The Use of the Melolabial Burow's Graft in the Reconstruction of Combination Nasal Sidewall–Cheek Defects

Background. Combination defects involving both the nasal sidewall or ala and cheek can be challenging to reconstruct.
Methods. Patients with skin cancers involving the nasal sidewall or ala and medial cheek treated with Mohs micrographic surgery were reconstructed using a cheek advancement flap in combination with a melolabial Burow's graft.
Results. This technique provides a simple, reproducible, and cosmetically excellent method of repairing these defects.
Conclusion. The use of this repair provides superb tissue matches and maintains natural aesthetic subunits, yielding an excellent result with minimal morbidity.     

Reconstruction of Nonhelical Auricular Defects with Local Flaps

BACKGROUND The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps.
OBJECTIVE The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps.
PATIENTS AND METHODS Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect ( n =11)—pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect ( n =3)—transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect ( n =2)— V-Y advancement flap from the skin of the antihelix; and tragus defect ( n =2)—periauricular cutaneous flap.
RESULTS All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation.
CONCLUSION It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.     

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.     

Modified Burow''s Wedge Flap for Upper Lateral Lip Defects

BACKGROUND: There are fundamental concepts we use in managing surgical defects. Whether planning a primary closure or a local flap, we frequently modify the basic design to maximize aesthetic outcomes, taking into consideration a number of factors including the location of the defect and tissue availability. OBJECTIVE: We describe a modified Burow's wedge flap for upper lateral lip defects. METHOD: Report of an illustrated case. RESULT: A patient with an upper lip defect was successfully reconstructed using the modified Burow's wedge flap, where the Burrow's wedge is placed on the mucocutaneous lip. CONCLUSION: Certain modifications of commonly used reconstructive techniques can be utilized in specific situations to enhance cosmesis. For the Burow's wedge flap, the dermatologic surgeon has several options in placing the Burow's triangle. This is an example of how alternatives in a closure can be used depending on the laxity of the skin and the size of the defect. Advantages and disadvantages of this alternative placement of the Burow's triangle are discussed.     

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.     

Introduction to Flap Movement: Reconstruction of Five Similar Nasal Defects Using Different Flaps

Background. There are several options for closure of a given surgical defect after tumor extirpation is confirmed. Flap reconstruction is one of these options.
Objective. The purpose of this article is to introduce the three basic types of flap movement: advancement, rotation, and transposition.
Methods. Five similar defects located on the nasal sidewall were repaired, each using a different flap design.
Results. The optimal flap design for a given defect on a particular patient is based on the answers to a series of questions: Where is the available tissue reservoir? How can tissue be mobilized from the reservoir to cover the defect? How do the resulting tension vectors affect critical structures? Where are the final incision lines?
Conclusion. Many factors must be evaluated before determining a method of reconstruction. Flap reconstruction requires a thorough understanding of anatomy and tissue movement.     

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.     

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.     

Crab-pincers style facial artery flap.

To reconstruct defects as large as 5 cm in diameter in the region extending from the columella and anterior nasal floor to the upper lip, we use a crab-pincers style facial artery (CPFA) flap technique combining nasolabial flaps and cheek advancement flaps. In the CPFA flap, the bifurcation of the facial artery allows the angle between the nasolabial flap and the cheek advancement flap to be freely altered in the manner of crab pincers. By combining the four leaves of bilateral CPFA flaps at the centre, appropriate reconstruction of the three-dimensional structures surrounding the columella can be achieved. In addition, this method requires only one operation to complete extensive reconstruction. The method does not result in adverse scarring or scar contracture. After the procedure,appropriate moustache growth gives a natural impression and conceals philtral distortion. We consider the CPFA flap to be very useful for reconstructing large defects in the central facial region.     

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.     

The Peng Flap: Reviewed and Refined

BACKGROUND The Peng flap was first described in 1987 and there has been only one subsequent article published about its use. The Peng flap is very versatile and has a greater range of application than previously described. It can be used for central and eccentric defects of the nasal tip and it is also an excellent choice for defects that bridge the proximal nasal tip with the distal dorsum.
OBJECTIVE In this series, we present several new modifications to the Peng flap.
METHODS We describe conceptual changes in the movement dynamics of the flap based on these design refinements. Additional detail regarding flap execution is provided.
RESULTS Presented here is retrospective data on the last 30 patients from our tumor registry who received Peng flap repairs between 2001 and 2006. The average defect size was 1.8 × 1.5 cm.
CONCLUSIONS Described herein is a refined flap design that: (1) hides incisions in cosmetic junctions, (2) achieves a wider pedicle, and (3) utilizes a larger component of cheek advancement than previously described.     

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.     

Reconstruction of sternal defects with pectoralis major muscle flap

The earliest treatment of the median sternotomy defects was serial debridements and secondary healing. The muscle flaps that can be used in reconstruction of the presternal defects are pectoralis major muscle flap, rectus abdominis muscle flap, vertical rectus abdominis muscle flap, latissimus dorsi muscle flap with or without skin island, bipedicled pectoralis-rectus muscle flap, and external oblique muscle flap. Pectoralis major muscle flap can be used either as bilateral or unilateral rotation advancement flap, island flap, turnover flap, split turnover flap, and segmental muscle flap. Forty-eight patients with median sternotomy defects, who were treated with pectoralis major muscle flap, were included in this study. The complications were mortality, flap loss, flap dehiscence, persistent infection, and hematoma. The patients were evaluated in terms of functional loss after the operation by shoulder movement measurements. Various techniques of flap transfer can be used for the closure of a presternal defect; almost all presternal defects can be covered with the pectoralis major muscle in a single stage operation. In our opinion, the pectoralis major muscle flap should be the first choice of treatment for sternal defects.     

