Modified Purse-String Closure for Reconstruction of Moderate/Large Surgical Defects of the Face

Background.  Large surgical defects of the face can often be difficult to repair. Extensive adjacent tissue transfer may be necessary and may result in significant scars and possible flap compromise. Often there may be less donor tissue available than is necessary to achieve closure. The alternative is a split-thickness skin graft, which often has a poor cosmetic outcome with poor color match and contour irregularities.
Objective.  A novel approach to closing large surgical defects of the face is described. This relies on a combination of side-to-side bilateral advancement and circumferential tissue recruitment utilizing the purse-string suture.
Methods.  Report of illustrated cases.
Results.  A 3.5 × 5.5 cm preauricular cheek defect, which could not be closed primarily side-to-side, was successfully completely closed in a curvilinear fashion by implementing both side-to-side bilateral advancement and circumferential tissue recruitment. A 3.8 × 5.5 cm cheek defect and a 6.0 × 8.0 cm temple defect were significantly decreased by using the modified purse-string closure. Healing by second intention in these two cases provided an excellent cosmetic result.
Conclusion.  The use of the purse-string closure utilizing circumferential tissue recruitment in combination with side-to-side bilateral adjacent tissue transfer allows seemingly large facial defects to be closed or significantly reduced in size. Such closure is evident even in cases where poor skin laxity and size of the defect would not appear to allow this. The modified purse string closure can result in an excellent cosmetic outcome.     

Closure of craniofacial defects after cancer resection

Resection of malignancies of the upper face and skull base may result in complex bone and soft tissue defects. To better define the optimal management of these defects, we conducted a retrospective review of 75 consecutive patients who underwent closure of 76 craniofacial defects after malignant tumor excision from 1966 to 1990. Wound complications requiring further surgery occurred in 30% of the defects (23 of 76). Wound complications at anterior, temporal, or combined sites were correlated with each method of reconstruction (scalp flap or split thickness skin graft, pedicled myocutaneous flap, and free flap). The presence of a large combined defect involving both frontal and temporal areas was the only significant risk factor for development of a wound complication requiring secondary surgery. These data suggest that anterior or temporal craniofacial defects may be closed with either scalp flaps and split thickness skin grafts or pedicled myocutaneous flaps with reasonable wound complication rates of 16% to 22%. Large combined defects have high wound complication rates (90%) when local tissue is used; therefore, other methods of closure such as free tissue transfer should be strongly considered in these patients.     

Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects

Background: Radical inguinal lymphadenectomy (RIL) for bulky metastatic melanoma and non‐melanoma skin cancers of the inguinal region, while shown to improve morbidity and survival oncologically, can result in substantial morbidity from wound complications. Skin defects cannot be closed primarily and the substantial dead space predisposes to seroma, wound dehiscence and infection. Despite the clear need for reconstructive options, extended series describing reconstruction of large inguinal defects in this setting have not been reported. Methods: A prospectively entered, retrospectively reviewed study of 20 consecutive patients undergoing quadriceps keystone island flaps (QKIF) for the closure of complicated inguinal defects is described. Results: There was 100% flap survival, with no partial or complete flap losses. A reduction in wound breakdown/dehiscence from reported rates was seen, with four patients (20%) having wound breakdown, compared to double that rate in reported series. Other wound complications comprised six patients (30%) with mild wound infections, seven patients (35%) with seromas and two patients (10%) with haematomas. Conclusion: The QKIF is an effective means of reconstructing inguinal defects after RIL, particularly in high‐risk patients, and is technically simpler than other reconstructive techniques advocated for this purpose. Furthermore, the QKIF offers patients with advanced disease (where management is primarily palliative) a potentially improved quality of life with reduced operative morbidity.     

Use of bilateral groin flaps in the closure of defects of the perineum: A case report

Reconstruction of perineal and groin defects is a challenging problem. Commonly used methods of reconstruction include skin grafts and local flaps. The groin flap is a vascularized axial flap based on the superficial circumflex iliac artery arising from the femoral artery just below the inguinal ligament. Due to the location, the donor defect can usually be closed primarily, leaving an acceptable scar. The use of bilateral groin flaps for coverage of defects of the anterior perineum following excision of condylomas is reported.     

Results of treatment of malignant soft tissue tumours in the groin

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or – if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.     

Results of treatment of malignant soft tissue tumours in the groin

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or - if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.     

Gluteal V-Y advancement fasciocutaneous flap for treatment of chronic pilonidal sinus disease

Although pilonidal disease is quite common, controversy still exists about the treatment. The procedure should cure the patient, and allow speedy resumption of normal activities by reducing pain and disability. This retrospective study was conducted to evaluate our experience with the V-Y fasciocutaneous advancement flap and to review current publications about flap surgery for the treatment of sacrococcygeal pilonidal sinus. We describe the application of the fasciocutaneous V-Y advancement flap for reconstruction of defects after radical excision of recurrent pilonidal sinus in 11 cases. Primary and uneventful wound healing was achieved in all patients but two who developed minor wound breakdown. Large defects after excision can easily be closed using the V-Y advancement flap. This type of flap closure in selected cases offers tension-free, recurrence-free, and reliable skin coverage while flattening the natal cleft that predisposes to recurrences. Reliable flap closure reduces hospital stay, costs, as well as disability and time spent off work.     

