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R ECONSTRUCTION AND B URNS

The“Reading Man”Procedure

A New Technique for the Closure of Circular Skin Defects

Mehmet Mutaf,MD,Mahmut Sunay,MD,and O¨mer Bulut,MD

Background:As most of the skin lesions tend to grow in a circular pattern,the resultant defects after surgical removal of these lesions are often circular.Although a number of local?ap procedures have been described,alternative techniques are still needed for the closure of circular defects.

Purpose:Here,a new surgical technique for the closure of circular skin defects is presented.This technique basically uses the extra skin relaxation gained with an unequal Z-plasty maneuver in favor of the defect closure.The procedure is named as“the reading man”because its surgical design resembles the silhouette of a man who is reading a book held in his hand.

Material and Methods:In this technique,2?aps designed in an unequal Z-plasty manner are used.The?rst?ap is transposed to the defect area whereas the second?ap is used for closure of the?rst ?ap’s donor site.For3years,this technique has been used for closure of the circular skin defects in27patients(19men and8 women)aged from2months to68years.The defect size was ranging between1.5and14cm in diameter.

Results:A tension-free defect closure was obtained in all patients. All?aps healed with no complications.There was no patient with dog ear formation.A mean follow-up of15months(6months–3 years)revealed an esthetically acceptable scar formation in all patients.

Conclusion:The reading man procedure was found to be a useful and an easy going technique for the closure of circular skin defects located on various anatomic regions.It enables surgeon to obtain a tension-free closure of considerably large skin defects with minimal scarring and additional healthy skin excision.

Key Words:defect closure,skin defects,circular defects,the reading man procedure,local?aps,unequal Z-plasty,Z-plasty, Limberg’s procedure

(Ann Plast Surg2008;60:420–425)A lthough several local?ap procedures1–14have been de-

scribed for the closure of circular skin defects,alternative techniques are still needed because the shape,size,and anatomic location of these defects vary in a wide spectrum. An ideal?ap procedure for the closure of circular skin defects should provide a tension-free closure with minimal additional healthy skin excision and scarring.Moreover,it should not cause dog ear formation and displacement of the neighboring mobile anatomic landmarks.To achieve these goals,we devel-oped a new technique namely“the reading man procedure”for the closure of circular skin defects.Here,we present our 3years of clinical experience with the use of this new technique for treatment of the circular skin defects located on various parts of the body.

Surgical Technique

In this technique,2skin?aps designed in an unequal Z-plasty manner are used.Before planning the?aps,we need to determine the relaxed skin tension lines(RSTL)at the defect area.To obtain a better resultant scar aligned with the relaxed skin tension lines,the central limb should be placed perpendicular to these lines(Fig.1B).Once its direction is decided,the central limb of the unequal Z-plasty is drawn as an imaginary tangential line passing through the margin of the circular defect(Fig.1C).The length of the central limb of the Z-plasty is designed to be50%longer than the diameter of the circular defect.Beginning from the free end of this line another imaginary line is drawn with an angle of60degrees (Fig.1D).Then beginning from the other end of the central limb our third imaginary line is drawn with an angle of45 degrees(Fig.1E).With this design,2skin?aps(f1and f2) are obtained(Fig.1E).The?aps are elevated as either pure cutaneous or fasciocutaneous as required in consideration with the anatomic location of the defect.After?ap eleva-tion,the f1is moved to the defect area whereas the f2is transposed to cover the?rst?ap’s donor site(Fig.1E).A suction drain is placed beneath the skin?aps as required and the skin closure was done in a2-layered fashion(Fig. 1F).

Clinical Material

Over3years,“the reading man procedure”was suc-cessfully used in27cases aged from2months to68years in our clinic.It was used for the closure of skin defects resulted from excision of the skin cancers located at facial area in15 patients and on the trunk in3patients.The technique was used after excision of large benign facial skin lesions in other

Received March21,2007and accepted for publication,after revision,May

31,2007.

From the Department of Plastic and Reconstructive Surgery,Gaziantep

University School of Medicine,Gaziantep,Turkey.

Presented in the10th Congress of the European Society of Plastic,Recon-

structive and Aesthetic Surgery;August30to September3,2005;

Vienna,Austria.

Reprints:Mehmet Mutaf,MD,Universite PTT Subesi,PK.6,Gaziantep,

Turkey.E-mail:doctormutaf@http://m.wendangku.net/doc/c609d7fc8762caaedd33d4f9.html.

