Reading Man Flap: Application to Plantar Defects

The plantar surface of the foot has highly specialized, densely adherent, glabrous skin, making functional replacement difficult. Glabrous skin defects should be replaced with similar skin to restore function and aesthetics. An innovative technique, the “reading man flap,” was developed for closure of circular skin defects. At locations such as the face, trunk, thigh, and calf, the “reading man” procedure provides tension-free closure with minimal additional healthy skin excision, and it does not cause “dog ear” formation. The potential exists for replacement of plantar defects with skin of the same quality using this procedure. In the present study, we report on 2 clinical cases in which intermediate-size plantar defects were reconstructed using the reading man flap. This method can provide tissue as durable, yet as sensitive, as skin that matches the unique characteristics of the plantar skin.     

A new technique for closure of large meningomyelocele defects

BACKGROUND: Although small meningomyeloceles may be amenable to direct closure by undermining of the surrounding skin, the closure of large meningomyelocele defects is a challenging reconstructive problem. PURPOSE: Here, we present a new surgical procedure for the closure of large meningomyelocele defects. MATERIAL AND METHODS: In this procedure, after neurosurgical repair and closure of the placode, the defect is surgically converted to a triangle in shape. Then, the triangular defect is closed by transposition of 2 skin flaps designed in an unequal z-plasty manner. Over 3 years, this new technique, namely Mutaf triangular closure procedure, was used for the closure of large meningomyelocele defects in 5 patients, aged between 2 days to 6 weeks. The defect size was 10.4 x 7.5 cm on average. RESULTS: In all patients, a tension-free 1-stage closure was obtained. Except one with a minimal hematoma, all patients healed with no complication. There was no patient with late breakdown of the wound during 2 years of mean follow-up. CONCLUSIONS: Besides the 2 major advantages of short operative time and minimal blood loss, our technique provides a well-vascularized soft tissue padding over the neural tissues, and no suture line overlies the cord closure. With these advantages, this new technique seems to be a useful and safe solution for closure of large meningomyelocele defects.     

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.     

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.     

Use of the Z-Plasty Technique for Forehead Defects

BACKGROUND: Surgical defects of the forehead are commonplace for the Mohs surgeon. The relaxed skin tension lines (RSTLs) of this region allow for repairs ranging from direct linear closures to more complex advancement flaps. Defects in which the longitudinal axis orients perpendicular to the RSTLs, whether secondary to wound shape or ease of tissue movement, present a somewhat more challenging problem. OBJECTIVE: To describe the use of the Z-plasty in repairing forehead surgical defects. METHOD: We illustrate two Mohs surgical cases in which the size and location of the forehead defect did not allow for a straightforward and cosmetically acceptable closure. Tissue mobility and defect shape permitted design and implementation of a Z-plasty. RESULTS: Use of the Z-plasty technique allowed a portion of the vertical incision line to be reoriented within the forehead RSTLs, producing a favorable cosmetic outcome. CONCLUSION: Forehead defects that are shaped such that the long axis is perpendicular to the RSTLs or located in a region where tissue mobility more easily permits a vertical closure can present a challenge for the reconstructive surgeon. Knowledge of tissue mechanics and use of rotation and advancement make the Z-plasty a favorable option in many of these situations.     

The ��reading man flap�� for pressure sore reconstruction

Background:

The treatment of pressure sores represents a significant challenge to health care professionals. Although, pressure wound management demands a multidisciplinary approach, soft tissue defects requiring reconstruction are often considered for surgical management. Myocutaneous and fasciocutaneous flaps can provide stable coverage of pressure sores.

Purpose:

Here, we describe our experience using a recent fasciocutaneous flap, which is named ‘reading man’ flap, in sacral, ischial, and trochanteric pressure sores.

Materials and Methods:

During a period of 1 year the authors operated 16 patients, 11 men, and 5 women, using the reading man flap. The ages of the patients ranged from 24 to 78 years. The location of pressure sores was 8 sacral, 5 ischial, and 3 trochanteric pressure sores. The mean size of pressure sores was 8 cm × 9 cm.

Results:

All pressure sores covered bt the Reading Man flap healed asymptomatically. After follow-up of 2-8 months, no recurrences were encountered and no further surgical intervention was required.

Conclusion:

The reading man flap was found to be a useful technique for the closure of pressure sore in different anatomic locations. The advantage of tension-free closure and the minimal additional healthy skin excision made this flap a useful tool in pressure sore reconstructions.KEY WORDS: Local flap, pressure sore, ‘reading man’ flap     

ISLAND FLAPS INCLUDING THE BEZIER TYPE IN THE TREATMENT OF MALIGNANT MELANOMA

Despite the trend in current surgical practice in the treatment of melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a fascial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the derma-tomes, which act as an aid memoire upon which the flaps are marked.     

Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results.     

