Modified bilateral advancement flap: the slide-in flap.

The bilateral V-Y advancement flaps are used commonly in the closure of circular skin defects. We modified the standard bilateral V-Y advancement flap technique to reduce the tension along the closure, and used it in 10 patients between 1995 and 1997. In the presence of a circular defect, bilateral V-Y advancement flaps were marked on the skin, with the height of the V flaps measuring 1.5 to 2 times the diameter of the defect. The limbs of the V were not drawn as straight lines, but were curved outward slightly, making the flap and its two extensions broader than the standard V-Y flap. The broad extensions of the V flaps encircled the defect from above and below. Skin incisions were made vertically down to the muscle fascia. Additional undermining was carried out to elevate the upper and lower extensions of the V flaps for a distance that equaled the radius of the defect. The upper and lower extensions of the V flap on one side were transposed into the defect and sutured to the concave base of the opposing flap V flap at its midpoint. These extensions were then sutured to each other. The extensions of the opposing V flap were then transposed into the defect; the upper being superior and the lower being inferior to the extensions of the first flap. The rest of the operation was completed by advancement of the V flaps and closure in a Y configuration. The efficient redistribution of available tissue by the combined use of transposition and advancement principles resulted in the repair of relatively large skin defects with reduced tension along the closure. Satisfactory results were obtained in all patients in this series without any surgical complication.     

Advancement Flaps: A Basic Theme with Many Variations

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 Burow's 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), Burow's triangle flap (Burow's 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.     

Freestyle perforator-based V-Y advancement flap for reconstruction of soft tissue defects at various anatomic regions

BACKGROUND: Perforator flap surgery has gained great popularity in the last decade because surgeons can prepare freestyle flaps in anywhere on the body if they find a perforator supplied to the flap. One of the basic principles of reconstructive surgery is that superior results can be obtained for color and texture match if immediately adjacent soft tissue is used to repair a defect. V-Y advancement flaps are used successfully based on this principle, but the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use. METHODS: We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem. The authors used 26 perforator-based V-Y advancement flaps in 24 consecutive patients for coverage of defects located at sacral (4), thigh (6), abdominal wall (3), inguinal (3), back (4), leg (2), and trochanter (2) regions. There were 14 female and 10 male patients with a mean age of 48.3 years (range, 22-70 years). RESULTS: The patients were followed up for a mean period of 14.2 months (range, 9-21 months). The size of the defects ranged from 3 x 5 cm to 15 x 20 cm. All flaps survived completely (92.4%) except 2 in which one of them had undergone total necrosis and the other had marginal necrosis. Fifteen flaps (57.6%) were elevated based on 2 perforators, 7 flaps (26.9%) were used with only one perforator, and the remaining 4 (15.5%) had 3 perforators. CONCLUSIONS: Perforator-based V-Y advancement flaps are safe and very effective for coverage of defects in which closure is impossible with a standard V-Y advancement flap. Dissection of the perforator or perforators offers remarkable excursion to the V-Y flap with minimal donor site morbidity. These axial pattern flaps can be used successfully with good esthetic and functional results at various regions of the body if there is any detectable perforator.     

15 years experience in the surgical treatment of decubitus ulcers of the pelvic region

We summarize our 15 year experience in the surgical treatment of pressure ulcers of the pelvic region. The technique of suggested operations is described (sacral defect--gluteus maximus musculocutaneous V-Y advancement flap, trochanteric defect--tensor fascia lata musculofasciocutaneous transpositional flap, ischial defect--biceps femoris musculocutaneous V-Y advancement flap). In recent years we cover defects in all these regions using the principle of Emmett's hatchet flap--i.e. with musculocutaneous hatchet flap. We performed 105 operations, 3 patients had recurrence.     

A Case of Postmastectomy Defect Reconstructed Using a Laterothoracic Bilaterally Pedicled V-Y Advancement Flap

BACKGROUND: The reconstruction of major defects of the trunk is generally achieved by means of pedicled or free musculocutaneous flaps, but for less extensive defects, local flaps or skin grafts are currently used. The bilaterally pedicled V-Y advancement flap differs from the traditional V-Y advancement flap and was described for soft tissue reconstruction in the face. In our unit, the bilaterally pedicled V-Y advancement flap is the most used local flap for face reconstruction, and our aim was to use it in a different location. METHODS: In this case report we present a postmastectomy defect reconstructed with good results using the bilaterally pedicled V-Y advancement flap. RESULTS: The flap healed without further problems, and a good aesthetic result was obtained. CONCLUSION: The bilaterally pedicled V-Y advancement flap is reliable and easy to harvest, and not only for face reconstruction. Its versatility and plasticity allow its use for the reconstruction of many defects at varying locations.     

