BASIC/CLINICAL SCIENCE
Outcomes of Wound Closure with the Reading Man Flap Technique Justinus A. Wagner, Jan C. Simon, Tino Wetzig, and Michael Kendler Background: In dermatologic surgery, numerous flap types have been described for wound closure after skin cancer surgery. The reading man flap was first published in 2008 for the closure of skin defects of the face, trunk, and extremities. Technically, this flap is based on an asymmetrical Z-plasty. Objective: To investigate the feasibility, clinical outcomes, and postoperative complications for wound closure with the reading man flap technique. Methods: We treated seven patients (facial and extremity defects) after microscopically controlled surgery using the reading man flap technique. The median defect size was 491.71 mm2. All of the patients were treated under tumescent local anesthesia. Results: A tension-free defect closure was created in all patients. One minor complication, a wound infection on one leg, was observed. Conclusion: The described technique is an easy and safe dermatologic surgery procedure that can be performed under local anesthesia. Contexte: En chirurgie dermatologique, on a recours a` de nombreux types de lambeau pour proce´der a` la fermeture de plaies apre`s une ope´ration pour un cancer de la peau. La description du lambeau en Z asyme´trique a e´te´ publie´e pour la premie`re fois en 2008 pour le comblement de pertes de substance cutane´e de la face, du tronc, et des membres. Du point de vue technique, il s’agit d’un lambeau qui ressemble a` ceux utilise´s dans la plastie en Z mais qui est asyme´trique. Objectif: L’e´tude visait a` e´valuer la faisabilite´, les re´sultats cliniques, et les complications postope´ratoires de la fermeture de plaies a` l’aide de ce type de lambeau asyme´trique. Me´thode: Sept patients (pertes de substance de la face et de membres) ont e´te´ traite´s a` l’aide de cette technique apre`s une intervention chirurgicale micrographique. La surface me´diane de la perte de substance e´tait de 491.71 mm2. Tous les patients ont e´te´ traite´s sous anesthe´sie locale par tumescence. Re´sultats: L’intervention a produit une fermeture exempte de tension chez tous les patients. Une complication mineure, soit une infection de la plaie sur une jambe, a e´te´ observe´e. Conclusion: Il s’agit d’une technique suˆre et facile en chirurgie dermatologique, qui peut s’effectuer sous anesthe´sie locale.
HE READING MAN FLAP DESIGN was first published in 2008 for the closure of circular skin defects of the face, trunk, and extremities.1 In brief, two flaps designed in an uneven Z-plasty manner are used. The first flap is transposed to the defect area, and the second flap is used to close the first flap’s donor site. The flap’s name, ‘‘the reading man,’’ was given because its sketch
T
From the Department of Dermatology, Venerology and Allergology, University of Leipzig, Leipzig, Germany. Address reprint requests to: Justinus A. Wagner, MD, Department of Dermatology, Venerology and Allergology, University of Leipzig, PhilippRosenthal-Str. 23, 04103 Leipzig, Germany; e-mail: justinus.wagner@ medizin.uni-leipzig.de.
DOI 10.2310/7750.2013.12090 # 2013 Canadian Dermatology Association
384
design looks like a man who is reading a book (Figure 1). In summary, this technique is a skin-saving procedure. In addition to a minimal triangular excision, the reading man flap results in minimal displacement of the neighboring mobile anatomic structures.1 Because of these advantages, we performed the reading man flap technique for the closure of medium-sized defects after surgery for tumors of the skin in different locations (head, neck, and leg). We investigated the feasibility, clinical outcomes, and postoperative complications.
