The Island Pedicle Flap

Background. Surgical defects following the extirpation of cutaneous neoplasia may present challenges to the dermatologic surgeon. There are many repair options for an individual defect, including second-intention healing, primary closure, skin graft, and skin flap closure. The island pedicle flap is a random pattern advancement flap well suited to reconstruct a variety of small- to intermediate-sized soft tissue wounds.
Objective. To review the utility of the island pedicle flap in reconstructive dermatologic surgery and to detail the operative technique to achieve reproducible functional and esthetic results.
Methods. The method of flap reconstruction is presented. A variety of defects repaired with this technique are reviewed.
Results. The subcutaneous island pedicle flap yielded excellent functional and cosmetic repair of the presented defects with minimal operative morbidity. Secondary to a well-preserved central vascular pedicle, complications are infrequent.
Conclusions. The random pattern island pedicle flap is a versatile and robust flap used to repair a variety of soft tissue wounds in a single-stage procedure with reproducible operative outcomes.     

Use of the "Spiral" Flap for Closure of Small Defects of the Nasal Ala

BACKGROUND: Multiple wound closure options exist for cutaneous defects of the nasal ala. The best option depends on the depth, size, and location of the defect. OBJECTIVE: To demonstrate a modification of the traditional rotation flap for closure of small alar defects. METHODS: The design and execution of the "spiral" flap for closure of a representative defect are described. RESULTS: Immediate and delayed postoperative views demonstrate expected outcome. CONCLUSION: The spiral flap modification of the rotation flap is a simple and elegant closure option for small nasal alar defects.     

Modification of the Zitelli bilobed flap: a comparison of flap dynamics in human cadavers

OBJECTIVE: To investigate the effects on overall flap dynamics of altering the length of the primary flap in the Zitelli bilobed flap procedure, because the standard Zitelli design can result in distortion of the alar margin after repair of cutaneous nasal alar defects. METHODS: Identical 1.5-cm circular cutaneous defects were made on the nasal alae and cheeks of 6 fresh human cadavers. A rectangle was inked around each cheek defect in a standardized fashion. A standard-design Zitelli bilobed flap was used to close the nasal and cheek defects on 1 side of each specimen (n = 6). The contralateral defect was closed with a modified design in which the primary flap was either 10% longer (n = 3) or 10% shorter (n = 3) than the standard primary flap as measured from the pivot point. Alar margin retraction and cheek defect distortion were measured from standardized photographs obtained before and after the repair. RESULTS: The long-flap design resulted in alar retraction that was 1.33 mm less in the nasal reconstructions (P = .02) and distal defect distortion that was 2.17 mm less in the cheek reconstructions (P = .01) compared with the standard Zitelli bilobed flap. The short-flap design caused more distortion than did the standard design for both types of defect. CONCLUSION: Lengthening the primary flap in the Zitelli bilobed flap design may reduce distal wound distortion and alar retraction in the closure of certain cutaneous defects.     

The Bilobed Flap for Reconstruction of Distal Nasal Defect in Asians

Background  The aim of this study was to overcome nasal alar retraction that occurs with the use of the standard Zitelli’s bilobed flap for reconstruction of a distal nasal defect. Zitelli’s bilobed flap offers the ability to aesthetically reconstruct difficult defects in the distal nasal area. However, the standard Zitelli bilobed flap may sometimes result in nasal alar retraction which is likely to the result of excessive tension upon closure of the primary lobe and primary defect. Methods  We modified the bilobed flap based on the design of the standard Zitelli bilobed flap. The modification of the bilobed flap was designed to have a primary lobe that was 10% longer than the length of the distal defect edge from the flap’s pivot point, and the width of the primary lobe was equal to the width of the defect. The length of the secondary lobe was 130% of the length of the distal defect edge to the flap’s pivot point, and the width of the secondary lobe was two-thirds the width of the primary lobe. To make a slight downward displacement of the ipsilateral alar margin, the primary lobe was transposed to fill the primary defects. Results  The results of the reconstruction were satisfactory: there was good nasal contour and appropriate symmetry of the nasal tip and no alar retraction. Conclusion  The modification of Zitelli’s bilobed flap to have a longer primary lobe, which slightly displaced downward the ipsilateral alar margin intraoperatively, can prevent nasal alar retraction in the reconstruction of distal nasal defects in Asians.     

Para-alar crescentic subcutaneous pedicle flap for repair of skin defects in the philtrum

Crescentic subcutaneous pedicle flaps prepared on the area lateral to the alar base were designed to cover the skin defects in and around the philtrum. In 1 patient a combination of the lateral lip advancement flap and the crescentic subcutaneous pedicle flap was applied to the skin defect on the lateral lip and philtrum. In another patient, a combination of two crescentic subcutaneous pedicle flaps was applied to the skin defect within the philtrum. Both methods have been successful.     