Gluteal V-Y advancement fasciocutaneous flap for treatment of chronic pilonidal sinus disease.

Although pilonidal disease is quite common, controversy still exists about the treatment. The procedure should cure the patient, and allow speedy resumption of normal activities by reducing pain and disability. This retrospective study was conducted to evaluate our experience with the V-Y fasciocutaneous advancement flap and to review current publications about flap surgery for the treatment of sacrococcygeal pilonidal sinus. We describe the application of the fasciocutaneous V-Y advancement flap for reconstruction of defects after radical excision of recurrent pilonidal sinus in 11 cases. Primary and uneventful wound healing was achieved in all patients but two who developed minor wound breakdown. Large defects after excision can easily be closed using the V-Y advancement flap. This type of flap closure in selected cases offers tension-free, recurrence-free, and reliable skin coverage while flattening the natal cleft that predisposes to recurrences. Reliable flap closure reduces hospital stay, costs, as well as disability and time spent off work.     

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis.

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.     

Pedicled posteromedial thigh (PMT) flap: A new alternative for groin defect reconstruction

The posterior medial thigh is mainly vascularized by the profunda femoris artery (PFA), which nourishes the adductor magnus muscle and overlying skin, to supply a number of perforators that can potentially be used as pedicles for local perforator flaps. Here we present two cases utilizing the pedicled posteromedial thigh flap (PMT) to reconstruct the groin defects. Two patients underwent resection for metastatic malignant melanoma resulting in large defects of the groin with exposure of major inguinal vessels; the dimensions of the skin defects were 15 cm × 5 cm and 16 cm × 6 cm, two ipsilateral pedicled PMT flaps were designed to cover the defects. The pedicled PMT flaps were based on perforators arising from the PFA and were transposed through a submuscular tunnel into the defect. The postoperative course was uneventful and the wounds were reconstructed successfully. The pedicled PMT flap may be an option for reconstruction of groin defects and could be incorporated into the armamentarium of the reconstructive microsurgeon. © 2015 Wiley Periodicals, Inc. Microsurgery 37:339–343, 2017.     

Thoracodorsal artery perforator (TAP) type I V-Y advancement flap in axillary hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic debilitating disease. Surgical removal of all apocrine glands in the affected region is the definitive treatment. The resulting wound may either be left to heal secondarily or closed primarily. Secondary healing in the axilla may cause contractures and stiffening of the shoulder. Primary healing requires direct closure, split-skin grafting or local flap application. Direct closure is associated with a high incidence of recurrence compared to skin grafting or flaps. Local flap cover is the ideal method of wound closure after excision of the glands. We have used a thoracodorsal artery perforator (TAP) V-Y advancement flap (type I) to achieve closure as a single-stage procedure successfully in four cases. It is a single stage procedure capable of closing large axillary defects whilst preserving the axillary contour.     

Complex abdominal wall reconstruction: a comparison of flap and mesh closure

OBJECTIVE: To analyze a series of patients treated for recurrent or chronic abdominal wall hernias and determine a treatment protocol for defect reconstruction. SUMMARY BACKGROUND DATA: Complex or recurrent abdominal wall defects may be the result of a failed prior attempt at closure, trauma, infection, radiation necrosis, or tumor resection. The use of prosthetic mesh as a fascial substitute or reinforcement has been widely reported. In wounds with unstable soft tissue coverage, however, the use of prosthetic mesh poses an increased risk for extrusion or infection, and vascularized autogenous tissue may be required to achieve herniorrhaphy and stable coverage. METHODS: Patients undergoing abdominal wall reconstruction for 106 recurrent or complex defects (104 patients) were retrospectively analyzed. For each patient, hernia etiology, size and location, average time present, technique of reconstruction, and postoperative results, including recurrence and complication rates, were reviewed. Patients were divided into two groups based on defect components: Type I defects with intact or stable skin coverage over hernia defect, and Type II defects with unstable or absent skin coverage over hernia defect. The defects were also assigned to one of the following zones based on primary defect location to assist in the selection and evaluation of their treatment: Zone 1A, upper midline; Zone IB, lower midline; Zone 2, upper quadrant; Zone 3, lower quadrant. RESULTS: A majority of the defects (68%) were incisional hernias. Of 50 Type I defects, 10 (20%) were repaired directly, 28 (56%) were repaired with mesh only, and 12 (24%) required flap reconstruction. For the 56 Type II defects reconstructed, flaps were used in the majority of patients (n = 48; 80%). The overall complication and recurrence rates for the series were 29% and 8%, respectively. CONCLUSIONS: For Type I hernias with stable skin coverage, intraperitoneal placement of Prolene mesh is preferred, and has not been associated with visceral complications or failure of hernia repair. For Type II defects, the use of flaps is advisable, with tensor fascia lata representing the flap of choice, particularly in the lower abdomen. Rectus advancement procedures may be used for well-selected midline defects of either type. The concept of tissue expansion to increase both the fascial dimensions of the flap and zones safely reached by flap transposition is introduced. Overall failure is often is due to primary closure under tension, extraperitoneal placement of mesh, flap use for inappropriate zone, or technical error in flap use. With use of the proposed algorithm based on defect analysis and location, abdominal wall reconstruction has been achieved in 92% of patients with complex abdominal 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.     