Methods We treated seven patients with circular facial and extremity defects after microscopically controlled surgery.2 All patients were treated under tumescent local anesthesia
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
Use of the Reading Man Flap Technique in Dermatologic Surgery
Figure 1. Left: Flap design like a ‘‘reading man’’; Middle: Two flaps are designed in an uneven Z-plasty manner. Flap ‘‘B’’ is used to close the defect, ‘‘D,’’ whereas ‘‘A’’ is transposed to close the donor site. Right: Final result after flap transposition. Adapted from Mutaf et al.1
(TLA) using the following ingredients: 430 mL of lactated Ringer solution, 50 mL of 2% lidocaine (Xylocaine, AstraZeneca GmbH, Wedel, Germany), 20 mL of 1% ropivacaine (Naropin, AstraZeneca GmbH), and 0.5 mL of epinephrine diluted 1:1,000,000 (Suprarenin, SanofiAventis, Frankfurt, Germany) were combined in a total volume of 500 mL.3 In general, regular local anesthesia can also be used. After appropriate disinfection, we identified the relaxed skin tension lines and subsequently marked the lines of the reading man flap (see Figure 1). To avoid necrosis, the flap preparations were sufficiently deep to ensure a safe vascular supply. Flap ‘‘B’’ was used to close the wound defect, ‘‘D.’’ The length of the ‘‘upper arm’’ (see Figure 1, middle) of the reading man flap is the central limb of this unequal Z-plasty and should measure 1.5 times the size of the defect’s diameter. The edge angle between lines a and b (see Figure 1, middle) is 60u.4 Flap ‘‘A’’ is transposed to close the donor site (see Figure 1, right). This line is positioned at an angle of approximately 45u to the central line and corresponds to the neck or trunk of our imagined
reading man (see Figure 1, left). This flap is transposed to cover the first flap’s donor site.
Results We treated seven patients (one male and six females), age 60 to 82 years (mean age 75.4 years), with facial and extremity circular defects (mean defect size 491.7 mm2) after microscopically controlled surgery2 for skin cancer. The treated cancers included basal cell carcinoma in four patients, squamous cell carcinoma in two patients, and lentigo maligna melanoma in one patient. The defect sizes ranged from 130 to 1,419 mm2. Patients were followed for 2 to 9 months postoperatively (mean 5.17 months) (Table 1). A tension-free defect closure was performed in all patients. All flaps healed without complications, with the exception of one patient who was treated with cefuroxime (500 mg twice daily) because of signs of clinical infection. Most of the treated tumors were localized to the face, and one was localized to a lower limb (see Table 1).
Table 1. Demographic Data Patient
Age (yr)
1 72 2 74 3 80 4 60 5 82 6 80 7 80 Mean (range) 75.43 (60–82)
Tumor Type
Defect Size (mm)
Location
Complications
Postoperative Follow-up (mo)
BCC SCC BCC LMM SCC BCC BCC
18 3 15 16 3 24 13 3 10 25 3 18 33 3 43 17 3 17 25 3 20 491.71 mm2 (130–1,419)
Cheek Cheek Cervical left Cheek Lower leg Cheek Temporal left
0 0 0 0 Postoperative antibiosis 0 0
5 2 3 4 8 9 * 5.17 (2–9)
BCC 5 basal cell carcinoma; LMM 5 lentigo maligna melanoma; SCC 5 squamous cell carcinoma. *Data missing (patient absent at follow-up).
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
385
Wagner et al
Figure 2. Patient 1. A, Clinical presentation after microscopically controlled surgery and plan for the flap. B, Follow-up after 3 weeks. C, Followup after 5 months.
Discussion Small defects can easily be closed by stretching the skin. However, primary vertical closure of large defects can cause lower eyelid distortion and ectropion. Numerous complications, such as lid retraction, ectropion, dog-ear, and scarring, have been described following wound closure during skin cancer surgery. A good clinical aesthetic outcome is needed, particularly after facial surgery. Microscopically controlled surgery for nonmelanoma skin cancer is the state-of-the-art procedure for cutaneous tumor excision in limited areas, such as the face.2 We performed the reading man flap in seven patients with defects located on the cheeks, lower leg, and cervical regions. The results were excellent. We observed flap swelling and a ‘‘trapdoor’’ phenomenon immediately after surgery; however, this effect recovered spontaneously after approximately 4 months (Figure 2). One patient showed clinical signs of a possible infection (redness and hyperthermia) on his lower leg and received antibiotics. We believe that this infection was not due to the flap technique itself but was instead due to the location and tension of the closure. Wound dehiscence and wound infection can be observed in older patients who have relatively less skin elasticity on the leg. The reading man flap is an easy to use and safe variation of the well-known Z-plasty. Seyhan and Caglar compared this flap to the Limberg and bilobed flaps.5 They have postulated that the reading man flap is the most suitable among these techniques in terms of total scar area and length and suggested that this new flap design can be used to reconstruct malar and infraorbital circular defects with good cosmetic results without creating any traction
386
forces on the eyelids. Additional advantages include the one-stage surgical option, a small dog-ear excision, closure for midsized defects, and the use of TLA or regular local anesthesia. However, disadvantages, including the flap design and its use in difficult anatomic areas, may be encountered.
