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Page 8 of 10 Schopper et al. Plast Aesthet Res 2022;9:25 https://dx.doi.org/10.20517/2347-9264.2021.72

Figure 7. Bernard-Burow flap. (A) Red portion represents a cutaneous lip defect. Blue dashed areas represent areas of excised skin to
allow for free opposing movement of the skin flaps. Flaps are moved along a horizontal plane as indicated by the arrows. (B) Closed
incision. An additional mucosal advancement flap is generally used for reconstruction of the vermillion lip.

Figure 8. Karapandzic flap. (A) Large lower mucosal and cutaneous lip defect that is full-thickness along the superior portion. Proposed
partial thickness incisions marked with purple ink. (B) Post-operative photo demonstrating closure of the defect. Incision lines are hidden
in the nasolabial folds and mental creases. (C) Dynamic view demonstrating minimal microstomia and intact orbicularis oris function.

Tissue expanders can also reconcile inadequate local tissue availability. Tissue expanders are often used for
scalp defects to generate hair-bearing donor tissue. Expanders are sometimes useful in the cheek and
forehead as well [33,34] .

Complications
Skin necrosis is most often associated with flaps of larger size or length, particularly at the distal end or in
areas of greater tension. Advancement flaps depend on a random pattern in blood supply that can increase
this risk. Therefore, care should be taken to monitor flaps closely for congestion. Nitro paste can be used to
improve congested or poorly perfused areas .
[5,6]

The trapdoor deformity is another potential complication of advancement flaps. This deformity is
characterized by depression of the scar along the transposed tissue with bulging of the native tissue
surrounding it. This deformity can be addressed in a number of ways including steroid injection, scar
revision with Z-plasties, or laser treatments. The risk of developing a trapdoor deformity can sometimes be
lessened with incision design and by sufficient undermining at the time of primary repair [35,36] .

CONCLUSION
Advancement flaps represent a useful option for appropriately selected facial skin defects. Surgeons armed
with the knowledge to effectively execute advancement flaps can close a variety of defects with limited
morbidity and excellent aesthetic results.