Background

A Rotation Flap Procedure is a category of local tissue transfer common in the specialty of plastic and reconstructive surgery. This technique is used to treat major congenital anomalies, malignant or benign skin tumor excisions, severe burns, trauma, or chronic ulcers. The process involves turning adjacent skin and fascia over the wound so that there is no need for skin grafts or distant tissue transfer.

Indications

Trauma 

After an accident or injury; especially with the loss of skin and tissue, so that there would be exposed bones, tendons, etc, rotating flaps can be applied to cover these exposed areas. 

Chronic Wounds 

This includes non-healing wounds or chronic wounds. These include such conditions as bedsores, pressure ulcers, diabetic foot ulcers, and others. Often, a rotating flap needs to close the defect and promote healing. 

Burns 

For example, with large burn wounds, when grafts of the skin are not sufficient or when considerable tissue loss has occurred, rotating flap procedures enhance closure and restore function. 

Scar Revision 

Rotating flaps improve appearance and mobility in cases where contracture or scars are functionally limiting or cosmetically concerning. 

Reconstruction of Congenital Defects 

Some of the congenital deformities are: 

Some patients have defects related to cleft lip or palate or any other deformity in the facial region. Some of these may benefit from a rotation flap procedure to achieve normal structure and function. 

Post-surgical Defects 

An example is the post-tumour surgery situation, after breast cancer or after head and neck cancers, to assist with closing the defect and further healing process, where a rotating flap is indicated. 

Contraindications

Inadequate Tissue for Flap Design: No sufficient tissue to be used in flap design.  

Rotating flaps cannot be raised if the surrounding tissue is not ample in elasticity, body or vascularity.  

Infection 

Acquired during the time at the Donor site or at the Recipient site. 

The infection at the site of the flap or around the area can slow the healing process and in severe cases result to flap necrosis or other complications.  

Smoking  

Microvascular circulation is highly and adversely affected within smokers, which leads to poor wound healing and higher incidences of flap necrosis.  

Malignancy at the Site 

If a malignancy is present at the site, reconstructing the area using this flap may not be possible until the cancerous growth is either treated or removed to avoid reoccurrence.  

Inadequate Recipient Site Preparation 

Recipient sites that are inadequately prepared such as those with excessive scar tissue, infection or radiation damage may not provide an appropriate environment for the healthy take of a rotating flap. 

Outcomes

Equipment

Scalpel and Blades 

Metzenbaum or Mayo Scissors 

Skin Hooks 

Mayo-Hegar or Castroviejo needle holders  

Forceps (Adson or DeBakey) 

Electrocautery Device 

Tissue Retractors 

Suture Materials 

Hemostatic Agents 

Doppler Probe 

Drain (e.g., Jackson-Pratt Drain) 

Patient preparation: 

Medical History: The patient’s medical history must be evaluated, and questions answered concerning such disorders as diabetes or vascular diseases and smoking habits of patients that significantly influence the healing of wounds.  

Postoperative Expectations: Explain the recovery process mainly the time taken for recovery and any after care needed after surgery.  

Flap Planning: Before surgery the surgeon should plan the area for the flap and plan the incisions in the direction according to the defect size, and location, and direction of the skin tension lines also known as Langer’s lines.  

Postoperative Expectations: Explain the treatment plan, the time the body takes to heal completely and essential post-operation care.  

Physical Examination: The choice of flap depends more on the evaluation of the defect or lesion and how the surrounding tissue is to be handled.  

Patient position:  

Depending on the surgical area, the position of the patient should facilitate access to that area Properly. 

Technique

Step 1: Preoperative Planning: 

Evaluate the Defect Measure its dimensions, shape, and location, estimate the tension that will be needed to close the defect, as well as the availability of tissue over the surrounding area. 

Flap Design: A curved skin incision should then be drawn alongside the defect; most of them are semicircular in shape. The radius of the flap is 3 to 4 times the size of the defect. The flap design must be planned while considering the tissue laxity and blood supply. 

Mark the Incisions: 

Flap Outline: Outline the flap from a pivot point situated adjacent to the defect. The arc length of the flap will be proportional to the defect size. 

Tension Reduction Lines: If necessary, draw additional incisions (Burow’s triangles) at the base of the flap to allow better mobilization and to avoid dog-ear deformities. 

Step 2: Anesthesia: 

It may be local or general anaesthesia depending on the area, size of the defect, the status of the patient and the condition.  

Step 3: Incision and Elevation of the Flap: 

Cut the Flap: Make an incision along the marked line with a scalpel, staying within the dermis and subcutaneous tissue to preserve the blood supply. 

Elevation: To raise the flap, slightly peel it off adjacent tissue without severing the vessels supplying the skin (random pattern flap). This shift should not go to a point of over exaggerating the undermining effect beyond what is necessary. 

Step 4-Mobilization of the Flap:  

Rotation: Afterwards, rotate the flap into the defect so that the skin edges of the flap properly fit over the edges of the defect.  

Tension Release: To release the tension, some more triangular areas must be removed around the base of the flap. This enables the flap to rotate into that position without straining the tissues adjacent to it. 

Step 5-Flap Inset and Closure:  

Suture the Flap: Begin with the flap’s tip being sutured over the defect; proceed from there.  

Deep dermal sutures to reduce tension with the use of superficial sutures for skin approximation.  

Assess Flap Viability: One should make sure that the flap properly fits in the defect not to be tighten and the tissue edges should be well aligned. It is crucial that proper circulation is maintained for the flap to heal.  

Suture the Donor Site: If the flap donor site is too large to be closed primarily, then it needs grafting, and this area may heal by secondary intention healing.  

Step 6-Postoperative Care: 

Dress the Wound: If necessary, put appropriate dressings or the patient must follow the advice given for wound management. 

Use of topical antibiotics or sterile dressing as determined by site and size. 

Monitoring for Complications: Teach the patient about assessing for infection, necrosis or dehiscence. The viability checks and flap monitoring need to be through follow up appointments on the scheduled dates to monitor the healing process. 

Complications  

Flap Necrosis: 

Partial or total flap necrosis may occur due to poor blood supply. This is among the most critical complications. 

Risk factors include tension in the flap, poor design, or interference with the blood supply during surgery. 

Infection: 

Either donor site or recipient site infection can develop after surgery. 

Infections may delay healing, cause wound breakdown, or even flap failure if not treated appropriately promptly 

Wound Dehiscence: 

The flap or donor site may not heal satisfactorily, and the wound may break down (dehisce). 

This is more likely to occur when there is high tension on wound closure or infection. 

Flap Edema: 

Swelling in the flap may occur after surgery due to venous congestion or disruption to lymphatic flow. 

Flap Contracture: 

The flap can retract with tension over areas of significant movement and tension after a certain period. This will result in either functional deficits or poor aesthetic results. 

References

Rotation Flaps – StatPearls – NCBI Bookshelf (nih.gov) 

References

Rotation Flaps – StatPearls – NCBI Bookshelf (nih.gov)