What is the CPT code for an advancement flap?
For example, if the surgeon performs a rotational flap for an area that is 7 x2 cm on the neck and then an advancement flap for an area that is 3 x4 cm on the foot, you would code 14041 x1 for the adjacent tissue transfer of 14 sq cm on the neck and then 14041 x1 again for the adjacent tissue transfer of 12 sq cm on the foot.
How do advancement flaps work?
This involves stretching the skin of the flap. Thus, advancement flaps work best in areas of greater skin elasticity. The most basic advancement flap is the simple linear layered closure, which involves undermining and direct advancement of tissue side to side to close the defect primarily.
When to convert a flap into a bilateral advancement flap?
If tension remains despite wide undermining, the surgeon may consider lengthening the flap or converting it into a bilateral advancement flap to obtain additional tissue movement. 11 If the surgical defect is secondary to Mohs micrographic surgery, it is likely that the wound edges are beveled.
What is the difference between an advancement flap and key suture?
FLAP MOBILIZATION AND KEY SUTURES. Once the flap is able to slide into the defect with minimal tension and hemostasis has been obtained, the key suture is placed in the advancing edge to close the wound. In an advancement flap, the key suture closes the primary defect and serves to align the flap.
What is an advancement flap?
Advancement flaps are conceptually the simplest local flaps and fall within the group of sliding flaps, along with rotation flaps. [1][2][3] For these sliding flaps, the tissue is moved or "slid" directly into the adjacent defect without "jumping" over the interposed tissue.
What is the CPT code for rotational flap closure?
For example, if a lesion is removed from the forehead, resulting in a 5.2 sq cm defect, and another lesion is removed from the neck, resulting in a 7.3 sq cm defect, and both require rotational advancement flaps to provide closure, then CPT code 14040 would be reported twice, with modifier –59 appended to the second ...
What is the CPT code 14301?
14301 - CPT® Code in category: Adjacent tissue transfer or rearrangement, any area.
How do you code adjacent tissue transfers?
The adjacent tissue transfer will be coded as 14060, adjacent tissue transfer or rearrangement. eyelids, nose, ears and/or lips, defect size 10 sq.
What is advancement flap closure?
The primary goal of an advancement flap is to transfer the tension of the scar that would result from side-to-side closure to a more cosmetically acceptable site. Such sites include relaxed skin tension lines and the boundaries between cosmetic units (eg, melolabial fold, melolabial crease).
What is the difference between adjacent tissue transfer and flap?
Moderator, CCO Instructor. Tissue transfer is when they take tissue from someplace else and cover the wound. A flap is also taking tissue but from close to the woud and it is flopped over the wound.
What does CPT code 19357 include?
CPT 19357 is used for tissue expander placement in breast reconstruction; includes subsequent expansion(s); and is separately re- portable if used in flap reconstruction.
What does CPT code 15240?
CPT® 15240, Under Autografts/Tissue Cultured Autograft. The Current Procedural Terminology (CPT®) code 15240 as maintained by American Medical Association, is a medical procedural code under the range - Autografts/Tissue Cultured Autograft.
What does CPT code 15734 mean?
For clarity, code 15734 represents a musculofascial flap involving the mobilization of the rectus muscle whether performed with anterior or posterior release. Code 15734 can only be reported once for each side. It cannot be reported four times—once for each posterior and anterior side.
What is an adjacent tissue transfer flap?
An adjacent tissue transfer (CPT® 14000-14350) relocates a flap of healthy skin from a donor site to an adjacent laceration, scar, or other discontinuity. A portion of the flap is left intact to supply blood to the grafted area.
Can 19301 and 14001 be billed together?
Answer:No, it is not appropriate to report either code 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less, or 14001, Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm, in addition to code 19301, Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, ...
What is procedure code 15002?
CPT® Code 15002 in section: Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs.
What is procedure code 14020?
CPT® Code 14020 in section: Adjacent tissue transfer or rearrangement, scalp, arms and/or legs.
What is included in CPT code 19364?
Code 19364 includes harvesting of the flap, microvascular transfer (one artery and two veins), closure of the donor site, and transfer to the chest and inset, including the creation of the breast mound. Examples are a free transverse rectus abdominis myocutaneous (TRAM) flap, a free DIEP, or free gluteal flap.
What does CPT code 19371 include?
CPT 19371 is for a complete capsulectomy and includes the removal of all intra-capsular contents. It cannot be reported with CPT 19328and 19370; however, 19342 can be separately reported for replacement of a new implant.
