Advancement Flaps: A Basic Theme with Many Variations

RAVI KRISHNAN, MD, MARY GARMAN, MD, JANNA NUNEZ-GUSSMAN, MD, AND IDA ORENGO, MD
Department of Dermatology, Baylor College of Medicine, Houston, Texas

BACKGROUND.

The advancement flap involves the linear advancement of tissue in one direction. Despite its straightforwardness
and simple concept, it can be used to close a variety of defects,
ranging from small defects on the scalp or extremities to large,
complicated defects involving cosmetic units on the face.
OBJECTIVES. To provide a basic and useful review for the indications, advantages, disadvantages, and techniques for the use of
advancement flaps in the reconstruction of defects in dermatologic surgery.
MATERIALS AND METHODS. We performed a literature search for
articles discussing advancement flaps and compiled a brief review
of our findings.

RESULTS. The movement of the advancement flap must be balanced by the blood supply of the flap. The excision of Burows
triangles along various aspects of the advancement flap can
increase movement and improve cosmesis of the flap. The types
of advancement flaps discussed include the single advancement
flap, double advancement flap, A-T flap (O-T flap), Burows triangle flap (Burows wedge flap), crescenteric advancement flap,
island pedicle flap (V-Y flap), helical rim advancement flap, and
facelift flap.
CONCLUSION. Advancement flaps are versatile and useful basic
flaps for repairing defects.

RAVI KRISHNAN, MD, MARY GARMAN, MD, JANNA NUNEZ-GUSSMAN, MD, AND IDA ORENGO, MD, HAVE
INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

THE ADVANCEMENT flap is one of the most basic and

versatile flaps at the disposal of the dermatologic surgeon.
Despite the apparent straightforwardness of the advancement flap, which simply involves the linear advancement
of tissue in one direction, it can be used to close a variety
of defects, ranging from small defects on the scalp or
extremities to large, complicated defects involving multiple cosmetic units on the face. A great deal has been written about advancement flaps, including new and innovative ways to use them. We review literature from several
disciplines to provide the reader with a comprehensive discussion about the fundamental principles underlying the
advancement flap, as well as the potential uses, advantages, and disadvantages of the various types of advancement flaps.

Basic Principles of Advancement Flaps

Many of the basic principles underlying all advancement
flaps can be derived from an examination of the classic
example of an advancement flap: the single advancement
flap. The single advancement flap is a very straightforward
extension of primary closure. In theory, a primary closure
is simply an advancement flap with a massive pedicle

Address correspondence and reprint requests to: Ida Orengo, MD,

Department of Dermatology, Baylor College of Medicine, One Baylor
Plaza FB 840, Houston, TX 77030, or e-mail: iorengo@bcm.tmc.edu.

(although, in practice, a primary closure is not an advancement flap because it lacks the additional incisions that
characterize a flap). If a defect is too large or requires too
much tension to be closed primarily, then additional tissue
movement must be achieved. This additional movement is
generated at the expense of the pedicle. When a lesion is
closed with a single advancement flap, as opposed to primarily, one exchanges a massive pedicle with insufficient
movement for a much smaller pedicle with adequate
movement. However, caution must be exercised because if
the pedicle is excessively sacrificed for the sake of movement, then the flap will be compromised. This trade-off
between movement and pedicle integrity characterizes all
advancement flaps.
The single advancement flap is designed by making incisions that are parallel to each other and along tangents to
the defect to be closed. Once the incisions are made, the
tissue between the incisions is elevated from the underlying structures, leaving a strip of tissue that may be
advanced into the defect. The thickness of the flap should
be commensurate with the thickness of the defect and
should include at least a thin layer of fat to ensure adequate vasculature. However, the thickness of a particular
flap may vary, depending on the anatomic site and other
factors specific to a particular case. If one is repairing a circular defect, small pieces of tissue at the borders of the
defect are often excised to convert it into a rectangular
defect. This will allow the flap to slide into the defect without redundancies. In addition, undermining should be car-

2005 by the American Society for Dermatologic Surgery, Inc. Published by BC Decker Inc
ISSN: 10760512 Dermatol Surg 2005;31:986994.

