Journal Logo

Letters

Reply

Free-Style Local Perforator Flaps

Versatility of the V-Y Design to Reconstruct Soft-Tissue Defects in the Skin Cancer Population

Brunetti, Beniamino M.D.; Tenna, Stefania M.D., Ph.D.; Aveta, Achille M.D.; Poccia, Igor M.D.; Segreto, Francesco M.D.; Persichetti, Paolo M.D., Ph.D.

Author Information
Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 434e-435e
doi: 10.1097/01.prs.0000438464.98592.6b
  • Free

Sir:

We appreciate the interest of Dr Chaput et al. in our article,1 and we are thankful for the opportunity to respond to their insightful comments. In agreement with the authors, we consider as obsolete the random flap concept and try to approach each reconstructive case adhering to the free-style philosophy.2 The best method to plan and move free-style local perforator flaps is still in debate. As a matter of fact, propeller flaps provide a wider range of motion, allowing the surgeon to reconstruct even distant defects in an elegant and tension-free manner. Nevertheless, we agree with the authors that their use is not always recommended because of the higher risk of venous insufficiency, especially in the elderly population, and the need to skin graft the donor site in medium-size to large defects. On the other hand, the V-Y design guarantees an increased vascular safety, despite its limited advancement and more difficult insetting. In this scenario, after performing a discrete number of cases [about 70 free-style local perforator flaps harvested in the last 3 years at our institution (unpublished data)], we truly believe that an ideal design does not exist, but each case should be approached by taking into consideration the dimensions, orientation, and anatomical site of the defect, as well as distance and anatomical features of the perforator. Our first choice to resurface soft-tissue defects is the V-Y advancement design.3 This model can be applied to almost any anatomical district, but it is contraindicated in the following instances:

  1. The perforator Doppler signal is only audible in close proximity to the defect.
  2. A significant advancement is preoperatively considered to be mandatory to obtain a complete, tension-free closure of the defect (narrow and long defects).
  3. The perforator vessels are judged to be too short to allow for adequate advancement movement (posterior tibial artery, dorsal intercostal artery perforators).
  4. The flap has to cross bony prominences4 (tibial shaft, elbow, thoracic spines) to reach the recipient site.

In such cases, we tend to adopt the propeller design without any hesitation. Nevertheless, in a discrete number of cases, the choice of the final design has to be postponed until the surgical exploration. In this situation, we adopt a cautious “cut as you go” approach, limiting the explorative incision to the length necessary to expose the perforator vessel. In selected cases, when adjacent free-style flaps can be hypothesized, we suggest performing the explorative incision in between the two flaps, allowing exposure of the perforators of both flaps with a single incision (Figs. 1 and 2). We congratulate the authors for their case series about the use of the “Pac-Man” design.5 We agree with them that the use of this technique may help to close bigger defects compared with the classic V-Y design; nevertheless, bigger flaps need to be planned and an additional scar is required, producing a less attractive cosmetic outcome. In our flap series, we never planned to adopt the Pac-Man design preoperatively, but we had to shift to this particular closure as a salvage procedure in a limited number of patients, in cases of restricted flap advancement (perforator located in the distal tip of the V-Y flap) or to avoid extensive pedicle dissection in elderly patients. Undoubtedly, further studies will be necessary to improve our knowledge about the real reconstructive possibilities provided by each described perforasome. Meanwhile, the key points discussed with the authors may help to optimize functional and cosmetic outcomes and minimize the vascular complication rate.

Fig. 1
Fig. 1:
A 53-year-old female patient was diagnosed with a 3.2-mm Breslow malignant melanoma arising in the posterior thigh. A 2-cm-margin enlargement was planned, resulting in a 7.5 × 5.5-cm defect. (Left) Preoperatively, two flaps with different designs (90-degree propeller and V-Y advancement) were planned on the same perforasome (profunda femoris artery perforator flap). (Right) Appearance of the flap 3 months postoperatively.
Fig. 2
Fig. 2:
Both skin islands were explored through a single incision made between the two flaps. The propeller design was excluded because the chosen perforator was found to have an oblique suprafascial course and was sacrificed during margin enlargement. (Above) Exploration of the V-Y flap revealed a good-caliber, viable perforator. (Below) The V-Y advancement flap completely islanded on the perforator vessel.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication. No intramural or extramural funding supported any aspect of this work.

Beniamino Brunetti, M.D.

Stefania Tenna, M.D., Ph.D.

Achille Aveta, M.D.

Igor Poccia, M.D.

Francesco Segreto, M.D.

Paolo Persichetti, M.D., Ph.D.

Department of Plastic, Reconstructive, and

Aesthetic Surgery

“Campus Bio-Medico di Roma” University

Rome, Italy

REFERENCES

1. Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Free-style local perforator flaps: Versatility of the V-Y design to reconstruct soft-tissue defects in the skin cancer population. Plast Reconstr Surg. 2013;132:451–460
2. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: A further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124(6 Suppl):e419–e426
3. Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Free-style local perforator flaps: Versatility of the V-Y design to reconstruct soft-tissue defects in the skin cancer population. Plast Reconstr Surg. 2013;132:451–460
4. Brunetti B, Tenna S, Aveta A, Poccia I, Segreto F, Persichetti P. Reconstruction of elbow defects with perforator-based propeller flaps. Plast Reconstr Surg. In press
5. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects. Br J Plast Surg. 2000;53:679–689

GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2014American Society of Plastic Surgeons