Nasolabial V-Y Advancement for Closure of the Midface Defects

BACKGROUND: V-Y subcutaneous advancement flaps receive an excellent blood supply from subcutaneous tissue and are ideal for use on the face. Also it is advantageous cosmetically compared to other local flaps. OBJECTIVE: Nasolabial V-Y advancement flaps are very useful in closing defects of the midface region after tumor resection. METHODS: Our experience with nasolabial V-Y flaps in 22 patients is reported. The average defect size was 2.4 cm x 3.2 cm. RESULTS: Minor flap necrosis occurred in one patient and simple lower eyelid ectropion in another. CONCLUSION: Nasolabial V-Y advancement flap is a simple and satisfactory alternative for closing relatively large defects in the midface when compared with other methods such as skin graft and rotation or transposition flaps. It is easy to design, reliable, and offers good cosmetic results.     

"Pac Man" flap for closure of pressure sores

The purpose of this study was to modify the classic bilateral V-Y advancement flap procedure to decrease the tension in its closure and to break the midline vertical scar by interdigitating the flaps. After debridement of a pressure sore, the V-Y flaps were marked on both sides of the wound. Skin incisions were carried down to the muscle fascia along the sides of the flaps. The upper and lower limbs of the V-shaped flaps were elevated as triangular flaps but remained attached to the main flap. The tip of the upper limb of one of the flaps was transposed into the defect and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect. The lower limb of the contralateral flap was then transposed into the defect and sutured to the first V-Y flap. To complete the interdigitated closure, the lower limb of the first flap was sutured below the contralateral flap, and the upper limb of the contralateral flap was sutured above the first flap. The final view of the flaps was similar to "Pac Man," so the authors decided to call this flap the Pac Man flap. The flaps healed well in all patients, and wound breakdown or recurrence of the pressure sore was not observed during the 3 to 14-month follow-up.     

Double-opposing V-Y inferior gluteal artery fasciocutaneous flaps for the restoration of the intergluteal cleft during reconstruction of large perineal defects

A technique for restoring the intergluteal cleft during the reconstruction of large perineal defects is described. A modification of the bilateral V-Y inferior gluteal artery advancement flaps with double-opposing, deepithelialised dermal flaps is used to recreate the intergluteal cleft. In our series of 15 patients, this technique produced reliable results with high patient satisfaction. We recommend this technique as a reliable and effective modification of the traditional V-Y advancement flap to give a more aesthetically pleasing intergluteal cleft for reconstructing perineal defects.     

Modified gluteus maximus V-Y advancement flaps

A modified method is presented for the closure of wounds using gluteus maximus V-Y advancement flaps. Extra tissue is included in each flap by extending the corners of its advancing edge. The extra tissue is utilised to aid closure by using a combination of rotation and transposition in addition to advancement. This modification is illustrated and examples of its clinical use described.     

Lower back defect coverage using a free-style gluteal perforator flap

Lower back defects remain a major challenge for reconstructive surgeons. Advances in perforator flap techniques now make it possible to repair lower back defects using a gluteal perforator flap based on the free-style flap design. We used a free-style gluteal perforator flap in 10 patients with lower back defects due to skin cancer treatment (6 patients) or infection following spine surgery (4 patients). V-Y advancement flaps were used for defects <6 cm in length, and rotation flaps for defects >6 cm. Perforators were detected at the upper parasacral area, and the flap design was drawn on the skin of the upper gluteal region. Coverage was successful and donor sites were closed primarily in all cases. There were 4 complicated cases: 1 of partial flap loss that led to delay of the wound closure, 2 of initial venous congestion, and 1 of hematoma. These complications resolved, and there was no case of flap loss during a 12 to 62 months follow-up (mean, 32.4 months). The present series indicated that the free-style gluteal perforator flap provides a safe, effective, and relatively easy option for lower back defect reconstruction.     