What is the CPT code 14060?
14060 - CPT® Code in category: Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips.
What is CPT 14020?
CPT 14020: Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs; defect 10 sq cm or less
What is advancement flap?
Advancement Flaps: An adjacent tissue transfer technique where incisions are made to create a flap that slides or “advances” forward from its normal location into a defect for repair. Here is a visual for this type of flap: Advancement Flap
How big is a defect in tissue transfer?
Once the defect being repaired with adjacent tissue transfer reaches an area of 30.1 sq cm or larger, instead of reporting the codes we have discussed above that are specific for different anatomic sites, we have special codes that are reported for “any area” larger than 30 sq cm.
What is a back cut?
From there, “back cuts” are made “all along the wound edge.” Back cuts are additional incisions made starting at the wound edge and working outward into the surrounding tissue. These incisions are often used to create flaps along the wound edge that can be brought together for repair. Therefore, the term “back cuts” might be a key word that confirms an adjacent tissue transfer since the required “additional incisions” needed to mobilize adjacent tissue for repair are met by stating that “back cuts” were made. From there, we see the surgeon designing “rotational flaps” that are then “rotated into the defect” and sutured to repair the area. This is an adjacent tissue transfer per CPT guidelines.
What is Z-plasty?
Z-plasty: An adjacent tissue transfer technique where additional incisions are made on either side of a wound creating a shape that resembles the letter Z. These additional incisions create flaps of tissue that are then sutured together to repair the wound.
What is the W-plasty technique?
W-plasty: An adjacent tissue transfer technique where additional incisions in the shape of the letter W are made along the edges of the wound to reduce tension on the edges of the wound and create some laxity in the tissue that allows the wound edges to come together to repair the wound.
What is a random island flap?
This island flap receives its blood supply from random non-dominant blood vessels in the subdermal plexus which is where the term “random” island flap comes in. The flap receives blood flow from the donor site where the flap is created and is then moved over or under other tissues to reach the defect needing repair.
How does a V-Y flap work?
The V-Y advancement flap is unique in that the V-shaped flap is not stretched or pulled toward the recipient site but rather achieves its advancement by recoil or by being pushed forward. Thus the flap is allowed to move into the recipient site in a nearly tension-free fashion. The secondary triangular donor defect is then repaired with wound closure tension by advancing the two borders of the remaining wound toward each other. In so doing, the wound closure suture line assumes a Y configuration, with the common limb of the Y representing the suture line resulting from closure of the secondary defect. The flap is optimally designed so that the common limb of the Y falls in the boundary of neighboring aesthetic regions or within a natural crease, fold, or wrinkle.
What is a subcutaneous tissue flap?
The subcutaneous tissue pedicle island advancement flap is a unipedicle advancement flap without a cutaneous component to the pedicle. The pedicle of the flap consists only of subcutaneous tissue, which is usually fat but on occasion may also incorporate muscle underlying the skin.
How are bilateral unipedicle flaps used?
Bilateral unipedicle advancement flaps are commonly combined to close various defects, resulting in H- or T-shaped repairs, depending on the configuration of the defect and the number of incisions used . Repair in this manner is often referred to as H-plasty (Fig. 9-2) or T-plasty. In both cases, advancement flaps are incised on opposite sides of the defect and advance toward each other. Each flap is responsible for covering a portion of the defect. When standing cutaneous deformities require excision, they are excised either in the area of the defect or along the borders of the flaps. The two flaps do not necessarily have to be of the same length. Flap length is determined primarily by the elasticity and redundancy of tissue at the donor site. The basic principles of tissue movement and wound closure are identical to those for single unipedicle advancement flaps. When designing and dissecting the flaps, it is wise to first incise and elevate only one flap. On occasion, sufficient skin movement is achieved with a single flap so that the second flap is not necessary or can be designed with less length. Like single unipedicle advancement flaps, bilateral flaps are useful for repairing skin defects of the forehead, eyebrow, and ear. Bilateral advancement flaps are particularly helpful for repair of defects of the central lips and chin. The advantage of bilateral flaps over a single flap for repair of these midline structures is that equal “pull” from the two opposing flaps lessens tissue distortion and the propensity toward deviation of midline structures toward one side. Similar to single advancement flaps, bilateral flaps will create wounds of unequal length often requiring removal of Burow triangles. These triangles may vary in size and location, depending on the location of the flaps and the elasticity of the tissues ( Fig. 9-3 ). 2 For instance, Figure 9-3 shows Burow triangles removed at different locations above and below the two flaps. In theory, these locations correspond to areas that result in the best scar camouflage. Figure 9-3B shows half-buried mattress sutures placed at the site of the Burow triangle excisions. Inferiorly, a four-point corner stitch is used.