Repair of lumbosacral myelomeningoceles with double Z-rhomboid flaps. Technical note

The authors describe a double Z-rhomboid technique for the closure of large lumbosacral myelomeningocele defects. After the dorsally displaced neural tissue has been reduced into the vertebral canal and a watertight closure of the dura lining the sac has been achieved, the skin defect is surgically converted to the shape of a rhombus. Equilateral Z-plasty flaps are elevated at the sides of the rhombus and transposed across the defect to secure wound closure. A successful experience with 10 consecutive cases of lumbosacral myelomeningoceles repaired with this technique is reported.     

The Keystone Design Perforator Island Flap in reconstructive surgery

Background: A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot. We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients. Results: In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap. Conclusions: The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.     

Reconstruction of the subglottic larynx with a myoperiosteal flap: clinical and experimental study

The literature describes numerous techniques for reconstruction of the subglottic larynx. The use of rigid bone grafts or flaps has been associated with problems because the rigid bone cannot conform to the defect and form an airtight seal. We have performed subglottic reconstruction using the sternocleidomastoid myoperiosteal flap with very optimistic results on long-term follow up. The sternocleidomastoid myoperiosteal flap is a relatively simple procedure that can be used for a large variety of defects. The pliable periosteal flap used for closing the defect can be molded over a stent to form an airtight seal. We have demonstrated bone formation in the periosteum which is crucial to the stability of the airway and long-term success of the procedure. The sternocleidomastoid myoperiosteal flap yields a pliable, durable tissue capable of airtight closure and a tension-free suture line. This technique will make the closure of subglottic defects a much more practical task.     

Plantar flap reconstruction for acral lentiginous melanoma

Background: Acral lentiginous melanoma continues to be difficult to diagnose despite an overall trend toward early identification of smaller and thin lesions. The insidious nature of this lesion often precludes primary closure of the surgical defect once it is excised, adding to the reconstructive complexity. Local flaps on the plantar foot offer an option for reconstruction when the defect is of intermediate size. Methods: Eight patients (5 men and 3 women, with an average age of 58 years) who underwent plantar flap reconstruction for defects isolated to the weight-bearing heel were retrospectively reviewed. Results: The average depth of the melanoma was 2.82 mm. Surgical margins were 2 cm or less in seven of the eight patients. Partial flap necrosis occurred in one patient, and loss of part or all of the skin grafts was noted in two patients. Currently five patients are alive with no evidence of disease. Conclusion: The plantar flap can provide local well-vascularized tissue for weight-bearing areas where skin grafting alone may not be appropriate. Coverage of these areas with well-padded flaps led to ambulation in all of the patients studied. We believe this flap offers durable coverage for medium-sized defects in acral lentiginous melanoma.     

Use of distally based intermetacarpal flaps to cover dorsal traumatic defects of the middle fingers

INTRODUCTION: The presence of distal intermetacarpal anastomoses between dorsal and palmar vascular networks makes it possible to dissect and isolate Distally Based Dorsal Hand (DBDH) flaps. Quaba and Davidson first described this possibility. The purpose of this paper is to report our experience using the DBDH flap to reconstruct complicated defects of the long fingers. MATERIAL AND METHOD: We are reporting our experience in eight cases (seven performed in emergency) where such a flap was used to cover dorsal traumatic skin defects of the long fingers. The average age was 40.3 years, ranging from 25 to 67 years. All the patients were males, seven of them had a job at the time of injury and the last one had already retired when injured. RESULTS: All the eight flaps survived, sometimes with minor complications. Only one case developed a whole-thickness distal necrosis treated successfully by regular dressings. In one case, a Z-plasty was performed to correct a retraction in the 2nd web-space two months after surgery. DISCUSSION: Many flaps have been described to cover dorsal skin defects in the fingers. All of them display some advantages and some disadvantages. The use of this flap allows coverage of vast skin defects and thereby early finger mobilisation. The surgical technique is rather easy, and it does not require microsurgical experience. Skin grafting to cover donor site is not always necessary.     

Bilobed fasciocutaneous flap closure of large meningomyeloceles

BACKGROUND: Closure of large meningomyelocele defects presents a challenging problem. In this paper, the procedure and outcome of bilobed fasciocutaneous flap closure of large meningomyeloceles have been discussed. MATERIALS AND METHODS: Bilobed fasciocutaneous flap was used in 20 patients with large meningomyelocele defects, the largest of which was 77 cm2. A fasciocutaneous dissection was performed and the defect area was covered by tension-free closure. RESULTS: In the follow-up period of 6 weeks, partial flap loss in a patient and cerebrospinal fluid leak inferior to the flap in another 2 were observed. These patients recovered by dressing without flap loss. CONCLUSIONS: Utilization of bilobed flaps for closure of large meningomyelocele defects seems to be an effective and reliable procedure, with advantages of decreased operative time, minimal bleeding, the suture lines for dura and flap not superimposed, and low morbidity.     

