RECONSTRUCTIVE SURGERY
A Local Flap That Never Disappoints
V-Y Rotation Advancement Flap
Nezih Sungur, MD,* Yüksel Kankaya, MD,* Koray Gursoy, MD,Þ Utku Can Dölen, MD,* and Uğur Koçer, MD*
Background: There are lots of ways to close a defect according to the recon-
struction ladder. In this article, we would like to share our experience with V-Y
rotation advancement flap on different parts of the body.
Patients and Methods: Between 2006 and 2009, we performed V-Y rotation
advancement flap on 68 patients (average age, 50 years). We performed this flap
for decubitus and neuropathic ulcer on 33 patients, for defect reconstruction
after tumor removal on 29 patients, and for trauma on 6 patients.
Results: The sizes of the defects ranged between 2  2 and 26  16 cm. All
flaps survived without any major complications. Patients were satisfied with
their scar appearance, and no sensory impairment was seen.
Conclusions: V-Y rotation advancement flap restores the defect with a perfect
color match and leaves an aesthetically acceptable scar. With its surgical flexi-
bility and durability, this flap disappoints neither the surgeon nor the patient.
Key Words: V-Y, rotation, advancement, flap, reconstruction, defect, local
(Ann Plas Surg 2013;71: 575Y580)
T here are lots of ways to close a defect according to the recon-
struction ladder. Elliptic excision and simple suture are the most
common and simplest methods. However, in 1974, Argamaso1
pointed out that tissue was displaced from either side during closure
and that may cause disturbing asymmetry in structures such as eye-
brows, lip commissures, and eyelids. To minimize that complication,
he defined V-Y rotation advancement flap which bore the properties of
rotation flap by having a rotation angle of 45 degrees and V-Y ad-
vancement flap. But, it differed from classic V-Y flap by having a
cutaneous pedicle that provided dissection of the base of classic V-Y
advancement flap. That flap ended up with an ‘‘S’’shaped scar and that
was why he named it V-Y-S plasty. Borman and Maral2 used the flap
unilaterally or bilaterally, according to the size of the defect on 15
patients to reconstruct the defects of sacral decubitus ulcer. Demir
et al3 performed V-Y rotation advancement flap on 22 scalp defects.
When we indicated the usefulness of this flap on sacral pilo-
nidal sinus defects in our previous study,4,5 we excluded those patients
with sacral pilonidal sinus and fingertip amputation from this article.
In this article, we would like to share our experience and the excel-
lent results with V-Y rotation advancement flap on different parts of
the body.
Received October 10, 2011, and accepted for publication, after revision, January
14, 2012.
From the *Ankara Training and Research Hospital, 1st Plastic, Reconstructive and
Aesthetic Surgery Clinic, Ankara; and †Balikesir Government Hospital, Plastic,
Reconstructive and Aesthetic Surgery Clinic, Balikesir, Turkey.
Presented at the 29th Congress of National Turkish Plastic Reconstructive and
Aesthetic Surgery Association, 2007, Eskisehir, Turkey, and at the 6th Congress
of Balkan Association of Plastic, Reconstructive and Aesthetic Surgery, 2007,
Kusadasi, Turkey.
Conflicts of interest and sources of funding: none declared.
Reprints: Utku Can Dölen, MD, Safranbolu cad. Urla Sk. No:11 Konutkent-2
Çayyolu, Ankara, Turkey. E-mail: utkuchan@gmail.com.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0148-7043/13/7105-0575
DOI: 10.1097/SAP.0b013e318250ba5d
Annals of Plastic Surgery & Volume 71, Number 5, November 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
MATERIALS AND METHODS
Between 2006 and 2009, we performed V-Y rotation ad-
vancement flap on 68 patients. There were 46 men and 22 women. The
ages of the patients ranged between 15 and 84 years (average,
50 years). Patients underwent surgery either under general anesthesia
or local anesthesia. We performed this flap for decubitus ulcer on 30
patients (20 sacral, 8 trochanteric, and 2 knee); for neuropathic ulcer
on 3 patients (heel); for defect reconstruction after tumor removal
on 29 patients (19 of the patients’ defect were on face, 2 on abdomen,
2 on tibia, 3 on hand dorsum, and 3 on scalp), caused by gunshot injury
on 3 patients (frontal and scalp) and motor vehicle accidents on 3 patients
(knee and hand). Antibiotic prophylaxis (cefazolin 1 g intravenously) was
given before the surgery. If there had been an infection, the surgery
would have been performed after adequate antibiotic treatment.
