INTRODUCTION
Among many indications for flaps, there is their use when simple closing techniques
do not produce an acceptable functional or aesthetic result. They also have the function
of reducing and/or redirecting tension, making them an indispensable tool in closing
complex wounds or in noble areas. They can be classified based on their primary movement:
transposition, advancement, and rotation1.
Transposition flaps incorporate the non- contiguous skin in a primary defect, lifting
the flap over the normal skin in a defect, and have head and neck skin defects as
their main indication2. Advancement flaps recruit adjacent tissue to close a defect in a linear direction,
while rotation flaps rotate adjacent tissue around an axis to close a primary defect,
rotating the skin into the defect1.
Numerous possible modifications can be learned from the literature in the described
flaps, as opinions vary between surgeries concerning the ideal development of a rotating
flap3.
Rotation flaps are indicated when other simpler types of closure do not provide a
functional and aesthetic result, being suitable for triangular defects adjacent to
the transferable skin, such as lesions in the zygomatic region, buccinator, chin,
and scalp; they can redirect stress around a free edge and avoid distortion. Such
flaps are created with an arched or curvilinear incision combining advancement and
rotation1,4.
Due to the primary movement of the flap, a cutaneous deformity on the rotation pedicle,
called “dog ear,” can form along the arch on the opposite side of the primary defect,
bringing aesthetic damage to the patient and the need for a new intervention to correct
this elevation in the pedicle. To minimize the defect and closing tension, the triangulation
technique must be adjusted so that the redundant tissue area is excised and the geometric
pivot point ideally coincides with the apex of the triangulated defect1,3,5.
The rotation flap archetype is framed by the bilobed flap, which, as it only rotates,
has all the disadvantages described above, such as a “dog ear” on a rotation pedicle,
fixed location of the pedicle in nasal reconstructions, with a pedicle that is obligatorily
lateral in reconstructions. of dorsal lesions and dorsal/central pedicles in reconstructions
of lateral lesions, which reduces its versatility in relation to the S-Apple proposed
here.
The flap proposed here, as a modification of the bilobed flap, manages to incorporate
the advantages of a rotation flap with the advantages of a transposition flap, providing
a versatile technique that can be used in different situations to produce excellent
functional and aesthetic results, without the restriction of the positioning of rotation
pedicle or sites of use. This archetype justifies the proposal of the present work
to develop the S-Apple flap.
OBJECTIVE
To describe a versatile mixed rotation and transposition flap for closing defects
without new interventions for aesthetic and/or functional refinements.
METHOD
The flap was developed based on the archetype of the bilobed rotation flap, a versatile
flap, but which has the disadvantages of raising the point of rotation – “dog’s ear”
and a limitation in the sizes and locations of the lesions that can be repaired, as
well as such as, in nasal reconstructions, the obligation to have a fixed rotation
pedicle in the dorsum/central region for lateral defects and a fixed lateral pedicle
for dorsal/central defects.
All patients were explained about the procedures, risks, and possible complications,
and an informed consent form for participation in the study was used.
Such procedures followed the norms of the Institution’s Research Ethics Committee
and CNS Resolution 196/96.
The S-Apple Flap flap was designed according to the scheme in Figure 1, in which the traced angles are observed, with the defect always removed in a circular
format and the flap arms drawn at approximately 60° (angles a and b). The line in
red demonstrates the creation of the “S” of the flap; it is made up as a zeta line,
being drawn at a 30° angle (angle c) of the X axis in relation to the defect. The
dimension of the arm of the flap adjacent to the defect must be of the same diameter
(diameter of A = diameter of B), with flaps D and E being transposed as in a zetaplasty
and flap C rotated to fill the space left by flap B, which will rotate to cover the
A defect resulting from excision of the lesion.
Figure 1 - Scheme for marking the S-Apple flap.
Figure 1 - Scheme for marking the S-Apple flap.
The justification for naming it the S-Apple Flap is the format resulting from the
marking of the flap, as shown in Figures 2 and 3, which depicts the shape of an apple at the end of the marking, also exemplified
in the cases described.
Figure 2 - Scheme showing the “S” of the flap, portions that will be transposed.
Figure 2 - Scheme showing the “S” of the flap, portions that will be transposed.
Figure 3 - Scheme demonstrating the shape of an apple.
Figure 3 - Scheme demonstrating the shape of an apple.