Dermatol Surg

31:8 Part 2:August 2005

ried out around the flap and the opposing wound edge to
reduce the tension needed to mobilize the tissue.1,2 The
advancement of the flap may necessitate the excision of
standing cones owing to the creation of sides of unequal
length, which are known as Burows triangles (Figure 1). A
Burows triangle may be excised if needed from any area
on the longer side, hidden in a crease, at a cosmetic unit
junction, or within a rhytid, if available.
The fundamental purpose of the single advancement
flap (and all other advancement flaps) is to achieve a
greater degree of tissue movement than that which could
have been achieved by undermining alone. The tissue
movement created by the advancement flap is generated by
three factors: movement of the flap toward the defect,
stretching of the flap itself, and movement created by the
excision of Burows triangles at the proximal edge of the
flap.3 Although the ostensible purposes of the excision of
Burows triangles are to remove tissue redundancies (ie,
standing cones) and to improve cosmesis, the removal of
these redundancies also significantly contributes to the
movement of the flap. However, despite these factors that
favor the movement of the flap, advancement flaps, in general, do not provide much additional movement compared
with primary closure with wide undermining.4,5 Furthermore, backcuts (ie, incisions into a flaps pedicle designed
to generate increased tissue movement) or other additional
incisions generally only compromise perfusion to the flap
without augmenting tissue movement.5
There are several considerations to keep in mind when
mobilizing tissue for an advancement flap. First, the surgeon should determine whether there is an adequate tissue

KRISHNAN ET AL: ADVANCEMENT FLAPS

987

reservoir from which to create the advancement flap. This

may be easily determined by simply pinching the skin with
the fingers in various directions. If the axis of greatest laxity lies along the short axis of the defect, then an advancement flap is appropriate. If the axis of greatest laxity is
along the long axis of the defect, then an advancement
flap is suboptimal because it would have to be much
longer to fill the defect.5 The surgeon should also endeavor
to make incisions such that the final suture lines are along
skin tension lines, borders of cosmetic units, and/or
rhytides.6 This will minimize wound tension and result in
a superior cosmetic outcome.5,7
To ensure adequate flap perfusion and to minimize the
risk of distal flap necrosis, a 3:1 length-to-width ratio is
often used.8 However, this ratio may be highly variable
depending on factors including location, the depth of the
pedicle, vascularity, and host factors (eg, smoking). Moreover, when using advancement flaps anywhere other than
the head or neck, an even smaller length-to-width ratio
should be considered to avoid partial flap necrosis.4
Another technique that helps ensure adequate blood
supply is the inclusion of an intact named vessel within the
pedicle of the flap. Such a flap, known as an axial flap, has
a lesser risk of hypoperfusion and subsequent necrosis
than a random pattern flap (which has no associated
named vessels and is dependent on a network of much
smaller vessels for perfusion).9 When creating an axial
flap, ultrasonography or other visualization techniques
may be required to identify the precise location and viability of an artery.10,11 Fortunately, such methods are seldom required when constructing advancement flaps on the
head and neck. On the head and neck, random pattern
flaps have excellent outcomes because of the abundant
blood supply7 in these anatomic sites. On the extremities,
however, the creation of an axial flap may be more essential.10

Types of Advancement Flaps

Single and Double Advancement Flaps

Figure 1. Diagram of a single advancement flap. Arrows indicate

direction in which tissue is moving.

The technique for constructing a basic single advancement

flap has been described above. The double advancement
flap (Figure 2) is made by placing two single advancement
flaps adjacent to each other and approximating their distal edges. Double advancement flaps generate additional
tissue movement at the expense of causing two additional
suture lines. When considering a double advancement flap,
the surgeon should completely mobilize and undermine
one of the flaps before making any of the incisions needed
for the second flap. This is done to ensure that both flaps
are necessary. Often one will discover that sufficient tissue
motion can be generated with a single flap, thus obviating
a double advancement flap and the associated additional
scarring.

