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.     

Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects.

Closure of large meningomyelocele wounds and defects always requires durable and safe coverage of the dural repair. A new technical method for the reconstruction of large thoracolumbar meningomyelocele defects is described in which bilateral musculocutaneous flaps are advanced and transposed medially in a V-Y sliding manner, based on the thoracolumbar perforatiors of the latissimus dorsi. This procedure provides a reliable, well-vascularized soft tissue coverage over the neural repair with minimum donor-site morbidity. Additionally, this method is particularly appropriate to the thoracolumbar area, as it preserves the lateral adjacent regions of the defect, for later alternative and/or reconstructive options.     

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.     

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.     

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.     

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     

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.     

Partially de-epithelialised and buried V-Y advancement flap for reconstruction of sacrococcygeal and ischial defects.

Defects in the sacrococcygeal and ischial soft tissues can be treated with gluteus maximus and posterior thigh V-Y advancement flaps. However, late complications include recurrence and dehiscence of the suture line. Increasing the amount of the soft tissues over the bony prominences and multilayered closure may have an advantage for long-term durability. We modified the V-Y advancement technique by de-epithelialising the medial parts of the flap and burying them under the opposing edge of the wound or the flap. Sixteen patients with various defects of the sacrococcygeal and ischial soft tissues were operated on using this technique. All the flaps healed well with no partial or complete loss of the flap. Three patients developed complications. The main advantage of our technique is the use of healthy tissues to obliterate the dead spaces under the edges of the wound or the opposing flap. In this way, not only the defect in the skin but the defect in the subcutaneous tissue, with its iceberg tip at the surface, is treated effectively. To have an additional layer of tissue between the bone and the superficial tissues provides an extra cushion of soft tissue and avoids putting the suture line directly over the bony prominences. We used this modification safely for both unilateral and bilateral flaps. It could also be used successfully in other parts of the body.     

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.     

Functional reconstruction of large anogenital defects with bilateral V-Y advancement posterior thigh fasciocutaneous flaps.

BACKGROUND: In patients with perianal extramammary Paget's disease, wide local excision is recommended. In the reconstruction of the resulting large defects not only the closure of the defect but also the preservation of anogenital function need to be considered. METHODS: We used bilateral V-Y advancement posterior thigh fasciocutaneous flaps for reconstructing three large anogenital defects, including the total anal canal, resulting from wide local excisions attributed to extramammary Paget's disease. A temporary anus was constructed at the same time to allow the wound of the reconstructed anus to heal. After the surgery, the course of bowel function was followed up through interviews and manometric examinations. RESULTS: All defects were successfully reconstructed with the flaps, and bowel function recovered satisfactorily. Manometric examinations were carried out in two cases; anal pressures were recorded regularly and used as parameters of the recovery of bowel function before closing the artificial anus. Eventually, the patients recovered the function of defecation. CONCLUSIONS: We recommend the bilateral V-Y advancement posterior thigh fasciocutaneous flaps together with manometric studies as one of the most effective techniques for managing large anogenital defects. The use of sensate flaps, the restoration of original structures and manometric studies are conducive to successful outcomes.     

The gluteus maximus musculocutaneous V-Y advancement flap for large sacral defects

Sacral soft tissue defects from 10 to 18 cm in diameter were closed with gluteus maximus musculocutaneous V-Y advancement flaps in 17 patients. Defects were secondary to pressure, radiation injury, or tumor resection and occurred in both ambulatory and nonambulatory patients. Technique varied according to the size of the ulcer and the ambulatory status. This musculocutaneous unit advanced in a V-Y fashion provides well-vascularized tissue for coverage of large sacral defects. It allows for restoration of normal contour, with primary closure of the donor site. Ambulatory patients noticed little or no functional deficit.     

Reconstruction of soft tissue defects of the fingers using homodigital V-Y flap]

A series of 54 patients is presented in which full-thickness soft-tissue defects on 57 digits were reconstructed using homodigital V-Y flaps. This is a modification of the Moberg procedure, which was designed for coverage of injuries of distal thumb. The V-Y flap is pedicled on two digital neurovascular bundles, possible advancement is up to 2 cm, and V-shaped base of the flap allows direct closure of the proximal defect, without skin grafting. This technique was used for the reconstruction both volar and dorsal tissue defects of the fingers. All flaps healed within 2-4 weeks. 14 patients (15 fingers) were evaluated after they recovered. In all affected fingers active range of motion was satisfactory, only with slight defect of extension in 2 cases. However, sensation of the light touch was decreased in 10 fingers, and 2PD discrimination was abnormal in 5 fingers. The versatility of V-Y technique in various clinical occasions and its low risk of complications was emphasized. This method is very useful, easy to learn even for trainees unfamiliar with microsurgery.     

