Surgical Pearls: Rotation Flaps

A patient at our clinic had 3 nonmelanoma skin cancers removed in close proximity (Figure 1). The surgical defect was too large and too tight to bring together with a primary closure. In addition, the patient had a beard and repair of the defect could alter the configuration of his hair. To limit distortion, an inferiorly based rotation flap was designed so the patient’s beard edge had natural symmetry on either side (Figure 2.) The surgical scar would also be hidden within his facial hair (Figure 3).

A type of tissue rearrangement designed to redistribute and redirect skin tension of the closure, rotation flaps were first described in the literature in 1842.¹ To visualize a rotation flap, a curvilinear incision is made along an arc adjacent to the primary wound.² Rotation flaps can be conceptualized as 4 parts: primary defect, primary tissue movement, secondary defect, and secondary tissue movement.² The primary defect is the surgical defect, whereas the primary tissue movement is the arc incision moving to cover the defect. The secondary defect is created along the arc and the tension in the secondary tissue movement can be evenly distributed in closing. This helps prevent necrosis of the skin.

When preparing for a rotation flap, consideration and attention must be made to its size. The functional flap length is shorter than the actual length of the flap’s incision due to it being rotated on an arc.³ As a general rule, the length of the designed rotation flap should be 4 times the width of the base of the defect. Ideally, the arc of the flap should be between 90 and 180 degrees in length; those less than 90 degrees are at risk for higher tension and those greater than 180 degrees alter tension vectors in a negative way.⁴

Extensive and careful undermining of the base of the flap enables advancement of the flap toward the defect during closure.⁵ If performing a rotation flap on the nose, undermining must be done in the submuscular plane; if on the scalp, undermining should be done in the subgaleal plane; and if performed in the periorbital area, undermining is done above the oribularis muscle. Flaps on the ear should be undermined above the perichondrium.⁴ If needed, a back cut can be made to create even less tension on the primary defect.²

In general, the facial area is a privileged vascular area and can support flaps.⁴ Before executing a rotation flap, one must consider the availability of an adequate blood supply to nourish the flap, a history of radiation to the area, whether the tissue surrounding the flap is an old scar, the patient’s smoking history, and if the patient is on anticoagulants that could compromise the flap. Patients with any of these considerations are at risk for tissue necrosis and dehiscence of the wound.

Seven months after surgery, our patient has achieved a cosmetically favorable closure and the scar is well hidden along his beard line (Figure 4). In the photo, we did delineate areas of actinic keratosis that the patient will treat with topical 5- fluorouracil cream but this is unrelated to the rotation flap. In conclusion, a rotation flap is an excellent option when a primary closure cannot be achieved or could cause cosmetic distortion.