Conclusion The reading man flap is a semisimple technique for the closure of circular skin defects located on various anatomic regions, particularly the face. This flap procedure allows a tension-free closure of skin defects with minimal scarring.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Mutaf M, Sunay M, Bulut O. The ‘‘reading man’’ procedure: a new technique for the closure of circular skin defects. Ann Plast Surg 2008;60:420–5, doi:10.1097/SAP.0b013e31812f5aa0. 2. Lo¨ser C, Rompel R, Breuninger H, et al. Microscopically controlled surgery (MCS). J Dtsch Dermatol Ges 2010;8:920–5. 3. Wetzig T, Averbeck M, Simon JC, Kendler M. Local anesthesia in dermatology. J Dtsch Dermatol Ges 2010;8:1007–17. 4. Sapountzis S, Park HJ, Kim JH, et al. The ‘reading man flap’ for pressure sore reconstruction. Indian J Plast Surg 2011;44:448–52, doi:10.4103/0970-0358.90819. 5. Seyhan T, Caglar B. ‘‘Reading man flap’’ design for reconstruction of circular infraorbital and malar skin defects. Dermatol Surg 2008;34: 1536–43, doi:10.1111/j.1524-4725.2008.34318.x.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Outcomes of Wound Closure with the Reading Man Flap Technique Justinus A. Wagner, Jan C. Simon, Tino Wetzig, and Michael Kendler Background: In dermatologic surgery, numerous flap types have been described for wound closure after skin cancer surgery. The reading man flap was first published in 2008 for the closure of skin defects of the face, trunk, and extremities. Technically, this flap is based on an asymmetrical Z-plasty. Objective: To investigate the feasibility, clinical outcomes, and postoperative complications for wound closure with the reading man flap technique. Methods: We treated seven patients (facial and extremity defects) after microscopically controlled surgery using the reading man flap technique. The median defect size was 491.71 mm2. All of the patients were treated under tumescent local anesthesia. Results: A tension-free defect closure was created in all patients. One minor complication, a wound infection on one leg, was observed. Conclusion: The described technique is an easy and safe dermatologic surgery procedure that can be performed under local anesthesia. Contexte: En chirurgie dermatologique, on a recours a` de nombreux types de lambeau pour proce´der a` la fermeture de plaies apre`s une ope´ration pour un cancer de la peau. La description du lambeau en Z asyme´trique a e´te´ publie´e pour la premie`re fois en 2008 pour le comblement de pertes de substance cutane´e de la face, du tronc, et des membres. Du point de vue technique, il s’agit d’un lambeau qui ressemble a` ceux utilise´s dans la plastie en Z mais qui est asyme´trique. Objectif: L’e´tude visait a` e´valuer la faisabilite´, les re´sultats cliniques, et les complications postope´ratoires de la fermeture de plaies a` l’aide de ce type de lambeau asyme´trique. Me´thode: Sept patients (pertes de substance de la face et de membres) ont e´te´ traite´s a` l’aide de cette technique apre`s une intervention chirurgicale micrographique. La surface me´diane de la perte de substance e´tait de 491.71 mm2. Tous les patients ont e´te´ traite´s sous anesthe´sie locale par tumescence. Re´sultats: L’intervention a produit une fermeture exempte de tension chez tous les patients. Une complication mineure, soit une infection de la plaie sur une jambe, a e´te´ observe´e. Conclusion: Il s’agit d’une technique suˆre et facile en chirurgie dermatologique, qui peut s’effectuer sous anesthe´sie locale.