How to repair a forehead defect?
Unipedicle advancement flaps are useful for repair of defects on the forehead. The flap is designed so that incisions are placed in or parallel to horizontal creases and, when possible, along the border of the eyebrow or anterior hairline. The unipedicle advancement flap should be conceptualized as rectangular in shape. Most cutaneous defects are round or oval, and a rectangular flap does not always precisely conform to a round defect. It may be necessary to modify the shape of the distal flap or the defect itself to minimize tissue distortion. It is usually preferable to “square off” the defect than to “round off” the flap. This is because angular incisions produce straight scars that have fewer propensities to develop trap-door deformities compared with curvilinear scars. Regardless of which option is selected, it is helpful to delay this modification until t he flap has been elevated and has demonstrated its ability to cover the defect completely. Unipedicle advancement flaps are usually designed with parallel incisions extending from one border of the defect. However, these incisions are sometimes designed to diverge from each other when a greater width to the pedicle is desired or divergence can allow placement of incisions in facial aesthetic borders. Typically, unipedicle advancement flaps are designed with a ratio of defect width to flap length of 1 : 3. 1, 2 Therefore, large defects are more easily repaired with bilateral opposing flaps.
What is the problem with T-plasty flaps?
The greatest problem with T-plasty repair of large (2 cm or greater) circular cutaneous defects of the lip is ectropion of the vermilion as the wound heals. This is due to the contracture of the vertical portion of the T-shaped scar. In addition, T-plasty flaps are not pure advancement flaps. Some pivotal movement occurs, and this causes a small reduction in effective flap length. This in turn causes shortening of the vertical wound closure line. To avoid vermilion ectropion, a modified T-plasty can be performed. Instead of excision of the standing cutaneous deformity that develops opposite the incision lines for the two opposing flaps, the tissue of the deformity is preserved and used to lengthen the vertical component of the T-plasty scar (Fig. 9-7). The two opposing borders of the flaps are first approximated at the vermilion line. The resulting standing cutaneous deformity that forms opposite the flap incisions is marked. Only half of the typical incision to excise the deformity is made. This creates a flap of skin that is pivoted and advanced into a second horizontally oriented incision made in the opposing lip segment. The orientation and length of the second incision are designed after the first incision creating the flap of skin has been performed. The flap is positioned over the adjacent lip segment, and the distal end of the overlapping flap is marked on the lip segment. A line is drawn from this point to the lip segment wound border. The line is angled so it is centered beneath the linear axis of the overlapping flap. An incision is then made along this line. The borders of the incision are undermined. The flap is then sutured into the recipient site created by the second incision. On occasion, a small portion of the flap must be trimmed to allow it to fit perfectly within the opposing lip segment. This technique in essence is a modified Z-plasty, which has the effect of lengthening the otherwise straight vertical component of the T-plasty scar. The vertical scar resulting from the modified T-plasty has an irregular Z-shaped configuration (Fig. 9-8).
How are unipedicle flaps created?
The flap is created by parallel incisions that allow a sliding movement of tissue in a single vector toward a defect. The movement is in one direction and flap advancement is directly over the defect. This form of wound repair is sometimes referred to as U-plasty. Complete undermining of the advancement flap as well as of the skin and soft tissue around the pedicle is important to enhance tissue movement. In contrast to pivotal flaps, which form a single standing cutaneous deformity, two deformities are created with all unipedicle advancement flaps. Unlike with pivotal flaps, in which the standing cutaneous deformity must be dealt with at the base of the flap, the deformities that develop from advancement can be excised anywhere along the length of the flap and not necessarily juxtaposed to the base. This is because of the mechanism of tissue movement.
Why is undermining the advancement flap important?
Complete undermining of the advancement flap as well as of the skin and soft tissue around the pedicle is important to enhance tissue movement. In contrast to pivotal flaps, which form a single standing cutaneous deformity, two deformities are created with all unipedicle advancement flaps.
What are the considerations of flap design?
