Flap-in-flap method for enhancing the advancement of a V-Y flap

Primary and secondary perforator-based flap-in-flap reconstructions of postexcisional head and neck soft tissue defects

INTRODUCTION

Perforator-based flap-in-flap (PBFIF) refers to the construct of one flap within another based on a perforator. Primary flap-in-flap is the simultaneous construct of two flaps, one within the other. It is particularly useful in cases where despite perfect planning, the flap does not fit congruently into recesses of the defect. It facilitates tension-free flap inset without the need for secondary movement from adjacent areas. Secondary flap-in-flap is the construction of a flap within a previously transferred settled flap. It is particularly useful in cases of wound dehiscence and partial necrosis, which results in a defect-warranting flap cover, when other flap options are either not feasible or other options have been exhausted.

AIM

To assess the outcome and define the biogeometry of primary and secondary PBFIFs, which were used in postexcisional head and neck soft tissue defects.

MATERIALS AND METHODS

Eight patients who underwent flap-in-flap head and neck reconstruction from January 2014 to January 2016 (four cases of primary PBFIF with nasolabial flaps, and four cases of secondary PBFIF with pectoralis major myocutaneous flaps) were retrospectively studied. All were nonsmokers with no associated comorbidities. At the end of the follow-up period, two independent observers and the patient assessed the outcome based on the Institutional Reconstruction Assessment Score (IRAS).

RESULTS

All flaps settled well with a mean follow-up of 16.75 months. All flaps were used for the reconstruction of postexcisional defects only. None of the patients had any loco regional recurrences. The mean IRAS obtained in 8 patients was 3.5 (primary PBFIF=3.87 and secondary PBFIF= 3.12). None of the flaps resulted in the late distortion of adjacent anatomical landmarks by hypertrophy or contracture of scars.

CONCLUSION

Flap-in-flap reconstruction (whether primary or secondary) is a useful technique to cover defects where reconstruction without anatomical distortion is required (e.g., face). It is a useful option for a tension-free flap inset. Flap-in-flap reconstruction is a relatively easy adjunct in the salvage reconstructive armamentarium of plastic surgeons.

The Chimeric Propeller Flap

A chimeric flap consists of multiple discrete tissues or flaps connected only by a common source vessel. Each component must have an independent source of circulation. Rotation of any included part only about its specific vascular supply, such as done with a propeller flap, would be possible. These characteristics, whereby the chimeric flap concept and propeller flap concept are combined, would result in a chimeric propeller flap . Such a choice will enhance overall flap insetting capabilities and versatility, while often limiting the reconstructive need to but a single donor site!

Double V-Y Flap to Cover the Fingertip Injury: New Technique and Cases

The volar V-Y flap is used in transverse or dorsal oblique amputations in fingertip injuries; however, its use is contraindicated in patients with volar oblique amputations and cannot advance distally enough to cover the defect. The aim of this report is to describe a technique of double V-Y flap to cover fingertip defects in which a simple V-Y flap is not enough. This technique allows advancement between 30% and 50% farther than the original, simple V-Y flap. Report of cases a series of fingertip amputation covered with this technique. This technique was performed in 7 patients between 25 and 64 years old, with transverse, volar and dorsal oblique defects in the fingertip. The advancing of the flap was between 3 and 5 mm. There were no infections or necrosis of the flaps. In all patients there were acceptable aesthetic results with 2-point discrimination between 4 and 6 mm in the proximal flap and up to 10 mm in the distal flap with a minimum follow-up of 6 months. With this double V-Y flap, we have seen a good coverage even in volar oblique amputation. In addition, it is possible to advance up to 5 mm more with this second V-Y flap without compromising the vitality of the flap. It is a simple and reproducible technique that can be used on any finger, with good results, without flap necrosis.

Salient Points in Reconstruction of Nasal Skin after Tumor Ablation with Local Flaps

Objective:

A variety of nasal skin reconstruction methods are available to meet the esthetic patient's needs. In this article, we review some of modifications of these procedures and share our experience in reconstruction of different parts of the nasal skin following skin tumor ablation.

Patients and Methods:

From January 2010 to January 2014, 171 patients underwent nasal skin reconstruction after excising cancerous lesions of the involved nasal skin. The patient's history, pre- and post-operation photographs, and the surgery data were collected and assessed. Demographic data related to the type of cancer, defect size and location, type of reconstruction were collected.

Results:

A variety of local flaps were used based on location and defect features. Nearly all flaps healed primarily without postsurgical significant complications.