Sacral Decubitus Ulcer
We covered sacral decubitus ulcer’s defect with bilateral V-Y
rotation advancement flap in 14 patients and unilateral flap in
6 patients. Of these patients, 15 were men and 5 were women. The
size of the defect size ranged between 8  6 and 20  18 cm (mean,
13  10 cm). All the patients were paraplegic because of spinal cord
injury except for 2 children who had meningomyelocele. The ages of
the patients ranged between 8 and 64 years (mean, 35 years).
Operative Technique
Patients underwent surgery in prone position. Operation had
begun after resecting necrotic and granulation tissues that were on
wound margins and also in the deeper layers. Sacral bone was often
involved and could have been seen in the defect’s base. All necrotic
parts and the prominent edges of the bone had to be resected. After the
debridement, flaps were planned and drawn (Fig. 1A). Flap’s pedicles
were planned randomly neither performing any imaging method nor
vessel dissection during surgery to visualize it. If bilateral flap had
been planned, distance between the center of the defect and the flap
corner would have been 1.5 times longer than its horizontal diameter.
We drew imaginary vertical lines passing through the flap’s corner,
short limb of the V, the wound edge, and the center of the defect; and
those lines would divide the imaginary horizontal line between defect’s
center and flap corner into 3 equal parts, which were all equal to the
radius of the defect. If a unilateral flap had been planned, distance from
the midpoint of the defect to the corner of the flap would have been 2
times longer than the horizontal diameter of the defect. These geo-
metric designs were the main rule for all V-Y rotation advancement
flaps that we performed on every part of the whole body. Flap elevation
was started from the defect side after incising the flap borders through
the sacral fascia (Fig. 1B). If the flap had extended to the gluteus
maximus muscle area, it would have been elevated on the gluteus
fascia, leaving the fascia of the muscle intact. The limbs of the V were
incised in a convex manner to include more perforator vessels in the
flap. After having done the back-cut (short limb of the ‘‘V’’), the flap
was advanced and rotated to the defect. Meticular hemostasis was
done before closure, and suction drains were inserted in all cases. If it
had been a unilateral flap, the tip of the flap would have been sutured to
1/3 cephalic part of the defect and the rest would have been closed
directly with half-buried mattress sutures by leaving a longitudinal
suture line. If it had been a bilateral flap, the flap’s tip, the pedicle
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Sungur et al
FIGURE 1. A, Photography of sacral
decubitus ulcer after debridement. B,
Elevation of the flaps. C, Typical ‘‘S’’
shaped suture line
FIGURE 2. Left, Abdominal defect
after bladder cancer surgery.
Center, Planning of the flap. Right,
Postoperative seventh day.
of which was situated caudally, would have been sutured to 1/3
cephalic part of the defect and the other flap’s tip would have been
sutured to 1/3 caudal part of the defect. The rest was closed directly
with half-buried mattress sutures and at the end an ‘‘S’’ shaped
suture line was obtained (Fig. 1C).
Abdomen
Two patients’ abdominal tissue defect was reconstructed with
unilateral V-Y rotation advancement flap. One of the 2 patients was
a 60-year-old woman who has diabetes. Her abdominal defect was
caused by suture dehiscence and infection after a gynecologic
surgery. The patient was followed with dressings and antibiotic for 3
weeks. When the patient was consulted to us, she had a 26  16-cm
tissue defect. The defect was covered with unilateral V-Y rotation
advancement that was harvested above rectus abdominis muscle
fascia. Two suction drains were placed under the flap.