Single-stage reconstruction of alar defect of the nose by subcutaneous island nasolabial and remnant alar flap

A single-stage technique for reconstruction of the medial nasal ala with a nasolabial flap and an inferiorly based remnant alar flap is presented in this article. The technique has been used in four cases. All the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique. The subcutaneous nasolabial island flap and alar remnant flap have become the method of choice in the author’s clinic for partial medial nasal ala reconstruction. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove. The remnant ala as an inferiorly based flap has been used by the author to cover the subcutaneous pedicle of the nasolabial flap to provide better shape to the alar base without its lateral drift during healing. Level of Evidence: Level V, therapeutic study.     

A Novel Technique Using a Rotation Flap for Repairing Adjacent Surgical Defects

BACKGROUND: The incidence of head and neck carcinomas continues to rise. Surgical excision is a frequently used method for removing these carcinomas. It is not uncommon to have multiple skin carcinomas present at the same time or in close proximity to each other. Therefore, surgeons can be presented with the challenge of repairing adjacent surgical defects while avoiding unacceptable wound closure tension and distortion of neighboring structures. OBJECTIVE: The presentation of a novel method for repairing adjacent surgical defects with a rotation flap. MATERIALS: Standard excision tray. CONCLUSION : We present a novel method for repairing adjacent surgical defects with a rotation flap. Surgeons are presented with adjacent surgical defects and challenged to find the repair option that will give the most optimal cosmetic result. The options for closing small adjacent surgical defects include making the defects a single large defect for primary closure, full-thickness skin grafting, primary closure of each defect separately, flap coverage, secondary intention healing, or any combination of these. The use of a single rotation flap to cover two adjacent surgical defects provides the surgeon with a convenient and cosmetically acceptable option that avoids unacceptable wound tension and does not distort neighboring structures.     

Island flap perineoplasty for coverage of perineal skin defects after repair of cloacal deformity

Background : Traumatic cloacal defect is an injury sustained during childbirth in which the anovaginal septum is completely disrupted and the anus and vagina open as a common channel. Such injuries result in complete faecal incontinence and are difficult to repair both in terms of improving function and obtaining skin closure. Methods : Four cases of traumatic cloacal defect with a delayed presentation are illustrated here. All were treated with an overlapping anterior sphincter repair in combination with island flap perineoplasty to achieve skin closure. Anorectal function before and after surgery and the success of achieving primary wound healing were evaluated. Results : In all four cases profound incontinence was found preoperatively; all patients returned to normal or near normal continence following overlapping anterior sphincter repair. Island flap perineoplasty was successful in achieving primary healing in all cases and no flaps were lost to necrosis. Conclusions : Island flap perineoplasty is an effective method of achieving skin closure after anterior sphincter repair of traumatic cloacal defects.     

Covering of soft tissue defects of the lower leg with adipo-facial flaps

AIM OF THE STUDY: Soft tissue covering on the lower leg is a difficult challenge. A plastic surgical method for covering of these soft tissue defects is presented. PATIENTS AND METHODS: From May 1997 until May 2003 36 patients were treated using neurovascular flaps. Above the sural or the saphenous nerve an adipo-facial flap is dissected, rotated into the defect and fixed without tension. Wound closure of the donor-site defect is done primarily or by mesh-graft. RESULTS: In 35 cases the flap healed without functional impairment. Primary healing was achieved in 30 patients. In 5 cases partial loss of the skin island was registered, whereby subcutaneous tissue remained vital. Revision by mesh-graft transplantation led to successful healing in these patients. In only one patient necrosis of the flap was seen. CONCLUSION: Neurovascular flaps usually result in reliable and complete healing of soft tissue defects of the lower extremity.     

Myelomeningocele repair by a combined fasciocutaneous flap closure

Summary The principles of myelomeningocele repair have been clearly described in the literature^1–5 and generally delineate a technique that calls for the dissection and closure of five separate layers: arachnoid, dura, fascia a subcutaneous layer, and skin. We should like to describe our technique of repairing the myelomeningocele defect following dural separation and closure by shifting complete fasciocutaneous tissue blocks from either side of the defect to the midline following dural closure. A full thickness primary closure can be obtained even in large defects.     

V-Y advancement flap and composite graft for alar-groove reconstruction.

A one-stage procedure combining a V-Y advancement flap with a composite graft for the reconstruction of alar-lobule and alar-groove defects is described. After tumour resection, a V-Y flap is advanced and retained at the level of the piriform margin to fill the dead space. To provide vascular support to the composite graft and to recreate the alar groove the advancing edge of the flap is de-epithelialised. In the same stage the composite graft is harvested and placed into the alar defect. A series of 12 patients underwent this procedure, with good results.     

Influence of small intestinal serosal defect closure on leakage rate and adhesion formation: a pilot study using rabbit models

Background  

The management of small intestinal serosal defects remains controversial. Non-closure of such defects is regarded as a risk factor of fistula formation or intestinal leakage, whereas defect closure with absorbable suture material is potentially associated with adhesion formation. The aim of our pilot study was to evaluate the influence of small intestinal serosal defect closure on peritoneal wound healing, leakage rate, and adhesion formation in a rabbit model.     