Primary skin closure of large groin defects after inguinal lymphadenectomy for penile cancer using an abdominal cutaneous advancement flap

PURPOSE Large groin defects may be created after inguinal lymphadenectomy for bulky metastatic penile cancer. We describe a new method of primary closure of a large groin skin defect.MATERIALS AND METHODS In 3 patients with large volume inguinal lymph node metastases with skin breakdown and secondary infection extensive inguinal lymphadenectomy was done with wide surgical excision of skin and subcutaneous tissue. The procedures resulted in a large groin defect. Sartorius muscle was transferred to cover the femoral vessels. An abdominal advancement cutaneous flap was placed for soft tissue and skin coverage of the wound.RESULTS Primary closure of a large skin defect was possible using an abdominal advancement flap. In all patients the wound healed primarily with good cosmesis. A single patient underwent postoperative external beam radiation therapy to the flap site with no untoward effect on graft survival.CONCLUSIONS Large groin skin defects can be closed primarily using an abdominal advancement flap. This technique may also be used for bilateral groin defects. Compared with other types of flaps advocated for this purpose the main advantages of the procedure are simplicity, lower morbidity and superior 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.     

Fasciocutaneous V-Y advancement flap for repair of sacral defects

Sacral defects from 6 to 11 cm in diameter were closed with bilateral fasciocutaneous V-Y advancement flaps. All the defects were easily closed without any postoperative complication. We believe that the V-Y advancement technique using the fasciocutaneous unit has some major advantages for repair of moderate-size sacral defects. It is a safe, simple, and less invasive procedure.     

Interdigitating fasciocutaneous gluteal V-Y advancement flaps for reconstruction of sacral defects

The authors describe a modification of the classic gluteal bilateral V-Y advancement flap for sacral defect closure. After initial debridement, the V-Y design is marked on both sides of the defect. The incision is carried down to the fascia of the underlying gluteus maximus muscle. The upper and lower arms of the flaps are elevated and advanced on the gluteal muscle toward the midline, interdigitating each opposing arm. The overall result is a zigzag, broken midline suture. This procedure was carried out in 14 patients with sacral pressure sores and in 1 patient with a chronic pilonidal sinus. All flaps survived without major problems. There were no recurrences during the 6 to 16 months of follow-up. The interdigitating fasciocutaneous V-Y gluteal flap design is effective in breaking the midline vertical scar and preserving the gluteus maximus muscle.     

Soft tissue closure and plastic surgical aspects of large dorsal myelomeningocele defects (review of techniques)

The large myelomeningocele defects that cannot be closed reliably by simple skin undermining require a close cooperation between the neurosurgeon and the plastic surgeon. In this study, a 3-year review was undertaken of nine consecutive patients with a myelomeningocele defect treated in our hospital. The aim of the study was to analyze the size, location of myelomeningocele defects, features of the surrounding tissue, and type and results of the reconstruction method for skin closure. Of the nine patients, five were repaired within the first 48 h of life, two within the 1st month of life, and two were repaired within the 1st year of life. Of the nine patients, seven (78%) underwent repair with direct skin approximation by the Neurosurgical Service. For three patients (33%) with large lumbosacral meningomyelocele defects, including one patient who had failed direct skin approximation, the Plastic Surgery Service achieved the skin closure by bilateral paralumbar fasciocutaneous rotational flaps. Minimal area in the patients referred to the Plastic Surgery Service was 24 cm² (range 24–48 cm²); patients having 18 cm² or less skin defect were not referred for closure. In conclusion, fasciocutaneous rotational flaps provided tension-free, durable, innervated and well-vascularized skin coverage over the dural repair in all three referred patients, without using skin graft. Since myelomeningocele defects vary in size, shape, and location, no single procedure applies to all. Therefore, other reconstruction methods involving skin grafts, fasciocutaneous flaps, and musculocutaneous flaps are reviewed in this report.     

Combined use of medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of scrotum

Summary A case of combined use of bilateral medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of a scrotal defect resulting from Fournier's gangrene is presented. The procedure provided a sac-like scrotum, and the donor sites were successfully reconstructed using bilateral gracilis musculocutaneous V-Y advancement flaps.     

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.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm² in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.