988

Dermatol Surg

KRISHNAN ET AL: ADVANCEMENT FLAPS

31:8 Part 2:August 2005

Single and double advancement flaps are useful for the

repair of defects on the forehead and eyebrow (Figure 3).
When these types of flaps are used for eyebrow reconstruction, this allows for restoration of a fairly normalappearing eyebrow and concealment of suture lines within
and along the borders of the eyebrow. When undermining
an advancement flap that involves the eyebrow or another
hair-bearing area, one must make sure that the undermining is done below the follicles so that they may be preserved.3,4 Single and double advancement flaps are also
advantageous because the resulting scars can be camouflaged within normal anatomic boundary lines (eg, foreheadscalp junction or vermilion border).
One of the major drawbacks to constructing a double
advancement flap is that one must potentially excise four
Burows triangles to eliminate standing cones of redundant tissue. It is advantageous to avoid creating standing
cones when possible because each standing cone excision
creates an additional scar. Sometimes standing cones can
be eliminated or diminished simply by sewing them out
using the law of halves. However, this is not always possible. Moody and Sengelmann described an elegant modification to the basic advancement flap that prevents standing cones from being formed.12 A curvilinear incision is
made along the limb of the flap to redistribute the redundant tissue along the length of the incision (Figure 4). The
result is an advancement without a Burows triangle.12
Although this modification does have the benefit of resulting in a more desirable final scar, it has some minor limitations, including a slight narrowing of the flap pedicle
and the relinquishment of the additional tissue movement
gained by Burows triangle excision. When constructing
larger flaps, attempts to avoid the excision of Burows triangles may lead to extensive stretching and subsequent
thinning of the flap. Because an excessively thinned flap

has a poor cosmetic outcome and is more susceptible to

necrosis (especially in smokers or diabetics),13 standing
cone avoidance may not always be the best approach. In
such cases, it may be best to simply excise standing cones

Figure 2. Diagram of a double advancement flap. Arrows indicate

direction in which tissue is moving.

Figure 4. Diagram of a technique to avoid standing cone formation.

Arrows indicate direction in which tissue is moving.

Figure 3. A defect on the left forehead repaired with a double

advancement flap. The final picture is at suture removal. Courtesy
of Anthony Brissett, MD, Department of Otolaryngology, Baylor
College of Medicine, Houston, TX, USA.

Dermatol Surg

31:8 Part 2:August 2005

in the traditional manner. The experienced surgeon will

balance these considerations when deciding how to manage the standing cones that may be created by the closure
of a particular defect.

A-T Flaps
The A-T flap, also known as the O-T flap, can be thought
of as half of a double advancement flap. The basic technique for an A-T flap involves imagining a triangular or Ashaped defect superimposed over the primary circular or
elliptical defect to be closed. The flap is constructed by
making an incision along the base of the imagined triangular defect and then joining the two basal tips of the triangle with the midpoint of the base (Figure 5). This results
in an inverted, T-shaped closure (ie, the T is inverted
with respect to the A). This will necessitate the excision
of a standing cone from the vertex that is opposite from
the base. Excision of Burows triangles from the other vertices may be required as well. However, if desired, the A-T
flap may be constructed with curvilinear incisions (as discussed above for single and double advancement flaps) to
avoid standing cones.12
The dimensions of the imaginary triangle that guides
the formation of this flap will obviously vary depending on
the size of the defect, the size of the standing cone that is
formed, and the proximity of adjacent structures. However, in the absence of any such limitations, Stevens and
colleagues determined that the optimal design (to minimize closure tension) for an A-T flap includes a height that
is twice the defect diameter, base extensions of one defect
diameter on each side, and three defect diameters (measured from the center of the defect) of undermining.14
The A-T flap is valuable when distortion of a structure
adjacent to one edge of a defect is undesirable.5 When this

Figure 5. Diagram of an A-T flap. Arrows indicate direction in which

tissue is moving.

KRISHNAN ET AL: ADVANCEMENT FLAPS

989

is the case, the base of the flap is placed along the border
of the edge to be preserved. This method prevents the violation of important structures and allows scars to be relatively well hidden. This flap is particularly useful on the
forehead, where the base incision can be concealed along
the eyebrow or hairline; on the chin, where the base incision can be concealed along the mental crease; and on the
lip, where the base incision can be concealed along the vermilion border.14 However, when using this flap on the lip,
the surgeon must take care to avoid secondary movement,
which may distort the free margin of the vermilion border.

Burows Triangle or Wedge Flaps

The Burows triangle flap, which is also called the Burows
wedge flap, is a type of advancement flap that one may
think of as half of an A-T advancement flap. This type of
flap is begun by incising and undermining in the manner
one would use if creating one side of an A-T flap. After this
has been completed, the flap is advanced into the defect
either horizontally or diagonally, and then a Burows triangle is excised from the end of the flap that is distal to the
primary defect (Figure 6). Because, unlike the A-T flap,
there is a single advancing flap instead of two, there is
usually more movement required of the flap, which may
result in a large standing cone of redundant tissue. This

Figure 6. Diagram of a Burows triangle flap. Arrows indicate direction in which tissue is moving.

