V-Y rotation advancement flap: A metanalysis and systematic review

Local skin flaps are used to close defects adjacent to the donor site. They are classified according to their method of movement: flaps that advance from its base to the defect (V-Y, Y-V, single-pedicle, and bipedicle advancement flaps) and flaps that move on a pivot point (rotation, transposition, and interpolation flaps). Despite its frequent use, there is not a unique name for V-Y rotation advancement flap; moreover, there is not a flap class called “rotation advancement” in the textbooks. A systematic review of the literature was conducted using “PubMed” and “Google Scholar” in December 2013. We made different searches using keywords “V-Y-S flap,” “V-Y rotation advancement flap,” and “hatchet flap”. The search was limited to the studies published in English and French. In total, 31 articles were found. Five articles presenting musculocutaneous hatchet flap, were excluded from the review. We included 26 articles in which cutaneous and fasciocutaneous flaps were described. We found 12 case series and five case reports presenting “hatchet flap.” Two case series and two case reports about “V-Y-S flap” were reported. Four case series and one case report about “V-Y rotation and advancement flap” were written. V-Y rotation and advancement flap were performed under different names on any regions of the body by several authors, and none of the authors reported flap loss or any dehiscence that resulted with a second surgery. With the help of this review, we would like to standardize its design and its dissection. Level of Evidence: Not ratable.     

‘The Crown flap’: a modification to the keystone flap types I and IIA

The Crown flap is a modification of the keystone flap first described by Felix Behan in 2003. A third V-Y advancement limb is incorporated into the design in the central region of the flap where the line of maximum tension exists. This added V-Y closure utilizes surrounding tissue laxity and has been found to aid in closure of the defect centrally whilst not compromising the flap. The Crown flap is a useful modification to the keystone flap. Level of Evidence: Level V, therapeutic study.     

New way to raise the V-Y advancement flap for reconstruction of the lower lip: bipedicled orbicularis oris musculocutaneous flap technique

We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.     

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.     

Making the V-Y advancement flap safer in fingertip amputations

Amputation of the fingertip is a common injury of the upper extremity. Over the years, a variety of reconstructive techniques have been described. For dorsal oblique and transverse amputations, the Atasoy V-Y advancement flap is a popular choice because it preserves finger length, sensation and function. However, closure under tension remains a problem, putting the flap at risk of partial or full necrosis. To avoid this untoward complication, the classic V-Y advancement technique has been modified to allow for a tension-free closure.     

New way to raise the V-Y advancement flap for reconstruction of the lower lip: Bipedicled orbicularis oris musculocutaneous flap technique

Abstract

We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.     

Transposition movement of V-Y flaps for facial reconstruction.

BACKGROUND: The V-Y advancement flap has been widely used for the reconstruction of cutaneous defects for decades; however, the movement of a V-Y flap is sometimes limited, allowing only for rotation or advancement movement. To overcome this limitation, the present study introduces a transposition movement of the V-Y flap and assesses its clinical outcome for facial reconstruction. MATERIALS AND METHODS: A modified V-Y flap was designed with a single laterally based pedicle and transferred to the defect through a transposition movement. The transposition movement was demonstrated with photographs and the clinical outcome was described in six patients. RESULTS: This modified V-Y flap was reliable and robust, and could be moved easily with less tension. Meanwhile, the flap allowed for a primary closure of the defects along the nasolabial fold or preauricular crease. More importantly, all six patients achieved satisfactory functional and cosmetic outcomes in facial reconstruction. Temporary sensory alteration was common in the flap skin during the initial postoperative period, but improved as time passed and disappeared about 6 months later. CONCLUSION: This modified transposition V-Y flap may serve as an alternative option for aesthetic reconstruction of facial defects.     

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.     

改良V-Y推进皮瓣联合甲床扩大治疗指端缺损

目的探讨改良V-Y推进皮瓣联合甲床扩大的方法治疗指端缺损的疗效。方法采用改良V-Y推进皮瓣联合甲床扩大的方法治疗42例患者共53指。结果所有皮瓣均存活,3例皮瓣远端部分坏死,经换药后愈合。患者均获得随访,时间6个月~2年。伤指指端和指甲外形满意。结论改良V-Y推进皮瓣联合甲床扩大是治疗指端缺损的有效方法。     

基于皮肤生物力学的推进皮瓣三维有限元模型与模拟分析

目的 探讨建立局部推进皮瓣的三维有限元模型,用以观测计算推进皮瓣手术后手术区域皮肤变形及应力分布情况,以供临床皮瓣设计参考.方法 通过人体额部离体头皮的生物力学实验研究获取皮肤的生物力学参数,再利用三维有限元软件MSC Marc/Mentat 2005建立局部推进皮瓣的三维有限元模型,设计同一皮瓣修复不同面积的创面,模拟出皮瓣在不同的抻长比例下,观测手术区域术后皮肤组织的变形情况、相应的应力-应变分布情况.结果 皮瓣推进后的抻长比例越大,术后手术区域的应力最大值也随之越大,但不符合线性规律.在不顾及皮瓣血运的条件下,理论上皮瓣抻长比例的最大限度可达到40%,若＞40%,皮肤应力将超过屈服极限.结论 利用三维有限元方法及人体皮肤生物力学参数模拟分析推进皮瓣具有可行性,但其抻长比例应控制在40%范围内,以确保安全.     

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.     