Subcutaneous Pedicle Limberg Flap for Facial Reconstruction

Background. A residual dog-ear arising from the traditional Limberg flap transposition sometimes influences the cosmetic outcomes, and the Limberg flap with a subcutaneous pedicle is an innovation applicable to a variety of facial defects and free from the dog-ear.
Objective. To investigate the outcome of the subcutaneous pedicle Limberg flap for the reconstruction of medium-sized facial skin defects.
Materials and Methods. From August 2002 to June 2004, the subcutaneous pedicle Limberg flap was designed to repair facial skin defects in 17 patients (19 flaps), and the size of the lesions ranged from 2.0 × 1.9 cm to 5.0 × 4.5 cm.
Results. All flaps survived with primary healing postoperatively. The patients were followed up from 1 to 22 months, and functionally and cosmetically satisfactory outcomes were achieved.
Conclusions. This subcutaneous pedicle Limberg flap provides a competitive repair alternative for the treatment of medium-sized skin defects in the face.     

Stepladder dorsal metacarpal flaps for dorsal finger and hand reconstruction.

The authors demonstrate successful cases of stepladder dorsal metacarpal V-Y advancement and rotation-advancement flaps for reconstructing defects on the dorsum of the finger and hand. One side of the flap is designed in a multilobed shape, and each lobed flap is designed on the dorsum of adjacent fingers. These flaps are supplied by dorsal metacarpal vessels. Consequently, this method has the elements of the stepped incision technique, in combination with the V-Y and rotation-advancement principle. All flaps survived completely. This technique may be a useful option for reconstruction of defects of the dorsum of the finger and hand.     

Novel Method for Training Skin Flap Surgery: Polyurethane Foam Dressing Used as a Skin Equivalent

Background. With a substantial rise in the incidence of skin cancer, skin surgery has become an increasingly large part of dermatology. Skin surgery is best performed by dermatologists. This demands effective training in dermatologic surgery, including flap surgery.
Objective. To find a modern alternative to traditional training on pig's feet skin in teaching flap surgery to residents in dermatology.
Materials and Methods. A face with expression lines printed on a nonadhesive hydrocellular polyurethane dressing (Allevyn, #66007638, 20 × 20 cm, Smith & Nephew Medical Limited, Hull, England). Tumors were marked in suitable locations, necessitating the use of transposition, advancement, and rotation flaps. Twenty-two residents were trained in flap construction, excision, and closure.
Results. Training on Allevyn was rated high by participants.
Conclusion. Allevyn has unlimited storing qualities and skinlike qualities when incised, extended, and sutured. Sutures stay tight without the help of an assistant. Training on Allevyn gives students a good understanding of the mechanics of skin flaps, including transposition, advancement, and rotational flaps. The Allevyn is kept by the student after the course and can be studied afterward. Skin surgery training on Allevyn is superior to traditional training in pig's feet skin.     

The Retroangular Flap Revisited

BACKGROUND To date, the retroangular flap has been used only for reconstruction of defects of the nose and the glabella.
OBJECTIVE The objective was to expand the indications of the retroangular flap in facial reconstruction.
MATERIALS AND METHODS We repaired the facial defects of 11 patients using 12 retroangular flaps. These defects were located on the nose in 4 patients, the lower eyelid in 4 patients, the upper eyelid in 2 patients, and the cheek in 1 patient.
RESULTS The mean follow-up time was 13.2 months. All of the flaps survived, and no revisional procedures were required. Cosmetic and functional outcomes were satisfactory in all patients.
CONCLUSION The retroangular flap is a valuable alternative for the management of small- to moderate-sized defects of the midface. We strongly suggest extending the use of this flap to include reconstruction of nasal, eyelid, and cheek defects.     

Repair of Defects on Nasal Sebaceous Skin

Background. Reconstructive procedures performed on sebaceous nasal skin are prone to partial flap necrosis, scar spread and inversion, and tissue mismatch. An ideal repair would optimize vascular integrity, minimize closure tension, and use adjacent tissue.
Objective. The purpose of this article is to describe a flap design and dynamics that permit satisfactory reconstruction of small- to medium-sized defects on nasal sebaceous tissue.
Methods. A modified advancement flap is described that may be used on central and off-midline defects of the nasal tip.
Results. Use of the modified advancement flap resulted in good cosmetic results with few adverse postsurgical events.
Conclusions. The modified advancement flap satisfies the requirements of a hardy blood supply, minimization of closure tension, and use of adjacent tissue. The surgical results are predictable and rarely associated with complications.     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

A Case of Postmastectomy Defect Reconstructed Using a Laterothoracic Bilaterally Pedicled V-Y Advancement Flap

BACKGROUND: The reconstruction of major defects of the trunk is generally achieved by means of pedicled or free musculocutaneous flaps, but for less extensive defects, local flaps or skin grafts are currently used. The bilaterally pedicled V-Y advancement flap differs from the traditional V-Y advancement flap and was described for soft tissue reconstruction in the face. In our unit, the bilaterally pedicled V-Y advancement flap is the most used local flap for face reconstruction, and our aim was to use it in a different location. METHODS: In this case report we present a postmastectomy defect reconstructed with good results using the bilaterally pedicled V-Y advancement flap. RESULTS: The flap healed without further problems, and a good aesthetic result was obtained. CONCLUSION: The bilaterally pedicled V-Y advancement flap is reliable and easy to harvest, and not only for face reconstruction. Its versatility and plasticity allow its use for the reconstruction of many defects at varying locations.