Figure 4.3 demonstrates some of the fundamental considerations of flap design, which include sufficient tissue laxity to allow for tension-free closure, no distortion of free margins, placement of incision lines in cosmetic junction lines, and reliable flap perfusion. In this case, by pinching the defect and surrounding skin, the surgeon was able to identify the melolabial fold as an available tissue reservoir and the lip as the free margin at highest risk for distortion. There was sufficient laxity to permit a horizontal side-to-side closure but this would have created standing cones that extended into the nostril and across the vermilion. Instead, an advancement flap that displaced the standing cones laterally instead of vertically was designed. The tension vector was oriented parallel to the free margin of the lip to minimize any distortion. The flap had a wide, tension-free pedicle that increased the likelihood of an adequate blood supply. Of note is that the defect was enlarged slightly to allow for placement of the incisions along cosmetic junction lines. Generally, the width of an advancement flap is determined by the height of the defect but in select circumstances, the surgeon may consider widening the defect to allow for better camouflage of incision lines and a more aesthetic outcome. 6 If desired, a Z-plasty may be incorporated into the leading edge of the advancement flap to further decrease the risk for upward pull on the lip with scar contraction ( Figure 4.4 ). This modification not only widens the flap tip, but also breaks up and partially redirects the scar line along which some contraction will occur during wound healing.
How does an advancement flap work?
Clearly not a recent innovation, the advancement flap can be thought of as a sliding flap that moves along a single vector directly into the surgical defect ( Figure 4.1 ). Once the defect is closed, the surrounding tissue provides the secondary movement or opposing force. 2 The flap is designed by extending parallel incisions (not necessarily of the same length) from one side of a surgical defect. Since the flap is created from adjacent skin, one edge of the defect becomes the advancing tip of the flap. This basic design has also been called a U-plasty or rectangular flap. The prominent horizontal lines make the advancement flap particularly useful in the reconstruction of the eyebrow and forehead areas. It can also be effective for reconstruction of defects on the upper lip, dorsal nose, and helical rim.
How long should a flap be for a pedicle?
In general, the maximum length for a random pattern flap on the face is limited to 3–4 times the width of the pedicle. 8 The surgeon may consider making the initial incisions slightly shorter than were originally designed to accommodate unexpected laxity discovered after undermining. These incisions can always be extended if additional length is needed. The flap should be thick enough to fill the defect and include the subdermal vascular plexus with at least a portion of the upper subcutaneous fat. In the absence of vital anatomic structures, the flap should become progressively thicker as it extends towards the base of the pedicle. This allows for larger caliber vessels to be recruited and may increase the likelihood of flap survival. If there is a question of sufficient blood supply, it may be appropriate to deepen the defect to accommodate a thicker flap with more robust perfusion.
What are the factors that determine the advancement flap?
The most important consideration is the amount of tissue laxity available for closure of the defect. An advancement flap does not lower the tension of closure much beyond that which can be achieved with a side-to-side closure and it is not a good choice for large defects without surrounding laxity. With experience, the surgeon can estimate the degree of tissue mobility and identify tissue reservoirs by pinching and stretching the defect and surrounding skin. The physical manipulation of tissue to estimate mobility cannot be stressed enough. Once the flap is incised from the surrounding tissue, it relies on the blood supply within its pedicle to maintain viability. The flap’s perfusion is determined largely by its dimensions, the quality of the vasculature within its pedicle, and the tension placed upon it during closure. 4 Blood flow to the tip of the flap is inversely related to the tension of wound closure and even a wide, well-perfused flap is at risk for necrosis if placed under too much strain. 5
What is an H flap?
In the H-plasty or bilateral advancement or rectangular flap, parallel incisions are created on opposite sides of the defect. The two limbs of the flap are then advanced centrally to form an H-shaped suture line ( Figure 4.6 ). This flap is most useful for locations with prominent horizontal lines such as the forehead, eyebrow, or glabella. The incision lines do not need to be exactly parallel and may be curved to conform to RSTLs. The advantage of an H-plasty is that each flap must advance only half as far as the single flap design. It is used in situations where a unilateral flap will not provide adequate tissue for tension-free wound closure. 14
What is the green arrow on a flap?
The green arrow indicates the primary motion of the flap. The prominent lines on the forehead are linear rather than curved and the circular defect will be squared to allow the advancing edge of the flap to form perpendicular lines. (c) Immediate postoperative appearance. (d) Appearance 6 months after surgery.
What is the advancement flap?
The prominent horizontal lines make the advancement flap particularly useful in the reconstruction of the eyebrow and forehead areas.
What is advancement flap?