The other patient was a 70-year-old man. He had a bladder
cancer surgery and his laparotomy incision’s sutures could not load
increased abdominal pressure. The patient was followed with
dressings and antibiotic for his abdominal dehiscence. Three weeks
after, his abdominal pressure decreased but primary suture was not
possible in consequence of the retraction of wound’s edges. We
performed unilateral V-Y rotation advancement flap for 25  12-cm
defect and placed 2 suction drains (Fig. 2).
Trochanteric Decubitus Ulcer
The trochanteric ulcer of 8 patients was reconstructed with
unilateral V-Y rotation advancement flap. There were 4 men and 4
women whose ages ranged from 19 to 76 years (mean age, 52 years).
Of these patients, 3 were paraplegic because of spinal cord injury, 4
had cerebral stroke, and 1 could not walk because of myelodysplasia.
The size of the defect ranged between 4  3 and 9  7 cm (average
size, 5  4 cm).
FIGURE 3. Left, View of the trochanteric defect after
debridement. Right, View of the sutured flap.
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Annals of Plastic Surgery & Volume 71, Number 5, November 2013
Patients underwent surgery in lateral decubitus position. Ulcer
debridement was achieved as previously mentioned. The flap size was
calculated in the same way as sacral decubitus ulcer. The flap was
elevated superficial to the muscles fascia by leaving them intact
(Fig. 3). Suction drains were applied in all cases.
Knee
Operations were performed on the knees of 4 patients (3 women
and 1 man). The ages of the patients ranged from 22 to 73 years
(mean age, 52 years). Two patients applied to our clinic after a motor
vehicle trauma. The other 2 patients had decubitus ulcer on their knees.
One patient had bilateral knee decubitus ulcer that was treated with
bilateral V-Y rotation advancement flap. The mean size of the defect
was 4  3 cm (range, 3  3 to 5  4 cm)
In all cases, bilateral flaps were planned from medial and lateral
sides after appropriate debridement. Flaps were elevated superficial
to patellar tendon (Fig. 4A). The leading edges of the flaps were su-
tured in the same way as sacral decubitus ulcer reconstruction. In all
cases, 2 small Penrose drains were inserted and their outer part was
left on medial and lateral sides (Fig. 4B). Then, the drains were taken
out the next day.
Tibia
Two patients underwent surgery because of tibial skin lesion.
There were 2 men who were aged 45 and 72 years. The sizes of the
defects after lesion removal were approximately 3  2 and 5  3 cm.
Bilateral V-Y rotation advancement flaps were planned in a
vertical line from proximal and distal part of tibia. The flaps were
elevated superficial to periosteum (Fig. 5). Penrose drain was placed
before defect closure with simple interrupted sutures. The patients
were advised to elevate their leg while sitting and lying and not to stand
for a long time.
Heel
Operations were performed on the heels of 3 patients (2 men
and 1 woman) because of neuropathic ulcer. A man and a woman have
diabetes and the other man had a spine injury that affected the sen-
sation of his feet. The sizes of the defects were 3  2, 3  3, and 4 
4 cm. A unilateral flap was planned from lateral or medial side of
calcaneus. The flap was elevated above the periosteum. Penrose drain
was placed. Foot elevation was advised.
Hand
Four patients were operated on their hand dorsum with uni-
lateral V-Y rotation advancement flap. There were 3 men and 1
woman. Ages of the patients ranged from 39 to 84 years (Fig. 6). Of
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Annals of Plastic Surgery & Volume 71, Number 5, November 2013
these patients, 3 underwent surgery because of skin lesions (from 2 
1.5 to 4  3 cm) and 1 because of motor vehicle accident (5  4 cm).
In all cases, unilateral flaps were planned from dorsal part of the
hand. The flaps were carefully elevated superficial to paratenon, and
tendon sheets were protected so as not to cause fibrosis that might
restrict tendon movement (Fig. 7). The patient who had a vehicle
accident had primary sutured skin flaps. Two weeks after the accident,
she was referred to our clinic because of her demarcated necrotic skin
on hand dorsum. After resecting the necrotic tissue, the defect was
covered as mentioned. In addition, static rest splint was applied to
decrease the tension on the pedicle and the shear forces caused by wrist
movement.
