PARTICULAR FLAPS

ROTATION FLAPS

INDICATIONS Large defects, especially triangular ones, if there is sufficient space to raise a large enough flap, especially on a patient’s scalp, buttocks, thighs, or trunk.

CONTRAINDICATIONS (1) Parts of the body where a patient’s skin is tight, or his circulation is poor, as in his hand and below his knee. (2) Don’t make a rotation flap over bone (other than the skull) or over tendon.

METHOD If possible, plan the flap so that its base is proximal. Give it as wide a base as possible so as to make sure it has an adequate blood supply and will not necrose.

CAUTION! Don’t let its base exceed its length.

Excise the defect cleanly to form a triangle as in Fig. 57-16. Extend the side of the triangle in a curved incision 4 to 5 times its length. Undermine the flap widely and twist it so as to distribute the tension in a wide area along the suture line.

If you cannot get the flap to rotate sufficiently, make a small right angled cut at the end of the curved line.

If a dog ear forms, don’t excise it immediately, because this may compromise the blood supply to the flap. Leave it, and if necessary, excise it later. Or, cut a small triangle and sew it up as in E, and F. If there is a gap, close it with a split skin graft, or let it granulate.

Figure 57.20: PLANNING A TRANSPOSITION FLAP. In the example here a lesion over the patient’s heel has been excised and a flap moved across to cover it. The area where the flap has come from is larger and will have to be graftedd, but it is no longer over a pressure area. Don’t take skin from the ball of his heel—it is very specialized. The same method is applicable whenever you move skin from one place to another. With the kind permission of James Smith.

DOUBLE PEDICLE ADVANCEMENT FLAPS

Make an incision parallel to the wound and some way away from it, so as to make a flap not more than twice the length of its base. Dissect the flap and the fat free and displace it as required. Close the secondary defect with a skin graft.

CAUTION! (1) Don’t make these on the lower leg, and particularly not on the shin, because the blood supply here is inadequate. (2) Don’t exceed the 1:1 length to breadth ratio.

Figure 57.21: A W–PLASTY is a cosmetic procedure which will make a scar less obvious. Use a pattern, and make sure that the triangles fit neaty together.