr. Brodland says he basically uses six methods in his flap procedures, and uses the acronym STARTS - for simple primary, transposition, advancement, rotation, tissue importation (two-stage) and skin graft - to be sure to consider each closure method while planning a reconstruction.

He breaks down the flap categories according to the movement dynamics of the tissue.

Choosing an option

According to Dr. Brodland, the sliding flaps can either be simple side-to-side closures, a Burrow's flap, an A to T flap, double tangent flaps (U-flap and H-flap) and rotation flaps.

He says these can all be thought of as "Burrow's triangle displacement flaps."

"I opt to use sliding flaps when the adjacent skin has adequate intrinsic elasticity, when there is a structure in the way of an elliptical closure, or when I want to displace a triangle(s) to a more strategic position, assuming that there is a sufficient vascular supply," Dr. Brodland says.

When using tissue rearrangement flaps, the rearrangement is usually completed by transposition. These flaps can either be a Z-plasty, a rhombic flap, a bilobed flap or transposition flaps such as Dufourmental, Webster 30 degree, or banner, among others.

"I use rearrangement flaps if the adjacent tissue has enough laxity, if the defect is near distortable and/or free margins, and if the orientation of skin laxity is in an inconvenient direction relative to the defect," Dr. Brodland explains.

He says that he categorizes IPFs as defect reconfiguration flaps that are extremely tissue-conservative.

According to Dr. Brodland, these flaps are completely dependent on the stretch of the pedicle and the adequacy of the vascularity of the pedicle. Therefore, these flaps are best used when there is loose, spongy subcutaneous tissue underlying the flap. The blood supply to the pedicle(s) must be sufficient to sustain the flap. Dr. Brodland says that the IPF scar lines hide well within the RSTLs and borders of cosmetic units, and this is an excellent option when the conservation of tissue is critical.

Dr. Brodland adds that he uses importation flaps in defects that can not be closed by adjacent flaps, and when grafts are not possible or not desirable.

"Importation flaps will provide superior reconstruction results in defects where it is crucial to rebuild infrastructure, as in large nose or ear wounds. These flaps serve to provide adequate blood supply for and promote engraftment of cartilage used to rebuild the infrastructure," Dr. Brodland says.