Copyright?2008by Lippincott Williams&Wilkins

ISSN:0148-7043/08/6004-0420

DOI:10.1097/SAP.0b013e31812f5aa0

Annals of Plastic Surgery?Volume60,Number4,April2008 420

3patients and a calf defect resulted from excision of a giant nevus in 1patient.In the remaining 5patients,it was used for the closure of the ?ap donor site defects on the extremities.The defect sizes were ranging 1.5to 14cm in diameter.Fifteen patients were operated under general anesthesia while the procedure was done with local in?ltration anesthesia provided with 1%lidocaine solution in the remaining 12

patients.All patients were operated by M.M.or under his supervision.

RESULTS

In all patients,a successful tension-free closure of the defect was obtained.Except 5patients who required a min-imal amount of additional healthy skin excision from the tips of the ?aps,defect closure was achieved without any addi-tional healthy tissue excision in all patients.There was no patient with dog ear formation.This technique was found to be useful for closure of the skin defects up to 14cm in diameter in this clinical series.All patients healed unevent-fully with no ?ap necrosis or infection.Because the defects were closed with alike neighboring skin,an excellent skin match was obtained.A mean follow-up of 15months (6months–3years)revealed a durable skin coverage with ?ne scars in all patients.There was no patient requiring secondary surgery.

Illustrative Case Reports Case 1

A 3-year-old boy referred to our department with mul-tiple giant hairy nevi occupying various regions of his body.He underwent a multistaged excision protocol.A reading man procedure was used for the treatment of a giant hairy nevus located at the left calf region.While planning the reading man procedure,a smaller nevus located near the defect was included within the incision (Fig.2A).Excision of the hairy nevus located on his left calf was resulted with a defect of 8cm in diameter (Fig.2B).The ?aps are elevated subfascially and the defect was closed with trans-position of the ?aps in a Z-plasty manner (Fig.2C).Despite it was a remarkably large defect involving the whole width of the calf,a tension-free closure was achieved.Defect closure was done with no

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additional

FIGURE 1.Illustration showing surgical technique.A,Circu-lar defect.B,Determining the direction of the central limb of the Z-plasty (dotted lines).To obtain a fine scar,this line should be perpendicular to the relaxed skin tension lines (RSTL).C,The central limb of the Z-plasty is drawn as an imaginary tangential line passing through the margin of the circular defect.D,E,Other limbs of Z-plasty are planned with angles of 45degrees and 60degrees according to un-equal Z-plasty concept.E,Flap nearby the defect (f 1)is used for the defect closure whereas other flap (f 2)is transposed for closure of donor site of first flap with Z-plasty maneuver.F,The final view after defect

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closure.

FIGURE 2.Case 1.A 3-year-old boy with multiple giant hairy nevi occupy-ing various regions of his body.A,Surgical plan for the treatment of a giant hair nevus located at the left calf.B,An excisional defect of 8cm in diameter.C,Immediate postoperative view.D,Late postoperative views at 2years after surgery.

Annals of Plastic Surgery ?Volume 60,Number 4,April 2008The Reading Man Procedure

healthy tissue excision and dog ear formation.The ?aps healed uneventfully.At 2years after surgery,the result was esthetically acceptable (Fig.2D).

Case 2

A 53-year-old man presented with a basal cell carcinoma located on his right preauricular region.Under local in?ltration anesthesia with 1%lidocaine solution,lesion was excised with 5mm of free margin.The resultant defect was found to be 3cm in diameter (Fig.3A).Defect closure was accomplished with the reading man procedure (Fig.3B,C).At 1year after surgery,there was no recurrence and the ?nal scar was almost invisible (Fig.3D).

Case 3

A 57-year-old man admitted to our institution with a large squamous cell carcinoma on his right heel.Under general anesthesia lesion was excised and the defect area was covered with a free sensate sartorius perforatory ?ap 15har-vested from his left thigh.The donor site of the sartorius ?ap was 11cm in diameter (Fig.4A).The defect was planned to be closed with this newly designed technique (Fig.4B).The

?aps were elevated fasciocutaneously.By transposition of the ?aps,a tension-free closure was achieved without any extra healthy skin excision and dog ear formation (Fig.4C,D).There were no postoperative complications,such as circula-tory compromise and infection (Fig.4E).The scar was ?ne at 11/2years postoperatively.