HE READING MAN FLAP DESIGN was first published in 2008 for the closure of circular skin defects of the face, trunk, and extremities.1 In brief, two flaps designed in an uneven Z-plasty manner are used. The first flap is transposed to the defect area, and the second flap is used to close the first flap’s donor site. The flap’s name, ‘‘the reading man,’’ was given because its sketch
T
From the Department of Dermatology, Venerology and Allergology, University of Leipzig, Leipzig, Germany. Address reprint requests to: Justinus A. Wagner, MD, Department of Dermatology, Venerology and Allergology, University of Leipzig, PhilippRosenthal-Str. 23, 04103 Leipzig, Germany; e-mail: justinus.wagner@ medizin.uni-leipzig.de.
DOI 10.2310/7750.2013.12090 # 2013 Canadian Dermatology Association
384
design looks like a man who is reading a book (Figure 1). In summary, this technique is a skin-saving procedure. In addition to a minimal triangular excision, the reading man flap results in minimal displacement of the neighboring mobile anatomic structures.1 Because of these advantages, we performed the reading man flap technique for the closure of medium-sized defects after surgery for tumors of the skin in different locations (head, neck, and leg). We investigated the feasibility, clinical outcomes, and postoperative complications.
Methods We treated seven patients with circular facial and extremity defects after microscopically controlled surgery.2 All patients were treated under tumescent local anesthesia
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
Use of the Reading Man Flap Technique in Dermatologic Surgery
Figure 1. Left: Flap design like a ‘‘reading man’’; Middle: Two flaps are designed in an uneven Z-plasty manner. Flap ‘‘B’’ is used to close the defect, ‘‘D,’’ whereas ‘‘A’’ is transposed to close the donor site. Right: Final result after flap transposition. Adapted from Mutaf et al.1
(TLA) using the following ingredients: 430 mL of lactated Ringer solution, 50 mL of 2% lidocaine (Xylocaine, AstraZeneca GmbH, Wedel, Germany), 20 mL of 1% ropivacaine (Naropin, AstraZeneca GmbH), and 0.5 mL of epinephrine diluted 1:1,000,000 (Suprarenin, SanofiAventis, Frankfurt, Germany) were combined in a total volume of 500 mL.3 In general, regular local anesthesia can also be used. After appropriate disinfection, we identified the relaxed skin tension lines and subsequently marked the lines of the reading man flap (see Figure 1). To avoid necrosis, the flap preparations were sufficiently deep to ensure a safe vascular supply. Flap ‘‘B’’ was used to close the wound defect, ‘‘D.’’ The length of the ‘‘upper arm’’ (see Figure 1, middle) of the reading man flap is the central limb of this unequal Z-plasty and should measure 1.5 times the size of the defect’s diameter. The edge angle between lines a and b (see Figure 1, middle) is 60u.4 Flap ‘‘A’’ is transposed to close the donor site (see Figure 1, right). This line is positioned at an angle of approximately 45u to the central line and corresponds to the neck or trunk of our imagined
reading man (see Figure 1, left). This flap is transposed to cover the first flap’s donor site.
Results We treated seven patients (one male and six females), age 60 to 82 years (mean age 75.4 years), with facial and extremity circular defects (mean defect size 491.7 mm2) after microscopically controlled surgery2 for skin cancer. The treated cancers included basal cell carcinoma in four patients, squamous cell carcinoma in two patients, and lentigo maligna melanoma in one patient. The defect sizes ranged from 130 to 1,419 mm2. Patients were followed for 2 to 9 months postoperatively (mean 5.17 months) (Table 1). A tension-free defect closure was performed in all patients. All flaps healed without complications, with the exception of one patient who was treated with cefuroxime (500 mg twice daily) because of signs of clinical infection. Most of the treated tumors were localized to the face, and one was localized to a lower limb (see Table 1).