All patients were followed up for 3, 6, and 12 months, with standardized photographic
records taken according to the protocol, a validated questionnaire on body image satisfaction,
and a scar quality scale. Data were tabulated for further statistical analysis.
RESULTS
As preliminary results, no necrosis, infection, or dehiscence occurred. All patients
had a satisfaction index of Good or Great. All presented scar quality classification
as satisfactory and extremely satisfactory; there was no recurrence in the sample.
Such data will be the motto of the complete work, with the demonstration of statistical
significance after analyzing the instrument data.
There were no trapdoor scars or elevation at the flaps’ rotation point. None of the
cases required re-approach to correct an unsightly scar or to thin the pedicle.
Below are pre- and postoperative examples to illustrate the aforementioned (Figures 4,5,6,7). The versatility of locating the flap in the nasal region and the possibility of
using it in larger lesions can be seen in Figure 8. Figures 9,10, 11 show an example of using the flap in breast reconstruction.
Figure 4 - Preoperative and 120th postoperative day.
Figure 4 - Preoperative and 120th postoperative day.
Figure 5 - Preoperative and 30th postoperative day.
Figure 5 - Preoperative and 30th postoperative day.
Figure 6 - Preoperative and 300th postoperative day.
Figure 6 - Preoperative and 300th postoperative day.
Figure 7 - Intraoperative, immediate postoperative, and 7th postoperative day.
Figure 7 - Intraoperative, immediate postoperative, and 7th postoperative day.
Figure 8 - Examples of markings and injury sites for using the flap in nasal reconstruction.
Figure 8 - Examples of markings and injury sites for using the flap in nasal reconstruction.
Figure 9 - Example of marking the S-Apple flap for breast reconstruction of the left superolateral
quadrant.
Figure 9 - Example of marking the S-Apple flap for breast reconstruction of the left superolateral
quadrant.
Figure 10 - Left image: preoperative patient with breast cancer in the left superolateral quadrant.
Image on the right with green background of a patient 30 days after surgery and reconstruction
with an S-Apple flap, demonstrating little structural change in the breast and minimal
displacement of the nipple-areolar complex.
Figure 10 - Left image: preoperative patient with breast cancer in the left superolateral quadrant.
Image on the right with green background of a patient 30 days after surgery and reconstruction
with an S-Apple flap, demonstrating little structural change in the breast and minimal
displacement of the nipple-areolar complex.
Figure 11 - Demonstration of the scar with 30 days of evolution of the S-Apple flap used for breast
reconstruction of the left superolateral quadrant.
Figure 11 - Demonstration of the scar with 30 days of evolution of the S-Apple flap used for breast
reconstruction of the left superolateral quadrant.
DISCUSSION
Among the different rotational flap techniques, double rotation flaps for closing
large defects in a single time are relevant in the literature and generally used on
the scalp and around the free margins. The O to Z flap is a double rotation flap used
in the central region of the scalp or large lesions on the trunk, which effectively
converts the circular or “O” shaped defect into a “Z” shaped suture line1,2. A variation of this flap is the pinwheel, which uses three or more rotation flaps,
useful for scalp and trunk defects.
The original Peng flap6 corresponds to an advancement flap, which can be modified to add a rotational component,
essentially a double rotation flap in which the point of articulation is located along
the midline at the nasal root. This flap can be indicated as an alternative for defects
that require a paramedian flap, but it can lead to distortion of the symmetry of the
nose and elevation of the nasal tip1,6.
Concerning exclusive rotation flaps, Rieger7 first proposed the dorsal nasal rotation flap in 1967, used for larger defects of
less than 2 to 3cm in size in the distal nose in a single stage. Marchac & Toth8 described an axial pattern flap, but some patients do not have the necessary tissue
laxity to perform the flap, which may cause loss of nasal symmetry, the elevation
of the nasal tip and ala, and distortion of the ala1,5,8.
Special care must be taken to avoid ectropion when addressing lower eyelid and infraorbital
cheek defects. Tenzel & Stewart9 and Mustardé10 described rotation techniques that disperse tension in the horizontal plane, avoiding
excessive tension in the lower eyelid. However, the Mustardé flap10 can induce ectropion due to the weight of the flap, requiring sutures. The Tenzel
flap9 is a myocutaneous flap with less rotation, not requiring sutures1,5,9,10.
The spiral flap has several proposed uses, including defects in the lower eyelid,
ventral fingertip, nasal ala, and lateral and inferior nasal tip, with the potential
to preserve the alar sulcus. The cervicofacial flap is used for very large cheek defects,
being created similarly to a Mustardé and Tenzel flap, with the incision made towards
the neck, also requiring sutures due to its size1,5,9,10.