The versatility of the hatchet flap in soft tissue reconstruction and a proposed new classification

The Hatchet flap is a well-known flap used to cover round defects with primary closure of the donor sites in a V–Y fashion. This provides a stable coverage of the defect by a skin flap from the adjacent area and thus having similar color, texture, and sensation to the lost skin. Literature showed the application of the hatched flaps in facial, fingertip, pressure sores, and meningomyelocele reconstruction but not in the other anatomic areas. The aim of this study was to demonstrate the versatility and reliability of two types of hatchet flaps to reconstruct soft tissue defects at various anatomical regions of the body. Forty-six hatchet flaps were used in 40 patients to reconstruct defects located at scalp, face, neck, chest, axilla, back, sacrum, trochanter, genitalia, perineum, buttock, thigh, knee, foot, and fingertip. The causes of defects were infection, trauma, tumor excision, pressure necrosis, congenital meningomyelocele, chemical burn, and radiation. Mean follow-up period was 6.6 months. Hatchet type I flaps were advanced without undermining using the viscoelastic properties of the skin, while hatchet type II flaps were undermined before rotation advancement. All defects were successfully covered. The flaps survived completely. Partial dehiscence occurred at the donor site of three flaps but healed without problems after re-suturing. In conclusion, hatchet flaps are versatile flaps that provide a simple but efficient solution to defects of different etiologies located at different anatomical regions in the body. Minimal blood loss and short duration of surgery make them first option flaps for patients with co-morbidities.     

Simultaneous coverage of ipsilateral ischial and trochanteric pressure sores--a case report

Multiple pressure sores represent recurrent problem in immobilized, mostly paretic patients. A lot of them undergo repeated surgeries and thus the positions of scars, directions of rotation or transposition of flaps limit other operations in the region. Then usually the length of hospital stay grows proportionally with the number of necessary operations and often exceeds 6 weeks. The authors present, in form of a case study, the simultaneous coverage of ipsilateral ischial and trochanteric pressure sores with V-Y advancement fasciocutaneous dorsal thigh flap supplied by perforators from the deep femoral artery, in a patient with multiple repeated decubiti.     

Local Hatchet Flap for Facial Skin Defects Reconstruction in Special Areas

BACKGROUND: The local hatchet flap has been used to reconstruct skin defects of the face with satisfactory results. Cosmetically, it has advantages over other local flaps when skin defects are located in special areas such as the eyelid. OBJECTIVE: The purpose of this study was to examine the application of local hatchet flaps for facial defect reconstruction, especially in cases where reconstruction is classically difficult for cosmetic and functional rehabilitation. METHODS: We report an illustrated case series. Results. In this study, all four cases achieved satisfactory functional and cosmetic results using the local hatchet flap. CONCLUSIONS: The local hatchet flap is an effective and simple alternative for reconstructing facial defects in special areas of the face, offering good cosmetic results and satisfactory function.     

V-Y Fasciocutaneous Advancement Flap Coverage of Soft Tissue Defects of the Foot in the Patient at High Risk

This single-center, observational case series involved a review of prospectively collected data pertaining to 16 V-Y fasciocutaneous advancement flaps performed on 16 consecutive patients between August 2006 and December 2008. Each patient underwent primary excision of a foot ulcer with debridement of soft tissue and bone, insertion of polymethylmethacrylate antibiotic–loaded bone cement, and immobilization. At an average of 3 days after the index procedure, soft tissue and osseous deformities were corrected in 13 of the 16 patients, and a V-Y fasciocutaneous advancement flap was used for coverage of the soft tissue defect in all patients. Patients were kept nonweightbearing and were followed up until clinical healing occurred or failure was declared. There were 12 male and 4 female patients with a mean age of 64.0 ± 7.4 years (range, 48–75 years). Fifteen patients had diabetes mellitus with a mean of 5.1 ± 1.8 (range, 3–8) medical comorbidities. There were 10 medial forefoot, 3 central forefoot, 2 lateral forefoot, and 1 dorsal midfoot full-thickness soft tissue defects that displayed a mean diameter of 2.3 ± 1.4 cm (range, 1.0–3.5 cm). All but 4 flaps healed primarily, with each developing marginal dehiscence that healed with local wound care measures. Two deep infections occurred despite healing of the flap, which necessitated transmetatarsal amputation with split-thickness skin graft coverage. When properly performed and after complete resolution of infection, V-Y fasciocutaneous advancement flap coverage of complex foot ulcerations represents a useful and reliable technique even in patients with multiple medical comorbidities.     