Nasalis Flap and Graft Repair Provides Reliable Closure for Denuded Defects of the Nose

BACKGROUND: Skin cancer surgery involving the nasal tip and dorsum sometimes results in exposure of underlying bone or cartilage. We describe a simple method of providing a vascular bed for the defect using the superficial nasalis musculoaponeurotic system (SNAS) of the nose, which allows full-thickness skin graft reconstruction of the defect and an acceptable cosmetic outcome. OBJECTIVE: The utility of nasalis flaps to provide a vascular bed for grafting has not been specifically addressed in the dermatology literature. Our experience with 26 SNAS flaps is outlined to demonstrate the utility of this closure in the appropriate situations. METHODS: A discussion of the relevant anatomy is followed by an outline of the surgical technique. Results: SNAS flaps provide a reliable vascular bed and contour for defects of the bridge and distal nose. Complications have been few. CONCLUSIONS: The SNAS flap and graft are simple to perform and provide a reliable alternative to interpolated nasolabial or forehead flaps when the defect exposes significant bare cartilage or bone.     

Closure of large myelomeningocele defects using dorsal intercostal artery perforator flap

Small meningomylocele defects can be closed primarily. Other repair techniques are required for closure of meningomyelocele defects of >5 cm. In this anomaly, in which random or musculocutaneous flaps are usually used, the technique for skin defect closure should have the following criteria: a safely harvested flap with good blood supply; minimal morbidity in the donor site; closure with adequate thickness to protect the underlying neural structure; and a repair to prevent leakage of cerebrospinal fluid. The dorsal intercostal artery perforator flap is a new perforator flap with a large skin island that can be used safely in the dorsal region. In this article, repair of large skin defects due to myelomeningocele has been attempted using a dorsal intercostal artery perforator flap, and the results are discussed.     

Kombinierter Latissimus-dorsi- und A.-thoracodorsalis-Perforatortranspositionslappen

BACKGROUND: Reconstruction or complete cover of extended but polygonal defects is limited by the size of transplantable tissue. One of the largest composite tissue components to be transplanted is the myocutaneous latissimus dorsi flap. Under certain circumstances even this large-scale flap is not sufficient for complete defect cover. Based on experiences with the thoracodorsal artery perforator (TAP) flap, the skin island adjacent to the latissimus muscle may be raised, pedicled on the perforator vessels penetrating the underlying muscle. Thus this island may easily be transposed or rotated to enable additional defect cover. METHODS: This method was applied in eight patients for defect cover at the extremities, thorax or for hypopharynx reconstruction. The exact location of perforator vessels may be determined pre- or intraoperatively with a hand Doppler so that skin flap transposition can already be planned before surgery. RESULTS: All of the skin flaps transposed or rotated healed without complications. It may even be assumed that utilizing this method helped to avoid further complications like scar contractures, because tension-free wound closure was feasible. CONCLUSIONS: The combined latissimus dorsi- thoracodorsal artery perforator-transpositional free flap is capable of covering very extensive polygonal as well as defects over joints in order to prevent scar contractions.     

The role of soft tissue reconstruction after melanoma resection in the head and neck

INTRODUCTION: Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience. METHOD: We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting. RESULTS: The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm2. Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results. CONCLUSION: Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas.     

Covering of soft tissue defects of the lower leg with adipo-facial flaps

AIM OF THE STUDY: Soft tissue covering on the lower leg is a difficult challenge. A plastic surgical method for covering of these soft tissue defects is presented. PATIENTS AND METHODS: From May 1997 until May 2003 36 patients were treated using neurovascular flaps. Above the sural or the saphenous nerve an adipo-facial flap is dissected, rotated into the defect and fixed without tension. Wound closure of the donor-site defect is done primarily or by mesh-graft. RESULTS: In 35 cases the flap healed without functional impairment. Primary healing was achieved in 30 patients. In 5 cases partial loss of the skin island was registered, whereby subcutaneous tissue remained vital. Revision by mesh-graft transplantation led to successful healing in these patients. In only one patient necrosis of the flap was seen. CONCLUSION: Neurovascular flaps usually result in reliable and complete healing of soft tissue defects of the lower extremity.     

The helix flap for circular skin defects: case reports

After tumor resection, skin defects generally form circular shapes. However, closure of circular skin defect cannot be achieved satisfactorily by direct suture. Local flaps or skin grafts can be used to cover such defects. However, performing a graft or flap can require additional tissue resection to convert the flap’s shape to the defect’s shape. Reconstruction of these defects may cause problems such as distortion of anatomic points and extra normal skin resection. To solve those problems, a new local flap is reported; this is a combination of transposition, rotation, and subcutaneous flap techniques. This flap has been performed with success on various body surfaces for defects of a size ranging from 1.5 to 9 cm in diameter. In this paper, technical details and some clinical cases are presented.