Transposition flaps, designed in a random pattern, must be elevated over an area of
normal skin to reach the eventual destination in the primary defect. They are generally
used in the head and neck because of their ability to redirect tension and recruit
a reservoir of tissue not immediately adjacent to the defect, redirecting tension
away from the primary defect, and may avoid distortion of the free margins. The classic
flap corresponds to a single lobe, which recruits tissue from an adjacent reservoir.
However, single-lobe transposition modifications include the Rhombic, Banner, and
Note2 flaps. Multilobed modifications of the transposition flap, such as bilobed, trilobed,
and tetralobed flaps, allow the recruitment of tissue reservoirs increasingly distant
from the primary defect2.
The bilobed flap, described for the first time in 1918 by Esser11 for use in the reconstruction of the nasal tip, consists of a local transposition
flap, presenting in its original variant a total arc of rotation between 90 and 110°,
this proposal by Zitelli12, which is currently the most used. Such an indication fell into disuse, as the large
arch created large flaps that required significant weakening, giving space to use
for the lateral portion of the nose.
The flap consists of a double transposition in which the first lobe fills the primary
defect, and a second lobe fills the secondary defect, distributing tension over a
wider area than the conventional rotational flap. Compared to the S-Apple, the incisions
create four flaps, two rotated, and two transposed. Differences in the rotation angles
and shapes of the arms of the flaps allow the closure of larger lesions without aesthetic
deformities and tissue distortions such as raised pedicles and trapdoor scars.
Contraindications for the transposition of bilobed flaps include any conditions that
substantially decrease soft tissue viability in the area in question, such as scarring,
history of radiation or infection, and active inflammation. As complications, we can
mention the trapdoor cushion deformity, which consists of a depressed area compared
to the surrounding tissue, being related to contraction of the subdermal tissue and
which can be minimized by decreasing the arc of rotation2,13.
In this regard, using the S-Apple Flap promoted the absence of trapdoor scars, no
elevation in the rotation point, and no need for a new approach for aesthetic refinement.
In addition, the absence of necrosis, infection, and dehiscence was also described,
as well as patient satisfaction regarding the quality of the scar. The versatility
of flap location and the possibility of performing it in larger lesions stand out
as another quality of the described flap.
Advantages of using rotation flaps include simplicity, good blood supply via a large
pedicle, minimal tissue redundancy, and the ability to place rotational lines in creases
or natural edges to extend the flap to increase laxity easily. On the other hand,
the disadvantages of the rotation flap are the need for careful design evaluation
and the potential for revisions inherent to all flaps.4,5
However, excessive tension, wound contracture, swelling, scarring, flap necrosis,
infection, and bleeding are common flap complications that can be avoided with careful
planning and proper technique. Furthermore, rotation flaps that do not adequately
disperse stress vectors can distort sensitive structures1,4,14.
The concern with force vectors circumscribes not only the flaps used for reconstruction
of important structures such as the nose15,16 but also several other body regions that need symmetry, such as breast reconstruction,
in which the positioning of scars and force vectors allow more natural and symmetrical
reconstructions to the untreated breast and avoid anatomical distortions due to subsequent
scar retractions17.
Such disadvantages were resolved by merging two types of flaps into one. With the
S-Apple Flap, it was possible to unite the advantages of rotation flaps with the advantages
of transposition flaps, using each one to overcome the inherent disadvantages of each
flap type. Preliminarily, there were no complications in the sample performed, with
excellent aesthetic and functional results and great versatility, allowing its use
for closing larger defects without anatomical distortions and without the need for
pedicles in fixed positions.
CONCLUSION
The S-Apple flap proved versatile and easy to mark, combining the advantages of the
rotation and transposition flaps.
1. Instituto Sundfeld de Cirurgia Plástica, São Carlos, SP, Brazil
3. Sociedade Brasileira de Cirurgia Plástica, São Carlos, SP, Brazil
3. Escola Paulista de Medicina, São Paulo, SP, Brazil
4. Unifai, Adamantina, MG, Brazil
Corresponding author: Daniel Sundfeld Spiga Real Rua Dr. Domingos Faro, 285, Jd. Alvorada, São Carlos, SP, Brazil. Zip code: 13.562-003
E-mail: dplasticsurgery@hotmail.com