Bilateral modified V-Y advancement flaps for closing meningomyelocele defects

Various reports describe surgical techniques for closing a meningomyelocele defect. We have used a combination flap consisting of a vertical bipedicled flap and V-Y advancement flap and used this technique in the successful repair of 11 meningomyelocele defects. The vertical bipedicled flap enhances the blood supply to the V-Y advancement flap with no sacrifice of muscle tissue. This flap can easily be moved to the midline, and the donor area can be primarily sutured with no complications. Our method has several advantages compared with previously reported methods: 1) no skin grafts are needed; 2) no muscle tissue is killed; 3) it is simple and easy, leading to less blood loss and minimal operative time; and 4) it is safe and produces reliable results while eliminating wound dehiscence and skin necrosis.     

基于皮肤生物力学的推进皮瓣三维有限元模型与模拟分析

目的 探讨建立局部推进皮瓣的三维有限元模型,用以观测计算推进皮瓣手术后手术区域皮肤变形及应力分布情况,以供临床皮瓣设计参考.方法 通过人体额部离体头皮的生物力学实验研究获取皮肤的生物力学参数,再利用三维有限元软件MSC Marc/Mentat 2005建立局部推进皮瓣的三维有限元模型,设计同一皮瓣修复不同面积的创面,模拟出皮瓣在不同的抻长比例下,观测手术区域术后皮肤组织的变形情况、相应的应力-应变分布情况.结果 皮瓣推进后的抻长比例越大,术后手术区域的应力最大值也随之越大,但不符合线性规律.在不顾及皮瓣血运的条件下,理论上皮瓣抻长比例的最大限度可达到40%,若＞40%,皮肤应力将超过屈服极限.结论 利用三维有限元方法及人体皮肤生物力学参数模拟分析推进皮瓣具有可行性,但其抻长比例应控制在40%范围内,以确保安全.     

基于皮肤生物力学的推进皮瓣三维有限元模型与模拟分析

目的 探讨建立局部推进皮瓣的三维有限元模型,用以观测计算推进皮瓣手术后手术区域皮肤变形及应力分布情况,以供临床皮瓣设计参考.方法 通过人体额部离体头皮的生物力学实验研究获取皮肤的生物力学参数,再利用三维有限元软件MSC Marc/Mentat 2005建立局部推进皮瓣的三维有限元模型,设计同一皮瓣修复不同面积的创面,模拟出皮瓣在不同的抻长比例下,观测手术区域术后皮肤组织的变形情况、相应的应力-应变分布情况.结果 皮瓣推进后的抻长比例越大,术后手术区域的应力最大值也随之越大,但不符合线性规律.在不顾及皮瓣血运的条件下,理论上皮瓣抻长比例的最大限度可达到40%,若＞40%,皮肤应力将超过屈服极限.结论 利用三维有限元方法及人体皮肤生物力学参数模拟分析推进皮瓣具有可行性,但其抻长比例应控制在40%范围内,以确保安全.     

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.     

Amplified V-Y flaps for nasal defects

Due to a paucity of subcutaneous tissue in the nose, mobilization of some flaps is impeded and large nasal defects are thus difficult to close with traditional V-Y flaps. The V-Y flap is modified by the addition of an amplified limb onto the advancing edge of the V-Y flap. This limb is located adjacent to the area requiring reconstruction and is hinged down on the end of the V-Y flap to close the distal portion of the defect. The amplified V-Y flap, a modified V-Y advancement flap, is very useful for the closure of relatively large defects on the nasal area. We have used this flap for nasal defects as large as 2.5 cm in diameter following excision of skin tumors on the nose in 11 patients. Most excised tumors were basal cell carcinomas. The results have been quite good, with only minor complications in two patients. Complications were encountered only in the nasal tip region, there was partial necrosis at the tip of the amplified portion of the flap. The modifications of the V-Y flap described has extended the application in closing nasal defects. Received: 2 May 1997 / Accepted: 22 July 1997     

The Use of the V-Y Fasciocutaneous Island Advancement Flap in Reconstructing Postsurgical Defects of the Leg

BACKGROUND: Soft tissue cover in the lower limb is difficult due to limited tissue mobility. OBJECTIVE: To present the V-Y fasciocutaneous island advancement flap as an alternative for reconstructing postsurgical defects of the leg. METHODS: Eleven patients with defects on the leg following tumor excision were reconstructed using the V-Y fasciocutaneous island advancement flap. RESULTS: There were no major complications, except for one partial distal flap necrosis in a patient who was a smoker. CONCLUSION: The V-Y fasciocutaneous island advancement flap is a viable alternative for reconstructing surgical defects of the leg.     

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.     

The keystone design perforator island flap. Part I: anatomic study.

BACKGROUND: The keystone design perforator island flap has been described as a curvilinear shaped trapezoidal design flap that is essentially two V-Y flaps end-to-side. Viability of the flap is thought to be supported by the subcutaneous vascular network and fascial and muscular perforators. The aim of this study was to assess the vascularisation of this flap and the behaviour of the skin paddle when submitted to important traction forces. METHODS: Fourteen flaps were raised after a skin defect was created on various regions of two fresh cadavers. Longitudinal and transversal cutaneous markings allowed analysis of the behaviour of the skin paddle during the course of direct closure and flap mobilisation. Injections of coloured solutions were performed before and after the flap elevation to visualise the vascularisation of the flap. DISCUSSION: The superficial vascular network was always preserved by the blunt dissection of the flap's margins and perforators arising from the underlying muscular tissue were constantly found. The dual vascularisation of the flap was then confirmed. Cutaneous markings showed the skin paddle to remain static in size with advancement of the surrounding tissues to meet the flap. The flap advancement opens a long and narrow defect on the lateral margin, the approximation of which in a V-Y fashion reduces even more the surface to be closed. Elevation of the flap also allows distribution of the tension forces over a greater surface both within the flap as well as the surrounding tissues. CONCLUSION: The vascular reliability of this flap and its versatile design potentially gives it a universal application all over the body.     

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。