Modified tensor fascia lata musculofasciocutaneous flap for the coverage of trochanteric pressure sores.

The method most frequently used for the coverage of trochanteric pressure sores is the tensor fascia lata (TFL) flap. The authors introduce a new, hatchet-shaped incision strategy for the TFL flap, which preserves the safe blood supply of the flap and keeps the flap mobile enough. The part of the flap including the muscle is adapted to the greater trochanter. This provides a good aesthetic result without dog-ear formation at the rotation point of the flap. The donor site is closed in a V-Y fashion, and the closure does not require any skin grafting or designing a local flap. The TFL hatchet flap was used nine times on eight patients to cover trochanteric pressure sores. With one exception all patients healed. No recurrence was observed during the follow-up period, and no contour difference developed on the lateral aspect of the thigh.     

Bilateral, extended V-Y advancement flap

A modification of the V-Y advancement flap for the closure of circular skin defects is presented to decrease the tension in the closure and to break the midline vertical scar. Bilateral, extended V-Y advancement flaps with additional limbs extending to the advancing edges of the standard flaps were marked on both sides of the wound. After advancement of the V-Y flaps on their subcutaneous pedicle, the upper and lower extensions were hinged downward as transposition flaps to close the middle portion of the circular defect, where maximum tension occurs. This procedure was applied to 10 patients with sacral and trochanteric pressure sores. No complications or recurrences were noted during the 2 to 10 months of follow-up. Bilateral, extended V-Y advancement flaps enable the reconstruction of large defects without midline tension. Also, the resulting scar where the flaps meet is a zigzag line, so a straight midline scar is avoided.     

双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣修复骶部巨大褥疮

目的:笔者设计了一种双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣,关闭巨大骶部溃疡,以增加皮瓣推进量,避免臀大肌功能性缺损。方法:清创后V-Y推进皮瓣标记于双侧臀部。在缺损近侧掀起筋膜皮瓣,在远侧臀大肌肌肉附件里保留臀上动脉远侧穿支,直至获得足够的皮瓣前移。结果:用此方法治疗15个直径7～15cm的骶部褥疮的患者,没有出现皮瓣坏死和溃疡复发,91%的皮瓣Ⅰ期愈合。结论:此技术使皮瓣推进量增加,皮瓣存活可靠,并保留了双侧臀部和臀大肌功能。     

Dorsal V-Y advancement flap for amputations of the fingertips.

Amputations of the fingertip are the most common injuries to the upper limbs, and they cause greatest socioeconomic losses. The first choice of the technique of repair should be the simplest and fastest, with rapid restoration of function and an acceptable aesthetic appearance, and should return the worker to his job rapidly to prevent economic loss. Volar V-Y advancement flaps should therefore be considered first, but unless the dorsal loss is greater than the volar, this first choice of flap cannot be used because of the inadequate donor area. We present here a method for amputations that are proximal to the matrix of the nail. Seven volar oblique or transverse amputations were treated with dorsal V-Y advancement flaps with or without volar V-Y advancement flaps. All flaps survived. The procedure is simple, versatile, and a reliable way of reconstructing amputations of the fingertip that are proximal to the nailbed.     

Dorsal V-Y advancement flap for amputations of the fingertips

Amputations of the fingertip are the most common injuries to the upper limbs, and they cause greatest socioeconomic losses. The first choice of the technique of repair should be the simplest and fastest, with rapid restoration of function and an acceptable aesthetic appearance, and should return the worker to his job rapidly to prevent economic loss. Volar V-Y advancement flaps should therefore be considered first, but unless the dorsal loss is greater than the volar, this first choice of flap cannot be used because of the inadequate donor area. We present here a method for amputations that are proximal to the matrix of the nail. Seven volar oblique or transverse amputations were treated with dorsal V-Y advancement flaps with or without volar V-Y advancement flaps. All flaps survived. The procedure is simple, versatile, and a reliable way of reconstructing amputations of the fingertip that are proximal to the nailbed.