Conclusion:

According to the results and the outcomes of the operations, we concluded that a certain flaps are more effective than others in nasal skin reconstruction. Local flap reconstruction of the nose has good esthetic result with low complication rate.

Geometrical analysis of the V-Y advancement flap applied to a keystone flap

BACKGROUND

The V-Y advancement flap and, more recently, the keystone flap are commonly used to cover skin defects. Both flaps allow for primary closure after advancement by substituting the initial defect for a narrower defect distributed over a greater length. The first objective of this study was to develop a geometrical analysis of the V-Y advancement flap. The second objective was to explain the benefit of using the keystone flap compared to a single V-Y advancement flap.

MATERIAL AND METHOD

A geometrical analysis is proposed using a two-dimensional analysis in which the flaps are assumed to have a rigid-body behaviour. First, in the case of the V-Y advancement flap, a trigonometric relationship is defined between the distance of closure before and after advancement, thus implying the value of the flap's apex angle. Second, by considering the keystone flap as the association of three V-Y advancement flaps, the trigonometric relationship is applied to the keystone flap.

RESULTS

In the case of the V-Y advancement flap, the optimal apex angles are between 20° and 60°. At less than 20°, the length of the flap increases in an exaggerated manner. At greater than 60°, the distance of closure, particularly at the apex of the flap where a corner stitch is performed, is greater than the distance of closure of the initial defect. In the case of the keystone flap, the width of the final defect around the flap is clearly smaller and more regular compared to the final defect around a single V-Y advancement flap.

CONCLUSION

The geometrical analysis of the V-Y advancement flap in our description illustrates the major benefit of the keystone flap over a single V-Y advancement flap.

Croissant-shaped v-y advancement flap with 2 horns for repair of small- and medium-sized facial defects

BACKGROUND

The use of a V-Y advancement flap is an effective technique for the reconstruction of small facial defects. However, in some areas, the use of a conventional V-Y advancement flap is not possible because of the tension caused by size variation. In the current study, we modified this method using a croissant-shaped V-Y advancement flap and repaired intermediate-sized defects without difficulty.

MATERIALS AND METHODS

A croissant-shaped modified V-Y flap was used in 15 patients (aged 53-82 y). To completely remove masses, wide excisions were performed in all cases (nasolabial area = 7, nasojugal area = 3, medial canthal area = 1, cheek = 2, nose = 1, forehead = 1), and the average size of the defects was 2.6 × 2.5 cm. The flap was designed after confirmation of clear resection margins on frozen section. The long axis of the V-flap was 1.5 to 2 times the length of the diameter of the defect and parallel to the nasolabial or nasojugal fold. In a conventional V-Y advancement flap, the lateral limbs of the V-flap begin at the end point of the central limb. However, in our design, the incision lines of the lateral limbs of the V-flap were extended to the end point of the defect to form a more convex shape. The flap was elevated in the subcutaneous layer above the mimetic muscles. The bilateral tips of the horns of the V-flap were sutured to each other and fixed medially to cover the distal aspect of the defect. The flap was then sutured with a 6-0 nylon. Donor site closure was performed with 6-0 Vicryl and 6-0 nylon in 2 layers. A Penrose drain was inserted at the donor site.

RESULTS

No complications were reported in any of the 15 cases. In 2 cases, there was minimal flap congestion immediately after surgery. However, in both cases, the congestion spontaneously resolved during the ensuing days. At follow-up (mean, 12 mo), all 15 patients demonstrated satisfactory cosmetic results.

CONCLUSIONS

This modified croissant-shaped V-Y flap may serve as an alternative to conventional V-Y flaps for reconstruction of soft tissue defects on the face.

[Bilateral latissimus dorsi V-Y musculocutaneous rotation flap for closure of a large dorsal radionecrosis. Geometric analysis and interest. About one case]

Reconstruction of a large dorsal radionecrosis with bilateral latissimus dorsi V-Y musculocutaneous flaps is reported. This procedure provides a reliable, well-vascularized soft-tissue coverage. Geometric analysis and differences between V-Y advancement flap and V-Y rotation flap are discussed.

Reconstruction of the nasal alar

The authors of this study describe a case of nasal alar deformity with a congenital deficiency of cartilage treated with a rotation flap. To choose the reconstruction technique, reference parameters such as the age of the patient, the presence of preexisting scars, and the size of the defect are assessed by focusing on the tissue structure and on the major aesthetic demands of the younger patients. Good aesthetic results, with an acceptable cicatricial outcome and an excellent morphofunctional reconstruction of the ala, were achieved in the treated subject. The postoperative course was also good with no complications.