Case 4

A 68-year-old woman with a round-shaped nodular squamous cell carcinoma located at the malar region (Fig.5A).Under local in?ltration anesthesia with 1%lidocaine solution,the tumor was excised with 1cm of intact margin (Fig.5B).The closure of the resultant defect was accom-plished with the reading man procedure (Fig.5B,C).The ?aps healed uneventfully and an esthetically acceptable scar was achieved (Fig.5D).

DISCUSSION

In this study,a new technique for the closure of circular skin defects is presented.The technique was named “the reading man procedure”because its design resembles

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the

FIGURE 3.Case 2.A 53-year-old man with a basal cell carcinoma on his right preauricular region.A,Excisional defect.B,Elevation of the flaps.C,Immediate postoperative view.D,Postoperative view of the patient at 1year af-ter surgery.

Mutaf et al Annals of Plastic Surgery ?Volume 60,Number 4,April 2008

silhouette of a man who is reading a book held in his hand.This technique basically uses extra skin relaxation provided with an unequal Z-plasty maneuver in favor of the defect http://m.wendangku.net/doc/c609d7fc8762caaedd33d4f9.htmle of Z-plasty principle for defect closure is not

new.Up today,many local ?ap procedures including the note,10banner,5Limberg,3Dufourmentel 2and double oppos-ing semicircular ?aps,13and the double-z rhomboid tech-nique 8used Z-plasty principle for the closure of circular

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skin

FIGURE 4.Case 3.A 57-year-old man presented with a large squamous cell carcinoma on his right heel.Lesion was excised and the defect area was covered with the free sartorius perfo-ratory flap harvested from his left thigh.The reading man flap was

planned for the donor site closure.A,Circular skin defect with a diameter of 11cm.B,Surgical plan.C,Flap eleva-tion.D,Immediate postoperative view.E,Postoperative view of the pa-tient 11/2year after

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surgery.

FIGURE 5.A 68-year-old woman with a round-shaped nodular squamous cell carcinoma lo-cated on her malar region.A,Surgical plan.B,Excisional defect and flap incisions.C,Immedi-ate postoperative view.D,Postoperative view at 1month after surgery.

Annals of Plastic Surgery ?Volume 60,Number 4,April 2008The Reading Man Procedure

defects.Among them,the Limberg ?ap 3seems to be the ?rst local ?ap procedure in which Z-plasty concept is used for defect closure.In this old and still useful technique,the defect is surgically converted into a rhomboid with a considerable amount of additional healthy skin excision and closed by means of an unequal Z-plasty with angles of 60degrees and 120degrees.Positioning one of the lateral limbs of the Z-plasty on the defect margin,the Limberg’s technique de-livers only one skin ?ap.The defect closure is achieved with transposition of this ?ap while the ?ap donor site is closed primarily often under remarkable tension despite undermin-ing and stretching of the wound margins.In the Dufourmen-tel,2banner,5and note ?ap 10techniques,Z-plasty principle is also used in a similar way and the defect is closed by means of a single transposition ?ap.In our technique,however,Z-plasty principle is used in a quite different way.Planning the Z-plasty separately on the neighboring skin and keeping all limbs of Z-plasty apart from the wound margins,2skin ?aps are obtained.One of these ?aps is used for the defect closure and the other one is used for the closure of the donor site of the primary ?ap.In our technique,using 2skin ?aps,

the amount of tissue relaxation provided by Z-plasty maneu-ver is maximized and the defect closure is achieved with a remarkably lesser tension as illustrated with a comparative sponge model study shown in the Figure 6.Moreover,in contrast with the Limberg’s procedure in which tissue is borrowed from 1direction only,our technique borrows tissue from 2directions.Thus,it distributes tension and causes a lesser tissue distortion and displacement of the neighboring mobile anatomic landmarks.

Another criterion to evaluate the ef?ciency of the defect closure techniques is the length of the resultant scar.Earlier techniques including double opposing semicircular ?ap,13double-z rhomboid 8and double rotation ?aps,and Z-plasty procedures 9result in a considerably long scar which extends up to 5to 11times the defect diameter.However,in our technique the length of the resultant scar is only 4times longer than the defect diameter.This length is equal with the scar resulted with the Limberg’s procedure.

