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.     

Two-Lobed Advancement Flap for Cutaneous Helical Rim Defects

BACKGROUND: Bilobed flaps, transposition repairs used primarily on the nose, recruit tissue from an area of laxity via rotational motion. A variant of the bilobe, the two-lobed flap based on the W-plasty, is a transposition flap that shifts tissue predominantly via advancement. OBJECTIVE: To apply the two-lobed advancement flap to the problem of reconstructing cutaneous helical rim defects of the ear. METHODS: Helical two-lobed advancement flaps were designed and implemented to correct small- to medium-sized defects. RESULTS: The ear helix was successfully repaired with two-lobed advancement flaps. There was minimal distortion of the ear architecture or cartilage, and blood supply was sufficient to ensure flap viability. CONCLUSIONS: In selected cases, cutaneous helical rim defects of the ear can be aesthetically repaired with a two-lobed advancement flap derived from the posterior auricular surface.     

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.     

"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.     

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.     

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.     

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.     

Repair of Large Defects in the Forehead Using a Median Forehead Rotation Flap and Advancement Lateral U-Shaped Flap

BACKGROUND: The forehead is a large and highly expressive and dynamic cosmetic unit. Most forehead defects that cannot be closed primarily are reconstructed with laterally based advancement flaps. OBJECTIVE: A combination of median forehead rotation flap and advancement lateral U-shaped flap for repair of medium- to-large-size defects in paramedian and lateral forehead is described. METHODS: Technically, the design of median forehead rotation flap based on supratrochlear vessels used here is similar to the median forehead transposition flap used to reconstruct large defects of the nasal dorsum. The length and the movement of the flap are much smaller in this case. Approximately 2/3 of the closure of the defect is achieved by displacing the median forehead flap while the remaining 1/3 corresponds to the advancement of the lateral U-shaped flap. RESULTS: The flaps are simple to perform, have minimal complications, and have good cosmetic results. A representative case is presented with photographs. CONCLUSION: For selected medium- to large-size horizontal defects in the paramedian and the lateral forehead, the combination of a median forehead rotation flap and an advancement lateral U-shaped flap offers a simple, visually pleasing repair that preserves the forehead architecture.     

Three-layer repair of nasoseptal defects.

PURPOSE: This article demonstrates technique and results of a 3-layer repair of nasoseptal defects using bilateral bipedicled advancement flaps and an autogenous cartilage graft. METHOD: After an extensive bilateral elevation of the mucosa from the entire septum, the nasal dome and the nasal floor bipedicled advancement flaps are created. The mucosal defects are sutured and an autogenous cartilage graft is interposed between the sutured mucosal flaps. RESULTS: Until now this technique has been applied in 403 patients. The success rate (complete closure) was 92.5%. Thirty-four patients redeveloped defects; 28 were <5 mm and did not cause complaints. CONCLUSION: Results show that the described technique is a most reliable method with the following advantages: 1 stage procedure, no visible scars, high success rate, and low complication rate. In case of an incomplete closure, the redeveloped defect will generally be considerably smaller than the original one and asymptomatic.     

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.     

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.     

Modified gluteus maximus V-Y advancement flaps

A modified method is presented for the closure of wounds using gluteus maximus V-Y advancement flaps. Extra tissue is included in each flap by extending the corners of its advancing edge. The extra tissue is utilised to aid closure by using a combination of rotation and transposition in addition to advancement. This modification is illustrated and examples of its clinical use described.     

Advancement Flaps: A Basic Theme with Many Variations

Background. The advancement flap involves the linear advancement of tissue in one direction. Despite its straightforwardness and simple concept, it can be used to close a variety of defects, ranging from small defects on the scalp or extremities to large, complicated defects involving cosmetic units on the face.
Objectives. To provide a basic and useful review for the indications, advantages, disadvantages, and techniques for the use of advancement flaps in the reconstruction of defects in dermatologic surgery.
Materials and Methods. We performed a literature search for articles discussing advancement flaps and compiled a brief review of our findings.
Results. The movement of the advancement flap must be balanced by the blood supply of the flap. The excision of Burow's triangles along various aspects of the advancement flap can increase movement and improve cosmesis of the flap. The types of advancement flaps discussed include the single advancement flap, double advancement flap, A-T flap (O-T flap), Burow's triangle flap (Burow's wedge flap), crescenteric advancement flap, island pedicle flap (V-Y flap), helical rim advancement flap, and facelift flap.
Conclusion. Advancement flaps are versatile and useful basic flaps for repairing defects.     

Clinical use of a tissue expander--enhanced transposition flap for face and neck reconstruction

Tissue expanders have been used in reconstructive surgery with increasing frequency, primarily to construct local advancement flaps of tissue immediately adjacent to a tissue defect or deformity. These flaps often lack adequate mobility to allow coverage of large areas. This report describes the use of tissue expanders to enhance the area and vascularity of shoulder skin to provide suitable, ample tissue that can then be used as large pedicled transposition flaps for reconstruction of the face and neck. It is a clinical study based on previous laboratory studies cited that demonstrates that large flaps with very narrow pedicles remain well vascularized and can be transposed to cover very large defects. The tissue expander appears to enhance the vascularity of the flap. The thinning of the dermis and subcutaneous tissue seems to make the donor skin more similar in quality to face and neck skin. These studies suggest that even larger flaps may be developed to supply tissue to resurface the entire face or very large portions of it.     

Multiple Y-V plasty

Webs and contracture, whether congenital or the result of trauma or surgical excision, have been resurfaced with local tissue utilizing the principle of multiple Y-V advancement flaps. Initially the procedure was used in releasing broad scar contracture following a burn wound of the torso, and for congenital soft tissue shortening of the dorsum of the foot, both with gratifying results. The procedure was later used to obtain adjacent soft tissue for resurfacing defects of the nasal tip or ala, resulting from trauma and following the excision of a tumor. (For example, it enabled us to compensate for a rotation flap defect.) It is also useful for additional release of scar contractures of the digits and extremities after transposition of Z-plasty flaps, which can be further advanced using the Y-V advancement principle.     

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.     

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.     

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     

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.     

Segmental Reconstruction of the Face

BACKGROUND: Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. OBJECTIVE: Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. METHODS: During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. CONCLUSION: Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.