Surgical Case Study: V-Y Flap Leg Repair

A Useful Flap for the Lower Leg

The closure of surgical defects in the lower leg after excision of skin malignancies is, by far, one of the most challenging anatomic locations for repair that we, as surgical dermatology providers, encounter. This is due to the following reasons:

  • Lack of skin distension in the area
  • Lymphovascular compromise
  • Pronounced tension to which the sutures are exposed
  • It is an area that naturally requires functional movement, increasing the risk for dehiscence and other postop complications

In this article, I am introducing another one of my workhorse flaps that has helped successfully repair this challenging area.  The flap is called…the V-Y Bilateral Advancement Flap.

Description

The V-Y Bilateral Advancement Flap, also referred to as the V-Y Bilateral Island Pedicle Flap, uses a triangular or V-shaped section of skin superiorly and inferiorly of the defect to repair the primary defect to the tensioned lower leg. 

Step-By-Step How to Perform the Flap 

Looking at Case Study 1 below, learn step-by-step how to perform this repair (Steps A-E)...

A. Right Medial Lower Leg (post biopsy results: SCC)

B. Mohs Defect (skin cancer resected with clear histologic margins). Note the blue dotted markings of where incisions will be made.

C. Triangular incisions are made superiorly and inferiorly of the defect to the level of the subcutaneous fat. The skin is completely separated from surrounding skin, creating two islands.  Despite the epidermal and dermal margins being detached from surrounding structures, the skin remains intact to the subcutaneous tissue, supplying rich vasculature at the base of the flap to the now formed island pedicles.

D. Because of its detachment, both triangular island pedicles are now able to have increased mobility and are both advanced medially towards the primary defect for closure.

E. After the flap and the surrounding skin of the primary direct is appropriately undermined along the edges, the flap is sutured in place using subcutaneous and epidermal sutures (Note: Limit undermining at the base of the pedicle as that would compromise viability of the flap).

More Case Study Examples

Next, check out the following 2 additional case study examples of where I was able to successfully repair two different Mohs patients utilizing the V-Y Bilateral Advancement Flap...

 

Advantages/Disadvantages of the V-Y Bilateral Advancement Flap

Advantages:

  • The pedicles provide a rich vascular supply as it relies on the the subcutaneous plexus compared to other random pattern flaps used for legs.
  • The island pedicle requires less undermining compared to other flaps, providing an advantage for patients at high risk of bleeding.
  • Decreased risk of flap necrosis b/c blood supply even throughout pedicle.
  • No limitation on width to height ratio of flap since viability relies on underlying pedicle.
  • Does not require resection of standing tissue cones.

Disadvantages:

  • Resistance to movement in lower legs increased. The triangular islands can be advanced as far as the underlying mobility allows and lower legs, often times, have limited laxity.
  • Secondary tissue movement limited in lowered legs. 
  • “Trapdooring” - Due to the design of the islands, the triangular shaped tissue incised may create surrounding contraction. This leads to flap bulkiness when the flap heals above the surrounding skin.

Take Home Points

Now that you have learned more about the V-Y Bilateral Advancement Flap, you can now add this to your library of options when repairing a challenging defect on the lower leg.

As a surgical dermatology provider, it is important to repair a defect that will provide the patient with the best option. Choosing the right flap for the appropriate patient is the first step to success, and being able to properly design it is crucial to the execution and outcome in order to achieve reproducible aesthetic results with minimal risk. 

Leverage Your Skills

If you found this article helpful and want to dive deeper into building your confidence in your surgical skills, I created an advanced suturing course tailored specifically for dermatology NPs/PAs that will break down how to perform these suture techniques, step-by-step.  

The course will help you minimize scarring and improve your patients’ outcomes. If this sounds like a course that will help leverage your skills, click HERE to learn more!

Source: Kantor, J. (2018). Dermatologic Surgery (1st Edition). McGraw-Hill Education. 

Serving with GRATITUDE,

Theresa Talens DNP, FNP-C (TheresaSurgDermNP)

P.U.L.S.E. Dermatology & Procedures, Inc.

Where we believe in Precision. Ultimate Care. Leverage. Skills. Excellence.