Pedicled omental flap and skin grafting to cover artificial mesh

Two cases are presented in which a large abdomino-inguinal defect, created during an extended hemipelvectomy, was closed using artificial patch, a pedicled omental flap and skin grafts. In the first case, early postoperative mortality arrested the wound healing process and prevented follow-up. In the second case, the wound was completely covered and there was no evidence of infection at three moths following the initial operation. We propose that pedicled omental flap with skin grafting is a viable means of covering artifical mesh repairs of giant abdominal wall and inguinal region defects.     

Axial flaps for treatment of penis lesions due to granulomas

Granulomas can result from subcutaneous injection of ointment into the penis to augment its bulk. Rigid, infiltrated granulomatous and scar tissue prevents coitus, often ulcerates, and must be excised. Large segmental or circumferential defects of the penile integument must be covered with soft, pliable skin. We describe our experience with axial skin-fat flaps taken for this purpose from the groin region. There are two well-known vascular bundles, the arteria circumflexa ilium superficialis (ACIS) and arteria epigastrica superficialis (AES). Both were used successfully (the ACIS in 3 patients and the AES in 1) to provide island skin territories sufficient for resurfacing even a completely degloved penis (1 patient) with primary donor wound closure and rapid healing. In addition, a new flap, based on the arteria pudenda externa, was designed and implemented in 1 patient. The donor potential of the groin and lower abdominal region amply meets the requirements for penis reconstruction. Therefore, it is surprising that axial flaps have not yet become broadly accepted.     

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.     

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.     

Soft-tissue repair of myelomeningocele defects using bilateral latissimus dorsi and trapezius musculocutaneous flaps

An urgent closure of myelomeningocele defects was carried out in 82 newborns using latissimus and/or trapezius musculocutaneous advancement flaps. A three-layer closure of skin, muscle, and fascia was achieved in a single stage without a flank skin graft. All of the wounds healed within a two-week period and no late breakdown of the wound occurred during the eight-year period of study. The urgent closure maximized the neurological salvage and facilitated early cerebrospinal fluid shunting by preventing both infection and neural desiccation. This report represents the largest number of sequentially treated myelomeningocele defects without a major wound healing problem or death. The advancement musculocutaneous flap closure is safe, simple, and effective and is recommended as the preferred method for closure of the myelomeningocele defect.     

Scalp reconstruction with inverted myocutaneous latissimus free flap and unmeshed skin graft

Limited skin paddle size, peripheral thinning, or lack of cerebral expansion after radiotherapy may necessitate secondary sculpting after latissimus free flap reconstruction of large scalp defects. This series presents a novel modification of the myocutaneous latissimus dorsi free flap for use in large scalp defects. After superficial artery isolation, titanium mesh is placed into the calvarial defect to recapitulate the inner table. The myocutaneous latissimus flap is harvested in standard fashion, deepithelialized, and inverted. The skin paddle is placed over titanium mesh to fill the calvarial defect, then sewn over a drain. The inverted latissimus muscle is draped over the defect and extended peripherally beneath the pericranium. The flap is sewn to the scalp internally using a vest-over-pants suture pattern, and the thoracodorsal and superficial temporal vessels are anastomosed and left facing outward. Unmeshed skin graft is draped over the muscle and vessels then sutured loosely. Patients with complex scalp defects whose soft tissue defect exceeded the size of latissimus skin paddle available with primary closure were considered eligible for inverted latissimus free flap reconstruction. Follow-up range was 6 months to 12 months. Over a 2-year period, five patients underwent inverted latissimus free flap reconstruction. Scalp defects ranged in size from 10 × 8 cm to 17 × 11 cm. The calvarial defect was smaller than the soft tissue defect in all cases. All flap donor sites were closed primarily. All five flaps took, and donor site outcomes were acceptable. Aesthetic outcomes were satisfactory with well-contoured, calvarial-shaped results. Cosmesis was most notably limited by skin graft joint lines. No patients underwent secondary surgical revision. The inverted myocutaneous latissimus free flap is a safe and effective method for reconstructing large or irradiated scalp defects.     

THE TENSOR FASCIAE LATAE MYOCUTANEOUS FLAP CLOSURE OF MAJOR CHEST AND ABDOMINAL WALL DEFECTS

Background : The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit'experience in pedicled and free TFL flaps. Methods : The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. Results : The defect was satisfactorily repaired in all cases without subsequent herniation. The closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. Conclusions : We conclude that the TFL flap is the method of choice for repairs of major truncal defects.