990

KRISHNAN ET AL: ADVANCEMENT FLAPS

standing cone is the Burows triangle, and its removal may

be necessary to eliminate tissue redundancy and generate
additional tissue movement. The size of the Burows triangle can be reduced by extending the length of the flap,3
but, ultimately, a Burows triangle that requires excision
almost always remains. The advantages of the Burows triangle flap include a wide, well-vascularized pedicle and the
ability to place the standing cone in and subsequently
excise it from a site that is relatively distant from the primary defect and/or any other structures or free margins,
which are best avoided (Figure 7).
This feature of Burows triangle flaps makes them indispensable when repairing defects on cosmetically sensitive
areas where there are scant tissue reservoirs from which to
excise large Burows triangles. This concept is illustrated
by the use of the Burows triangle flap in upper cutaneous
lip repair.3 In this situation, tissue from the upper cutaneous lip and cheek is advanced medially to close the
defect. The resulting Burows triangle is placed away from
the upper cutaneous lip, which, after removal of the defect,
has little excess tissue to spare, and puts it on the inferior
cheek, an area of relative tissue excess. Dang and Greenberg described an interesting modification of this technique that involves placing the Burows triangle within the
vermilion lip.15 This variation also moves the Burows triangle away from the upper cutaneous lip and offers the
advantage of replacing an obvious scar below the oral
commissure (which is the result of the traditional use of a
Burows triangle flap in this area) with scars hidden within
the lip and along the vermilion border.15,16
The Burows triangle flap is also useful in repairs on
other sites. Designing a Burows triangle flap (or any other
flap) is based on a determination of where the tension is,
where the final incision lines will fall, and where the redundant tissue will be. At certain anatomic sites, these events
will result in a predictable flap design. Various authors have
described site-specific uses of the Burows triangle flap and
given them each distinct names. Although it is important to
be familiar with these flaps from a conceptual standpoint,
it is also important to realize that they are not different flaps

Figure 7. A preauricular defect closed with an advancement flap

demonstrating Burows triangles displaced under and behind ear. A
small graft is used to close a tragus defect. The final picture is at
suture removal.

Dermatol Surg

31:8 Part 2:August 2005

but rather applications of the same Burows triangle flap

with different (and perhaps unnecessary) names.
Goldberg and Alam described an application of the
Burows triangle flap, which they refer to as a horizontal
advancement flap, that is useful for closure of defects on
the lateral nasal supratip.17 This flap involves excising a
Burows triangle from the nasal tip and results in a repair
with well-concealed scars and minimal distortion of the
architecture of the nose. However, because the size of the
Burows triangle is limited by the relatively small amount of
excess tissue available on the nose, this repair is useful only
for relatively small lateral nasal supratip defects.17 In addition, Kouba and Miller described a modified Burows triangle flap, which they name a J-plasty, that is helpful in the
repair of malar cheek defects near the orbital rim.18 This
flap is advantageous because it places little, if any, tension
on the lower eyelid and places incision lines within a cosmetic subunit border. Finally, the Burows triangle flap can
also be used on the temple or forehead in such a way that
the Burows triangle is hidden within the scalp.3

Crescentic Advancement Flaps

Crescentic flaps are similar in principle to basic single
advancement flaps, but instead of relying on rigid, geometric incisions at tangents to a defect, crescentic flaps
involve curved incisions at obtuse angles, which lend
themselves to concealment within suture lines. The most
commonly described crescentic flap is the perialar crescentic advancement flap.19,20 This flap, as the name suggests, is useful for defects along the perialar region (either
on the nose, on the cheek, or involving both). To construct
this flap, crescents of redundant skin are excised along the
melolabial fold and ala. This is followed by advancement
of skin from the lateral cheek toward the melolabial fold
and ala. The final suture lines should lie within the melo-

Figure 8. Diagrams of perialar crescentic flaps for the nose and for
the ala. Arrows indicate direction in which tissue is moving.

Dermatol Surg

31:8 Part 2:August 2005

labial fold and against the side of the nose, making the
eventual scar relatively inconspicious (Figure 8).19
Unfortunately, when using this type of closure, the
resulting scar, although well hidden, is often significantly
longer than the original defect. Therefore, a simpler closure (ie, one with a shorter final scar length) should always
be considered. However, one will often find that the longer
but well-hidden closure is preferable. Furthermore, caution must be taken when using this technique for superiorly located defects beause poorly designed perialar crescentic flaps can place tension on the lower eyelid, resulting
in an ectropion.20
Alam and Goldberg described a crescentic-type flap,
which they referred to as the oblique advancement
flap.21 This flap is to be used for small defects that are
located on the lateral nasal supratip. It is constructed by
removing crescents of redundant skin along the alar crease
and the nasal sidewall (Figure 9). The flap is then
advanced anteromedially toward the tip of the nose. This
results in a scar that is nicely concealed within the alar
crease and against the nasal sidewall. Great care must be
taken with this flap to avoid elevating the alar rim relative
to the contralateral side.