Table 1. Demographic Data Patient
Age (yr)
1 72 2 74 3 80 4 60 5 82 6 80 7 80 Mean (range) 75.43 (60–82)
Tumor Type
Defect Size (mm)
Location
Complications
Postoperative Follow-up (mo)
BCC SCC BCC LMM SCC BCC BCC
18 3 15 16 3 24 13 3 10 25 3 18 33 3 43 17 3 17 25 3 20 491.71 mm2 (130–1,419)
Cheek Cheek Cervical left Cheek Lower leg Cheek Temporal left
0 0 0 0 Postoperative antibiosis 0 0
5 2 3 4 8 9 * 5.17 (2–9)
BCC 5 basal cell carcinoma; LMM 5 lentigo maligna melanoma; SCC 5 squamous cell carcinoma. *Data missing (patient absent at follow-up).
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
385
Wagner et al
Figure 2. Patient 1. A, Clinical presentation after microscopically controlled surgery and plan for the flap. B, Follow-up after 3 weeks. C, Followup after 5 months.
Discussion Small defects can easily be closed by stretching the skin. However, primary vertical closure of large defects can cause lower eyelid distortion and ectropion. Numerous complications, such as lid retraction, ectropion, dog-ear, and scarring, have been described following wound closure during skin cancer surgery. A good clinical aesthetic outcome is needed, particularly after facial surgery. Microscopically controlled surgery for nonmelanoma skin cancer is the state-of-the-art procedure for cutaneous tumor excision in limited areas, such as the face.2 We performed the reading man flap in seven patients with defects located on the cheeks, lower leg, and cervical regions. The results were excellent. We observed flap swelling and a ‘‘trapdoor’’ phenomenon immediately after surgery; however, this effect recovered spontaneously after approximately 4 months (Figure 2). One patient showed clinical signs of a possible infection (redness and hyperthermia) on his lower leg and received antibiotics. We believe that this infection was not due to the flap technique itself but was instead due to the location and tension of the closure. Wound dehiscence and wound infection can be observed in older patients who have relatively less skin elasticity on the leg. The reading man flap is an easy to use and safe variation of the well-known Z-plasty. Seyhan and Caglar compared this flap to the Limberg and bilobed flaps.5 They have postulated that the reading man flap is the most suitable among these techniques in terms of total scar area and length and suggested that this new flap design can be used to reconstruct malar and infraorbital circular defects with good cosmetic results without creating any traction
386
forces on the eyelids. Additional advantages include the one-stage surgical option, a small dog-ear excision, closure for midsized defects, and the use of TLA or regular local anesthesia. However, disadvantages, including the flap design and its use in difficult anatomic areas, may be encountered.
Conclusion The reading man flap is a semisimple technique for the closure of circular skin defects located on various anatomic regions, particularly the face. This flap procedure allows a tension-free closure of skin defects with minimal scarring.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Mutaf M, Sunay M, Bulut O. The ‘‘reading man’’ procedure: a new technique for the closure of circular skin defects. Ann Plast Surg 2008;60:420–5, doi:10.1097/SAP.0b013e31812f5aa0. 2. Lo¨ser C, Rompel R, Breuninger H, et al. Microscopically controlled surgery (MCS). J Dtsch Dermatol Ges 2010;8:920–5. 3. Wetzig T, Averbeck M, Simon JC, Kendler M. Local anesthesia in dermatology. J Dtsch Dermatol Ges 2010;8:1007–17. 4. Sapountzis S, Park HJ, Kim JH, et al. The ‘reading man flap’ for pressure sore reconstruction. Indian J Plast Surg 2011;44:448–52, doi:10.4103/0970-0358.90819. 5. Seyhan T, Caglar B. ‘‘Reading man flap’’ design for reconstruction of circular infraorbital and malar skin defects. Dermatol Surg 2008;34: 1536–43, doi:10.1111/j.1524-4725.2008.34318.x.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 384–386
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
