Since Baron and Emmet 1 published their report on subcutaneous pedicle flaps, there have been many reports concerning the transfer of flaps using the elasticity of the subcutaneous tissue. 2–6 Today, subcutaneous pedicle flaps are used frequently because of their advantages in terms of ease of execution and satisfactory results, but the limited shifting capacity of these flaps has always been a problem.
Several modifications of the V-Y advancement technique have been described to achieve effective advancement of the available tissue and to decrease the tension along the closure line. 7–13 We present a new modification of the bilateral V-Y advancement flap that we think serves the previously stated purposes better, especially in the closure of large defects.
Patients and Methods
In Ankara Numune Hospital II, Plastic and Reconstructive Surgery Clinic, between February 1999 and March 2000, we used our technique on 10 patients who ranged in age from 15 to 58 years (median age, 35.1 years). Eight patients (80%) were diagnosed with sacral pressure sores and 2 patients (20%) had trochanteric pressure sores (Table). Mean defect size was 16.1 cm in diameter in the sacral pressure sore group and 11 cm in the trochanteric pressure sore group.
After debridement of the pressure sore, extended V-Y advancement flaps with extension limbs not exceeding two thirds of the diameter of the defect were marked on both sides of the defect (Fig 1A). Skin incisions were carried down to the muscle fascia along the borders of the flaps. The upper and lower limbs of the flaps were elevated but remained attached to the main flap at their base. After advancement of the V-Y flaps on their subcutaneous pedicle, the upper limb was hinged downward and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect (Fig 1B). The lower limb of the contralateral flap was then transposed into the defect and sutured to the midpoint of the opposing V-Y flap. After placing these key sutures, closure was completed with interrupted sutures (Fig 1C).
Use of bilateral, extended V-Y advancement flaps resulted in decreased tension along the closure line and brought the main flaps together with less advancement. The flaps healed well in all patients, and no complications were observed during the 2 to 10 months (mean, 5.4 months) of follow-up (Fig 2).
There are many reports in the literature concerning the use of subcutaneous pedicle flaps for the closure of circular skin defects on various body surfaces, 1–4,8 and the V-Y advancement flap is one of the most commonly used procedures. 5–7,9–14 Bilateral or single advancement flaps can be used to close skin defects, and many modifications have been described.
Campus and colleagues 7 closed a rhomboidal defect using a unilateral, modified V-Y advancement flap. The use of apical flaps enabled further reach of the flap into the defect with less mobilization required. The disadvantage of this modification was the requirement for excision of extra healthy tissue to convert a circular defect into a rhomboidal one. 15 Vaubel 9 combined two Limberg flaps with a V-Y advancement flap; however, the same disadvantage applies to this modification.
Blair and associates 12 used V-Y advancement flaps to close lower extremity defects, making an elliptical incision as if direct closure had been attempted, and then they advanced the flaps bilaterally to close the defect in a V-Y fashion. Because the extensions of the V-Y flaps were not used, larger defects could not be closed and midline tension was not decreased, even though larger flaps were designed.
Pribaz and coworkers 10 first defined the use of the extended V-Y flap in 1992, in closing defects after excision of facial lesions. They reported the technique to be effective in larger defects in areas that typically have inadequate subcutaneous tissue. Terashi and colleagues 13 also used this method and reported excellent cosmetic results in 11 patients. Our technique combines the advantages of the standard bilateral advancement technique with the extended V-Y advancement procedure to enable the closure of very large defects on all body surfaces. In addition, the distortion at the base of the flap (noted in earlier studies), was not noted in our patients. 13
Several advantages were found to be related to the use of this modified technique when compared with the standard V-Y advancement procedure. The amount of advancement is limited by the nature of the subcutaneous tissue in the standard, bilateral V-Y advancement flaps. The greatest tension along the closure line occurs at the midpoint, where the flaps meet. Using our modified technique, the advancement of flap extension into the defect closes the major part of the defect even before the V-Y advancement of the main flaps. Bilateral V-Y advancement of the flaps approximates their transposed extensions further and serves to decrease the tension along the closure line. The efficient redistribution of available tissue by the combined use of transposition and advancement principles results in the closure of larger defects with less advancement. There is no need to excise extra healthy tissue, unlike that required in some other modifications.
The main concern in using this modified technique is ensuring the viability of the transposed extremities of the V-Y advancement flaps. In our experience, this has not been a problem.
Bilateral, extended V-Y advancement is a safe procedure, and we prefer it over the classic, bilateral V-Y advancement because it decreases the tension along the closure line, it breaks the central vertical scar into a zigzag line, and it can be applied to all body surfaces. Large defects that are difficult or impossible to close with the conventional technique can be closed with ease using this modified procedure.
1. Barron JN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast. Surg 1965; 18: 51–78.
2. Emmett AJJ. The closure of defect by using adjacent triangular flaps with subcutaneous pedicles. Plast Reconstr Surg 1977; 59: 45–52.
3. Spira M, Gerow FJ, Hardy SB. Subcutaneous pedicle flaps on the face. Br J Plast Surg 1974; 27: 258–263.
4. Trevaskis AE, Rempel J, Okunski W, Rea M. Sliding subcutaneous pedicle flaps to close a circular defect. Plast Reconstr Surg 1970; 46: 155–157.
5. Maruyama Y, Iwahira Y, Ebihara H. V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle. Plast Reconstr Surg 1990; 85: 759–764.
6. Zook EG, Van Beek AL, Russell RC. V-Y advancement flap for facial defect. Plast Reconstr Surg 1980; 65: 786–797.
7. Campus GV, Lissia M, Pancrazi E. The amplified sliding flap. Ann Plast Surg 1993; 31: 318–321.
8. Nakajima T, Yoshimura Y, Kami T. The subcutaneous pedicle flap: widening of its applications. Ann Plast Surg 1987; 19: 103–116.
9. Vaubel E. The V flap: combination of V-Y advancement and two Limberg transposition flaps. Ann Plast Surg 1991; 26: 64–69.
10. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg 1992; 90: 275–280.
11. Akan IM, Ulusoy MG, Bilen BT, Kapucu MR. Modified bilateral advancement flap: the slide-in flap. Ann Plast Surg 1999; 42: 545–548.
12. Blair JW, Bainbridge LC, Knight SL. Double V-Y advancement flaps in the reconstruction of skin defects of the anterior lower limb. Br J Plast Surg 1993; 46: 644–646.
13. Terashi H, Kurata S, Hashimoto H, et al. Extended V-Y flap: patient reports and reconsideration. Ann Plast Surg 1997; 38: 147–150.
14. Heywood AJ, Quaba AA. Modified gluteus maximus V-Y advancement flaps. Br J Plast Surg 1989; 42: 263–266.
15. Golomb FM, Neumann CG. An experimental method for comparing primary closure of skin defects. Plast Reconstr Surg 1958; 22: 194–203.