Island Pedicle Advancement Flaps

The island pedicle advancement flap differs from all of the
aforementioned flaps in that it lacks any dermal or epidermal attachments to its site of origin. Unlike the other
advancement flaps, which have pedicles that include adjacent skin, the island pedicle advancement flap derives its
perfusion solely from a subcutaneous pedicle. An island
pedicle advancement flap is constructed by making two
incisions from a single point away from the defect and
extending them to two separate points on the border of the
defect to be repaired (Figure 10). These two incisions may
be linear or slightly curved (depending on the defect to be
repaired) and should have an angle of approximately 30
degrees between them so that the secondary defect may be
closed primarily without standing cone formation. Furthermore, these incisions should be made to form a
roughly triangular island of skin that is two to three times
as long as the diameter of the primary defect6,9,22 and has a

Figure 9. A defect on the left nasal supratip is repaired with an

oblique advancement flap. Incision lines are drawn out, and the
flap is undermined and reflected. The flap is pulled into place and
closed with two layers of sutures.

KRISHNAN ET AL: ADVANCEMENT FLAPS

991

width equal to the largest perpendicular diameter of the

wound.22,23 Once again, as with the single advancement
flap, these measurements are merely guidelines and may be
modified depending on a variety of factors. After these
two incisions are made, and undermining around the
defect and flap is performed, the resulting island of skin
and subcutaneous tissue is advanced into the defect and
sutured in place. Unfortunately, closure of the primary and
secondary defects leads to the formation of suture lines
that form a conspicuous geometric pattern, making them
difficult to conceal.
Because the initial incisions have a V-shaped geometry
and because the final suture lines form a Y-shaped pattern,
this flap is sometimes referred to as a V-Y flap. If curved
incisions, rather than linear ones, are used to create the
flap, then the term horn flap is sometimes used because
the resulting island has a shape resembling a rhinoceros
horn.24
Several considerations must be taken into account when
creating an island pedicle advancement flap. First, one
must make incisions to construct a pedicle of appropriate
depth. The initial incisions should generally extend down
to the subcutaneous fat,9 taking care to avoid any important superficial motor nerves (eg, temporal branch of the
facial nerve) that may be in the vicinity of the repair.3 Furthermore, in some cases, for reasons of increased flap
mobility and better flap perfusion, it may be desirable to
include fascia25 or even muscle9,2628 within the pedicle. In
these situations, the initial incisions will obviously be
much deeper.
The diameter of the pedicle is another feature of this
flap that the surgeon must carefully consider. To preserve
perfusion to the greatest extent, the cross-sectional area of
the pedicle should be roughly equal to the area of the overlying skin. The pedicle can (and should) be narrowed to
achieve greater tissue movement. However, as with all
flaps, excessive narrowing of the pedicle can severely compromise perfusion to the flap. If an island pedicle advancement flap is created in an axial fashion, then any amount
of pedicle narrowing is probably acceptable as long as the
associated named vessel remains within the pedicle. On the

Figure 10. An island pedicle flap is drawn out along the melolabial
fold to repair a deep defect involving the nose and cheek. The flap
is undermined peripherally to retain a central pedicle and pulled
into place to fill the defect. The flap is repaired with two layers of
sutures.