Golomb and Neuman,16comparing various local ?ap procedures in an experimental model,stated that the ef?-ciency of a technique for the closure of a circular defect

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was

FIGURE http://m.wendangku.net/doc/c609d7fc8762caaedd33d4f9.htmlparative sponge model study of the reading man and Limberg’s procedures.Borrowing tissue from 2directions,unlike Lim-berg’s technique,the reading man procedure results in minimal distortion and displacement of the neighboring mobile anatomic

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structures.

FIGURE 7.Metric analysis of the reading man and Limberg’s procedures.The amount of ad-ditional healthy skin excision is 10mm 2in our technique whereas it is 26mm 2in the Lim-berg’s procedure.

Mutaf et al Annals of Plastic Surgery ?Volume 60,Number 4,April 2008

inversely related with the amount of the healthy tissue ex-cised during the procedure.However,most of the previously reported closure techniques much or less require some addi-tional healthy skin excision either for the alteration of de-fect’s shape2,3,6–8or to convert the?aps into the shape of the defect.5,10,13,14Although it requires some additional healthy tissue excision in the paper and sponge models,the amount of additional healthy tissue excision in our technique is consid-erably lesser in comparison with those procedures converting the defect in a rhomboid as documented with a metric analysis shown in the Figure7.As a matter of fact,the results of these model studies cannot re?ect the clinical circum-stances properly.Despite the defect closure was achieved with no additional healthy tissue excision in most of our patients,there was no patient with dog ear formation in our clinical series presumably due to elastic nature of the human skin.

In conclusion,the reading man procedure seems to be an easy going and useful alternative for the closure of circular skin defects with different sizes and locations.

REFERENCES

1.Zimany A.The bi-lobed?ap.Plast Reconstr Surg.1953;11:424–434.

2.Dufourmentel C.Le fermeture des pertes de substance cutanee limitees.

Le lambeau de rotation en L pour losange dit LLL.Ann Chir Plast.

1962;7:60–66.

3.Limberg AA.Design of local?aps.In Gibson T,ed.Modern Trends in

Plastic Surgery.2nd ed.London:Butterworth;1966;38–61.

4.Trevaskis AE,Rempel J,Okunski W,et al.Sliding subcutaneous

pedicle?aps to close a circular defect.Plast Reconstr Surg.1970;

46:155–157.

5.Masson JK,Mendelson BC.The banner?ap.Am J Surg.1977;134:419–

423.

6.Becker H.The rhomboid-to-W technique for excision of some skin

lesions and closure.Plast Reconstr Surg.1979;64:444–447.

7.Borges AF.The rhombic?ap.Plast Reconstr Surg.1981;67:458–466.

8.Cuono CB.Double Z-plasty repair of large and small rhombic defects:

the double-Z rhomboid.Plast Reconstr Surg.1983;71:658–667.

9.Golomb FM.Closure of the circular defect with double rotation?aps and

Z-plasties.Plast Reconstr Surg.1984;74:813–816.

10.Walike JW,Larrabee WF.The note?ap.Arch Otolaryngol.1985;111:

430–433.

11.Campus GV,Lissia M,Pancrazi E.The ampli?ed sliding?ap.Ann Plast

Surg.1993;31:318–321.

12.Ono I,Gunji H,Sato M,et http://m.wendangku.net/doc/c609d7fc8762caaedd33d4f9.htmle of the oblique island?ap in excision

of small facial tumors.Plast Reconstr Surg.1993;91:1245–1251. 13.Keser A,Se?nso¨z O¨,Mengi AS.Double opposing semicircular?ap:a

modi?cation of opposing Z-plasty for closing circular defects.Plast Reconstr Surg.1998;102:1001–1007.

14.Ulusoy GM,Akan I˙M,?Senso¨z O¨,et al.Bilateral,extended V-Y

advancement?ap.Ann Plast Surg.2001;46:5–8.

15.Mutaf M,Bulut O¨,I?s?k D,et al.A new perforator?ap:sartorius

perforator?ap.Oral presentation at:The28th Turkish National Congress of Plastic,Reconstructive and Aesthetic Surgery;September20–23, 2006;Ankara,Turkey.

16.Golomb FM,Neumann CG.An experimental method for comparing

primary closures of skin defects.Plast Reconstr Surg.1958;22:194–203.

Annals of Plastic Surgery?Volume60,Number4,April2008The Reading Man Procedure

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