Nasalis Myocutaneous Island Pedicle Flap with Bilevel Undermining for Repair of Lateral Nasal Defects

BACKGROUND: The superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining is a recently described bipedicled flap used for repair of nasal tip and supratip defects. This flap was used for the repair of small to medium-size defects of the nasal tip and supratip regions. OBJECTIVE: To describe a single-pedicled modification of this flap for the reconstruction of lateral nasal defects at or above the alar groove. METHODS: With the use of diagrams and fresh cadaver dissection, we demonstrate the method of preparing, raising, and placement of this new flap. We further elucidate in an illustrative way the efficacy of bilevel undermining as it is used for achieving greater flap mobility. Finally, we show representative cases with pre- and postoperative results. RESULTS: We describe the senior author's 4-year experience in the development of this flap. CONCLUSION: The nasalis myocutaneous island pedicle flap with bilevel undermining, a new method for repair of lateral nasal defects at or above the alar groove, yields excellent functional and cosmetic results. Bilevel undermining is a new and valuable method of achieving greater tissue mobility in muscle-based flaps.     

The stair-step flap for nasal reconstruction

The stair-step nasal flap, which was originally designed to allow re-creation of the alar rim, has proved to be equally versatile for reconstruction of many other soft tissue defects of the nose. When a skin graft is unwarranted, this is a simple method for local flap transposition that minimizes any aesthetic deformity while allowing primary donor site closure. It is best suited for small or moderate sized defects of the lower and middle thirds of the nose.     

The management of the postoperative disrupted abdominal wall

BACKGROUND: Dehisced abdominal wounds are common. Their management is generally difficult and often prolonged, with incisional hernias a common occurrence. A new technique is presented that results in accelerated delayed primary healing with full thickness skin and subcutaneous tissue coverage. METHODS: The technique involves a combination of vigorous wound toilette, the judicious use of sutures and tissue expansion produced by the application of specially designed external tissue expanders. Gradual approximation of the wound edges is achieved and final suture allows closure by full thickness skin and subcutaneous tissue. RESULTS: Sixteen patients, 10 with one or more intestinal fistula, developed abdominal wall dehiscences. At discharge all wounds were closed, from 2 days in wounds averaging 12 x 5 cm to 18 days in a 29 x 24 cm wound. The follow-up, both in numbers and length, was limited for various reasons. CONCLUSIONS: The technique appears to be generally successful. The simplicity allows easy learning and may avoid a major operative procedure. Accelerated delayed primary closure by full thickness skin and subcutaneous tissue has considerable economic benefits for the patient and the health service.     

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.     

基于鼻部美学亚单位鼻翼缺损修复术式的选择

目的参照鼻部美学亚单位的原则,根据鼻翼缺损的大小和毗邻亚单位的缺损,选择鼻翼缺损的修复术式。方法自2011年7月至2013年6月,我们共收治6例鼻翼缺损的患者。其中鼻翼亚单位缺损4例,行耳郭复合组织游离移植;鼻翼合并鼻尖亚单位缺损2例,应用显微外科技术,行逆行颞浅血管供血的耳前皮瓣游离移植,血管蒂与受区邻近的鼻唇沟处角动、静脉吻合。结果本组6例游离组织均成活,随访6～12个月,重建的鼻翼皮肤色泽与周边接近,弹性正常,瘢痕隐蔽。结论大于鼻翼亚单位50％的缺损,用耳郭复合组织游离移植修复;鼻翼合并鼻尖亚单位的缺损,用吻合血管的逆行游离耳前皮瓣修复。     

Treatment of cicatricial lagophthalmos: very small orbicularis oculi muscle pedicled skin flap.

There are many methods for the correction of cicatricial lagophthalmos. Skin and soft tissue should be used to reconstruct the defect after release of tension. We used a very small orbicularis oculi muscle pedicled skin flap for the correction of mild to moderate degrees of cicatricial lagophthalmos in six cases. A small skin island flap from near the skin defect, pedicled on the orbicularis oculi muscle, was transposed to fill the defect. The length of the skin flap ranged from 5 mm to 11 mm. With a follow-up period ranging from 6 months to 18 months (mean: 11 months),we obtained satisfactory functional and aesthetic results. The eyelid closure was much improved and the discomfort was relieved. All the flaps survived without any healing problems. This small orbicularis oculi myocutaneous flap is very reliable and has a wide range of motion. This technique can be applied to eyelid-skin defects of various causes.     

Vastus lateralis muscle flap for infected hip defects: a report of four cases

Background: Infected prosthetic hip joints can often be salvaged through one- or two-stage procedures. When these measures fail and prosthesis has to be removed, an infected defect is created that has very little chance of being closed directly or by secondary healing. It is well established that such defects can be successfully closed with the introduction of a well vascularized tissue, such as muscle, into the defect. Methods: We present four patients with infected hip defects following prosthesis extraction who were treated with vastus lateralis pedicled flaps transposition. Results: All four patients were successfully treated using the vastus lateralis muscle flap, with no signs of infection and a stable skin coverage in all of the patients to date. Conclusions: We found vastus lateralis to be a reliable and sufficiently large flap for closure of infected hip defects. A small technical point of leaving the suction drain in the recipient site for 14 days is suggested. Having observed a great number of operations performed on these patients and a long waiting time before closure of the defect is achieved, we recommend a much closer collaboration between orthopedic and plastic surgeons.