"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.     

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.     

Closure of meningomyelocele defects with bilateral modified V-Y advancement flaps

BACKGROUND: Although several different methods were described in the literature, closure of large meningomyelocele defects presents a challenging problem. Wound dehiscence may lead to devastating complications. In this paper, the efficacy of the bilateral modified V-Y advancement flap procedure was investigated in terms of simplicity, donor-site morbidity, and reliability. PATIENTS AND METHODS: The authors presented 10 neonates treated with a modified subcutaneous advancement procedure. Unlike the typical V-Y advancement techniques, the apical extensions of the "V" flaps were elevated based on the paraspinous perforators. A standard closure algorithm was not followed, as the well-vascularized apical extensions facilitated intraoperative decision making for the most appropriate adaptation pattern, depending on the size, shape, and localization of the defect. As well as that, transposition of these apical flaps to the defect site was further supported by the advancement of the V-Y flaps to decrease the tension along the closure. RESULTS: Mean follow-up period was 13.6 months (range 3-37 months), and no complications that might be attributable to the operative procedure were observed. CONCLUSIONS: Utilization of bilateral modified V-Y flaps for the closure of large meningomyelocele defects is a simple and effective procedure. Main advantages of the method described in this paper may be listed as follows: simplicity, reliability due to coverage of the defect with well-vascularized flaps, minimal bleeding, decreased operative time, and no donor-site morbidity.     

The Modified Bilateral Advancement Flap

BACKGROUND: Bilateral advancement flaps are commonly used in the closure of circular skin defects because of their ease of execution and satisfactory result. However, the limited sliding capacity of these flaps has always been a problem. OBJECTIVE: The modified bilateral advancement flap maximizes the amount of tissue that can be brought into the defect. It relies on both advancement and transposition principles and borrows tissue from two planes. Thus the length of the flap could be shortened for increased flap survival. METHODS: Bilateral transposition flaps are created from tissue on both sides of the wound. These are then approximated and sutured together to form a single, new tip (apex), which is then advanced and sutured into the concave base of the opposing advancement flap at its midpoint. RESULTS: The modified bilateral advancement flap has been used effectively to close defects in the temporal, cheek, forehead, and lower eyelid, among 11 patients, providing a well-contoured and aesthetically pleasing reconstruction. CONCLUSION: This method extends the capacity of the bilateral advancement flap to reconstruct and improves its applications and advantages.     

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.     

应用菱形皮瓣修复皮肤缺损

目的：评价应用菱形皮瓣修复皮肤软组织缺损的效果。方法：2005年1月～2010年12月,我们应用菱形皮瓣修复色素痣、瘢痕、体表肿瘤等切除后缺损患者46例,术中将病变组织行圆形或椭圆形切除,于缺损邻近处设计菱形皮瓣,将菱形皮瓣转移修复缺损,供区直接缝合。结果：皮瓣全部成活,切口Ⅰ期愈合,形态满意。结论：菱形皮瓣是修复皮肤软组织缺损理想的选择,其效果满意,方法简便。     

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.     

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.     

双V-Y推进皮瓣修复拇指指端缺损的临床应用

目的 介绍双V-Y推进皮瓣修复拇指指端缺损的方法及疗效.方法 对9例拇指指端缺损采用双V-Y推进皮瓣修复,小V-Y推进皮瓣远端与甲床仔细缝合,再缝合带尺侧血管神经束的大V-Y推进皮瓣,覆盖创面.术中切取皮瓣面积为14 mm×25 mm～15 mm×35 mm.供区创面直接闭合.结果 术后9例皮瓣全部存活,创面Ⅰ期愈合.随访时间为4～12个月.皮瓣质地柔软,外形与周围组织接近,无臃肿.拇指末节指腹指纹重新建立,指间关节活动正常,无钩甲畸形,指腹两点分辨觉为5～6 mm.根据中华医学会手外科学会上肢部分功能评定试用标准评定:患指主动活动为优7例,良2例.结论 双V-Y推进皮瓣手术操作简单,是修复拇指指端缺损的理想方法之一.     

以上臂外侧穿支为蒂的V-Y推进皮瓣修复肘背部较小创面

目的探讨以上臂外侧穿支为蒂的V-Y推进皮瓣修复肘背部纵向缺损距离<3.5 cm的较小创面的方法及疗效。方法 2008年3月-2010年8月,收治6例肘背部较小创面患者。男4例,女2例;年龄16～76岁,平均53岁。碾压伤3例,冲床伤2例;受伤至入院时间4 h 30 min～7 d,平均29.5 h。肘背部慢性感染1例,病程12个月。创面范围为4.0 cm×2.5 cm～9.5 cm×3.5 cm,均伴有骨或肌腱外露。采用大小为6.0 cm×4.0 cm～12.5 cm×9.5 cm的以上臂外侧穿支为蒂的V-Y推进皮瓣移位修复肘背部缺损。供区直接拉拢缝合。结果术后6例皮瓣完全成活,创面Ⅰ期愈合;供区切口Ⅰ期愈合。患者均获随访,随访时间6～12个月。皮瓣外形无臃肿,质地、颜色与周围组织相似。末次随访时皮瓣两点辨别觉为12～16 mm。肘关节活动无障碍,屈伸活动度95～125°,平均105°。结论以上臂外侧穿支为蒂的V-Y推进皮瓣手术操作简便、对供区影响小,是修复肘背部较小创面的较好方法之一。     

‘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.     

The V-flap and the Berlin tulip flap: two new concepts in conventional flap techniques

Microsurgical operations are costly and technologically demanding. We have therefore developed new conventional flap techniques using state-of-the-art knowledge of skin anatomy and circulation. The V-flap is a combination of the V-Y advancement flap and two Limberg flaps [2]. Sixty patients treated by the new flap technique have shown a low rate of complication. Even when used in difficult regions of the body or in very large defects, the V flap has proven to be very effective. It has been adopted as a standard flap technique in our hospital. The Berlin tulip flap is another very reliable flap. To form the tulip flap, the outer corners of a subcutaneous pedicle flap are curved backwards. When detached, they can be transposed to the healthy tissue on the contralateral side. This completely relieves the midzone, which then can be safely closed in the same manner as a V-Y flap. The Berlin tulip flap is particularly useful for covering trunk defects and managing sacral ulcers in paraplegics.Correspondence to: E. Vaubel     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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