992

KRISHNAN ET AL: ADVANCEMENT FLAPS

other hand, if a random pattern flap is created, then the

surgeon should be somewhat more cautious when narrowing the pedicle to gain movement. When repairing
defects on the extremities, this is an important concern.
Fortunately, however, when repairing defects on areas
such as the nose, which have an excellent blood supply, the
surgeon can narrow the pedicle quite liberally.23 This is
evidenced by the observation that even rather large
Burows grafts, which are essentially island pedicle
advancement flaps without the pedicle, result in excellent
outcomes on the face.29,30
A useful general guideline to remember when considering the amount of movement one might achieve when creating an island pedicle advancement flap is that the thicker
the tissue is under the flap, the greater the potential for tissue movement because, in these areas, the pedicle can be
substantially narrowed without major effects on flap perfusion.9 A notable exception to this general principle is the
scalp. Island pedicle advancement flaps should generally
be avoided on the scalp because significant tissue mobility
(beyond that which can be achieved by undermining) cannot be realized without incisions into the galea and/or
periosteum. Because the scalp receives most of its perfusion from above the galea, an island pedicle advancement
flap on the scalp that moves adequately is likely to be
hypoperfused.22
Several authors have described a modification of the
standard central subflap pedicle that allows for greater tissue movement.6,9,31 Instead of creating a pedicle that
attaches underneath the center of the flap, they advocate
elevating the center of the flap from the subcutis and forming two lateral pedicles that perfuse the flap via the horizontal plexus of vessels that run through the subcutaneous
fat (Figure 11).32 Pontes and colleagues used this technique
for over 400 reconstructions on the face, with excellent
results.6 Moreover, in sites with an excellent blood supply,
such as the face, a single lateral pedicle may be sufficient.6,9,25
The island pedicle advancement flap has several distinct
advantages over other advancement flaps that have pedicles with epidermal attachments. First, in most cases, a
greater degree of tissue mobility can be achieved with an

Figure 11. Diagram of an island pedicle flap with lateral pedicles.

Arrow indicates direction in which tissue is moving.

Dermatol Surg

31:8 Part 2:August 2005

island pedicle advancement flap. In the melolabial fold, an

island pedicle advancement flap can be advanced up to 3
to 4 cm depending on the patients individual anatomy.22
This degree of advancement would be extremely difficult
to achieve with another type of advancement flap. Furthermore, because the island pedicle advancement flap has
a centrally located pedicle, it can be made much larger
than a single advancement flap, whose pedicle is separated
from the distal tip by the entire length of the flap. The surgeon should be cognizant of this important factor because
many defects that are amenable to single advancement
flaps are also readily repaired by island pedicle advancement flaps. The island pedicle advancement flap is also
advantageous because no standing cones are created. The
design of the island pedicle advancement flap is such that
the secondary defect is closed primarily without the need
for the excision of Burows triangles. Other types of
advancement flaps normally require the removal of
Burows triangles or modifications to avoid them.
The island pedicle advancement flap is an extremely versatile type of advancement flap and can be used for defects
almost anywhere on the face (Figure 12),11,22,24,27,28,3234
including the glabella, cheek, nose, and lips (vermilion and
cutaneous portions). These flaps may also be used, albeit
more cautiously, on the extremities.35,36 Some of the modifications that are used in conjunction with simple advancement flaps can be applied to island pedicle advancement

Figure 12. Diagram of possible uses of an island pedicle flap.

Dermatol Surg

31:8 Part 2:August 2005

flaps. One simple modification is the double island pedicle

advancement flap. This flap is constructed in a manner that
is analogous to the double advancement flap described
above. However, instead of creating two single advancement flaps adjacent to each other, the surgeon creates two
island pedicle advancement flaps that are adjacent to each
other. This technique is useful for the repair of the same
types of defects that lend themselves to repair with a double advancement flap, such as eyebrow and lip defects.

Other Advancement Flaps

Once the basic principles of tissue advancement have been
mastered, the surgeon can construct a variety of advancement flaps that do not precisely fit into any of the above
categories. Two such flaps that are frequently used are the
helical rim advancement flap and the face-lift flap. The
helical rim advancement flap is used for the repair defects
involving skin and cartilage on the helix (for defects
involving only the skin, a basic double advancement flap
is simple and effective). There are several variations of this
type of flap.3740 One variation, which we commonly use,
involves full-thickness incisions along the helical sulcus
(including anterior auricular skin, cartilage, and posterior
auricular skin).3,38 Next, full-thickness Burows triangles
are excised from the scapha (skin and cartilage) and from
the lobule (skin) to facilitate movement and prevent excessive cupping. Finally, the two ends of the primary helical
defect and the sites of the Burows triangle excisions are
approximated and sutured (Figure 13). Although this flap
is quite labor intensive, it is a superb technique to repair
large helical defects because it preserves the architecture of
the ear,37 with only an inconspicuous reduction in the size
of the ear. Other variants of this technique involve only
partial-thickness incisions (ie, only anterior auricular skin)
of the helical sulcus. These alternative helical rim advancement flaps also produce good cosmetic results and reduce
the risk of flap necrosis.
The face-lift flap is used to repair large defects of the lateral cheek, lateral orbit, inferior temple, and zygomatic
arch.41 The design of this flap is derived from rhytidectomy