Advancement flaps are modified linear closures with one, or both, apical standing cones moved to the side. When a free margin, such as the eyelid, lip, or alar rim, or cosmetic subunit junction, such as the nasolabial fold or orbitomalar groove, would be violated by a linear closure; advancement flaps may be utilized to direct the standing cones away from these natural boundaries (Figure 1). Additionally, advancement flaps often camouflage scars by placing incision lines along natural creases or cosmetic subunit junctions. Common locations for advancement flaps include the upper and lower cutaneous lip, the nasal sidewall, the infraorbital cheek, and the lower eyelid, the forehead and temple, the preauricular cheek, and the helical rim. [7] [8] [9]
Where are advancement flaps located?
Common locations for advancement flaps include the upper and lower cutaneous lip, the nasal sidewall, the infraorbital cheek, and the lower eyelid, the forehead and temple, the preauricular cheek, and the helical rim. [7] [8] [9]
What is the anatomic plane of flap elevation?
The anatomic plane of flap elevation also impacts the flap’s blood supply. Deeper undermining plans include larger caliber arteries with greater perfusion pressures, but critical anatomic structures, such as branches of the facial nerve, may be damaged. Ideal undermining plans for advancement flaps balance flap vascularity with the risk of damaging critical anatomic structures. For the majority of advancement flaps on the lateral face, the preferred anatomic plane is just above the superficial musculoaponeurotic system (SMAS). On the nose, flap elevation and undermining are commonly performed in a deeper and relatively avascular tissue plane, just above the nasal bone or nasal cartilage.
What is the ratio of the length of a flap to the width of its pedicle?
The ratio of the length of the flap to the width of its pedicle impacts blood flow. As a general guideline, random pattern flaps on the face can sustain a 3:1 length to width ratio, while those on the trunk and extremities may be best designed with a 2:1 ratio. However, these guidelines are not absolute.
What is a local flap?
Local, random pattern flaps are workhorse reconstructive options for cutaneous defects. Advancement flaps are conceptually the simplest local flaps and fall within the group of sliding flaps, along with rotation flaps. [1] [2] [3] For these sliding flaps, the tissue is moved or "slid" directly into the adjacent defect without "jumping" over the interposed tissue.
How does a flap survive?
A flap’s survival depends on the delivery of oxygenated blood to the leading edges of the flap. Perfusion of blood through the vascular plexuses decreases as the distance from the feeding artery or arteriole increases. The portions of an advancement flap most vulnerable to necrosis are the distal tip since it has fewer blood vessels to nourish it and is most distant from the feeding artery or arteriole, and the portion of the flap sutured under the greatest tension since the tension from the closure results in compressive forces on blood vessels. [4] [5] [6]
Who performs advancement flaps?
Advancement flaps are usually performed by the plastic surgeon. These flaps play a vital role in wound coverage. the monitoring of patients with advancement flaps is usually done by nurses trained in surgery. The key is to inform the plastic surgeon ASAP when the flap has poor perfusion or is showing signs of flap necrosis.
What is a local flap?
Local flaps can be defined by their vascularity. Random flaps are based on blood flow through the subdermal plexus to provide vascularity to the distal end of the flap ( FIG 1 ). Axial flaps are based on a longitudinal blood vessel incorporated into the flap design that can extend the effective length of a flap ( FIG 2 ). Perforator flaps are based on underlying septocutaneous or musculocutaneous perforators into the central area of the flap ( FIG 3 ).
What is the purpose of closure of a flap?
Once flap has adequate advancement to fill defect, closure often occurs from the base of the flap to help “push” the flap into the defect, which can help alleviate tension over the distal closure ( FIG 4C ).
What is flap design?
Flap design includes evaluation of tissue laxity, optimization of scar position, and management of standing cutaneous deformities.
Why should all areas be prepped?
All areas should be prepped widely to allow for access to all local and regional flap option. All extremities should be prepped and draped circumferentially. For areas where symmetry is important (such as the face or breasts), it is important to have the contralateral side in the operative field as well.
Why should flaps be inset?
Flaps designed around joints should be inset under the greatest tension of the joint to avoid postoperative dehiscence.
Why are advancement flaps considered local flaps?
Advancement and rotation flaps are both considered local flaps because they borrow from the tissue adjacent to the defect. Distant flaps use tissue from areas away from the defect, and free flaps involve the transfer of tissue from a distant site by means of a microsurgical anastomosis.
What is advancement flap?
Advancement and rotational flaps are tissue transfer techniques used in reconstructive surgery for the closure of acquired defects.