KRISHNAN ET AL: ADVANCEMENT FLAPS

993

principles (hence its name) and involves extending an incision from the defect through the preauricular region, curving around the ear, and then extending postauricularly. The
flap is extensively undermined toward the inferomedial
cheek, and then it is advanced superiorly and laterally to
repair the defect. The resulting scars are extremely well
hidden around and behind the ear. The disadvantages of
this procedure include the creation of at least some degree
of facial asymmetry and the potential for damage to the
superficial temporal, buccal, or marginal mandibular
branches of the facial nerve while widely undermining.41 It
is also important to realize that this flap, although useful,
is far more extensive than any of the others that have been
discussed. It is a technique requiring advanced training and
is often better done with sedation or general anesthesia.

Conclusion
Advancement flaps are an indispensable part of the dermatologic surgeons armamentarium. These flaps can be
used to repair a wide variety of surgical defects at almost
any anatomic site. Advancement flaps offer several significant benefits, some of which are shared by other types of
flaps. Most importantly, advancement flaps are a relatively
easy way to reduce wound tension, which, in turn, reduces
the risk of perioperative wound edge necrosis, dehiscence,
and scar widening.42 Advancement flaps can also provide
excellent cosmetic results. These flaps allow for excellent
matching of skin color, texture, and thickness.22 Furthermore, when advancement flaps are planned judiciously,
the resulting scars can be well hidden in natural boundary
lines. Advancement flaps do have two notable disadvantages. They provide relatively little movement compared
with other types of flaps and occasionally result in large,
geometric scars that may be difficult to conceal.
Acknowledgment We are greatly indebted to Mary Garman,
MD, for kindly drawing all of the illustrations. Dr. Garman is a
dermatology resident at Baylor College of Medicine.

References
1. Cox KW, Larrabee W Jr. A study of skin flap advancement as a function of undermining. Arch Otolaryngol 1982;108:1515.
2. Larrabee WF, Sutton D. The biomechanics of advancement and rotation flaps. Laryngoscope 1981;91:72634.
3. Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in dermatologic surgery. St. Louis: Mosby; 1989.
4. Wheeland RG, editor. Cutaneous surgery. Philadelphia: W.B. Saunders Company; 1994.
5. Khouri R. Skin flaps. In: Nouri K, Leal-Khouri S, editors. Techniques
in dermatologic surgery. Edinburgh: Mosby; 2003. p. 1415.
6. Pontes L, Ribeiro M, Vrancks JJ, Guimaraes J. The new bilaterally
pedicled V-Y advancement flap for face reconstruction. Plast Reconstr Surg 2002;109:18704.
7. Bennett RG. Local skin flaps on the cheeks. J Dermatol Surg Oncol
1991;17:1615.

Figure 13. Diagram of helical advancement.

994

KRISHNAN ET AL: ADVANCEMENT FLAPS

8. Fazio MJ, Zitelli JA. Flaps. In: Ratz JL, Geronemus RG, Goldman
MP, et al, editors. Textbook of dermatologic surgery. Philadelphia:
Lippincott-Raven; 1998:2257.
9. Hairston BR, Nguyen TH. Innovations in the island pedicle flap for
cutaneous facial reconstruction. Dermatol Surg 2003;29:37885.
10. Maruyama Y, Yoshitake M. The axial dorsal metacarpal V-Y
advancement flap for the repair of distal forearm skin defects. Br J
Plast Surg 1991;44:2745.
11. Ohsumi N, Tadashi I, Shibata Y. Reconstruction of nasal tip defects
by dorsonasal V-Y advancement island flap. Ann Plast Surg
1998;40:1822.
12. Moody BR, Sengelmann RD. Standing cone avoidance via advancement flap modification. Dermatol Surg 2002;28:6325.
13. Obadiah JM, Koss T, Ratner D. Advancement flaps. Available at:
http://www.emedicine.com/derm/topic868.htm (accessed July 7, 2004).
14. Stevens C, Tan L, Kassir R, Calhoun K. Biomechanics of A-TO-T
flap design. Laryngoscope 1999;109:1137.
15. Dang M, Greenbaum S. Modified Burows wedge flap for upper lateral lip defects. Dermatol Surg 2000;26:4978.
16. Albertini JG. Regarding the modified Burows wedge flap for upper
lateral lip defects. Dermatol Surg 2000;26:981.
17. Goldberg LH, Alam M. Horizontal advancement flap for symmetric
reconstruction of small to medium-sized cutaneous defects for the
lateral nasal supratip. J Am Acad Dermatol 2003;49:6859.
18. Kouba DJ, Miller SJ. The J-plasty advancement flap for reconstruction of malar cheek defects. Dermatol Surg 2004;30:7880.
19. Jackson IT. Local flap reconstruction of defects after excision of nonmelanoma skin cancer. Clin Plast Surg 1997;24:74767.
20. Yoo SS, Miller SJ. The crescentic advancement flap revisited. Dermatol Surg 2003;29:8568.
21. Alam M, Goldberg LH. Oblique advancement flap for defects of the
lateral nasal supratip. Arch Dermatol 2003;139:103942.
22. Zook EG, Van Beek AL, Russell RC, Moore JB. V-Y advancement
flap for facial defects. Plast Reconstr Surg 1980;65:78697.
23. Hauben DJ. Subcutaneous V-Y advancement flap for closure of nasal
tip defect. Ann Plast Surg 1989;23:23944.
24. ODonnell M, Briggs C, Condon KC. The horn flap: a curved V-Y
advancement flap with lateral pedicle. Br J Plast Surg 1992;45:423.
25. Dini M, Innocenti A, Lo Russo G, Agostini V. The use of the V-Y fasciocutaneous island advancement flap in reconstructing postsurgical
defects of the leg. Dermatol Surg 2001;27:446.

Dermatol Surg

31:8 Part 2:August 2005

26. Robbins TH. The deep pedicle V-Y advancement flap. Plast
Reconstr Surg 2004;113:4634.
27. Narsete TA. V-Y advancement flap in upper-lip reconstruction. Plast
Reconstr Surg 2000;105:24646.
28. Bayramicli M, Numanoglu A, Tezel E. The mental V-Y island
advancement flap in functional lower lip reconstruction. Plast Reconstr Surg 1997;100:168290.
29. Kim KH, Gross VL, Jaffe AT, Herbst AM. The use of the melolabial
Burows graft in the reconstruction of combination nasal sidewallcheek defects. Dermatol Surg 2004;30:2057.
30. Zitelli JA. Burows grafts. J Am Acad Dermatol 1987;17:2719.
31. Vandeput J. The new bilaterally pedicled V-Y advancement flap for
face reconstruction. Plast Reconstr Surg 2003;111:13634.
32. Gardner ES, Goldberg LH. Eyebrow reconstruction with the subcutaneous island pedicle flap. Dermatol Surg 2002;28:9215.
33. Bocci A, Baccarani A, Bianco G, et al. Double V-Y advancement flap
in the management of lower lip reconstruction. Ann Plast Surg
2003;51:2059.
34. Spinowitz AL, Stegman SJ. Partial-thickness wedge and advancement
flap for upper lip repair. J Dermatol Surg Oncol 1991;17:5816.
35. Maruyama V, Iwahira V, Ebihara H. V-Y advancement flaps in the
reconstruction of skin defects of the posterior heel and ankle. Plast
Reconstr Surg 1990;85:75963.
36. Kojima T, Kinoshita Y, Hirase Y, et al. Extended palmar advancement
flap V-Y closure for finger injuries. Br J Plast Surg 1994;47:2759.
37. Butler CE. Reconstruction of marginal cheek defects with modified
chondrocutaneous helical rim advancement flaps. Plast Reconstr
Surg 2003;111:200913.
38. Calhoun KH, Slaughter D, Kassir R, et al. Biomechanics of the helical rim advancement flap. Arch Otolaryngol Head Neck Surg
1996;122:111923.
39. Ramsey ML, Marks VJ, Klingensmith MR. The chondrocutaneous
helical rim advancement flap of Antia and Buch. Dermatol Surg
1995;21:9704.
40. Low DW. Modified chondrocutaneous advancement flap for ear
reconstruction. Plast Reconstr Surg 1998;102:1747.
41. Flynn TC, McDonald WS, Chastain MA. The facelift flap for reconstruction for cheek, lateral orbit, and temple defects. Dermatol Surg
1999;25:83643.
42. Raposio E, Nordstrom RE. Tension and flap advancement in the
human scalp. Ann Plast Surg. 1997;39:203.