Face
V-Y rotation advancement flap was performed in 20 patients’
face (10 nasal areas, 3 mental regions, 4 malar regions, and 3 frontal
FIGURE 6. A, Patient, who was 84 years old, had squamous
cell carcinoma on the ulnar part of his right hand. B, Drawing of
the flap. C, Closure of the defect. D, Postoperative third day,
flap is viable despite the parchment-like skin and the lack of
subcutaneous tissue.
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A Local Flap That Never Disappoints
FIGURE 4. Left, Photography of the
decubitus ulcer placed on the knee.
Center, View of the adapted flaps.
Right, Postoperative third month.
FIGURE 5. Left, Excision of a skin
lesion placed on the proximal part
of the tibia and planning of the flap.
Center, Elevation of the flaps. Right,
Intraoperative result.
regions). The flaps harvested from nasal and malar regions were
unilateral, whereas mental and frontal flaps were bilateral. There
were 15 men and 5 women. The patients’ ages ranged between 35
and 67 years (mean age, 48 years). All the defects were caused by
skin lesion excision except frontal defects. One frontal defect was
caused by gunshot injury and the other happened after a motor
vehicle accident. Small Penrose drain was placed in all cases and
removed on the day after.
Nine patients were operated on under local anesthesia and in-
travenous sedation and the rest under general anesthesia. Skin lesions
were resected with adequate healthy margins. The mean defect size
was 3  2 cm (between 2  1 and 5  4 cm).
In the nasal area, the flap was elevated superficial to peri-
chondrium and periosteum; and in the glabellar area, procerus
muscle was left intact. Left or right trochlear artery was kept inside
the flap as a pedicle. After sliding the flap, the defect was closed
with simple interrupted sutures (Figs. 8 and 9).
In the malar area, random unilateral V-Y rotation advancement
flap was planned. Flap was harvested superficial to superficial mus-
cular aponeurotic system.
In the mental region, random bilateral V-Y rotation advance-
ment flaps were planned horizontally. They were elevated superficial
to mental muscle’s fascia (Fig. 10).
In the frontal region, where the defects were caused by a
gunshot injury and a motor vehicle accident, they were first cleaned
from foreign bodies. Necrotic tissues were resected. Operation
could only be performed after being sure of the surrounding tissues’
viability. Random bilateral V-Y rotation advancement flap was
harvested superficial to periosteum, keeping a part of the frontal
muscle inside the flap.
Scalp
Operations were performed on the scalps of 3 patients with
unilateral V-Y advancement flap and 2 patients with bilateral flaps.
There were 3 men and 2 women (age ranged from 28 to 45 years).
Of these patients, 3 underwent surgery because of skin lesions
(from 3  1.5 to 5  4 cm) and 2 because of a gunshot injury
(from 6  4 to 8  6 cm).
In all patients, flaps were elevated superficial to pericranium
through the loose areolar tissue. Suction drains were placed in all
patients. One patient, who was injured by a gunshot, had parietal
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Sungur et al
FIGURE 7. Left, Two skin lesions on hand dorsum and drawing of proximally pedicled V-Y rotation advancement flap. Center,
Elevation of the flap. Right, Intraoperative result.
bone defect (6  5 cm) in addition to skin defect (Fig. 10). After
the debridement, the defect was closed with a unilateral V-Y ad-
vancement flap.
RESULTS
Between 2006 and 2009, 90 V-Y rotation advancement flaps
were performed on 68 patients [bilateral flap on 29 patients (1
patient had bilateral knee decubitus ulcer) and unilateral flap on 40
patients]. The sizes of the defects ranged between 2  2 and 26 
16 cm (mean, 7  4 cm). We did not see any major complications
that could affect flap viability such as flap necrosis, hematoma,
seroma, and infection. Penrose drains were removed the day after
FIGURE 8. A, Basal cell carcinoma situated on the nasal dorsum,
close to the radix. B, Harvest of the left trochlear artery pedicled
flap. C, Closure of the defect. D, Postoperative third month.
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Annals of Plastic Surgery & Volume 71, Number 5, November 2013
the surgery and suction drains were removed postoperative second
or third day. Dressings were changed every other day and sutures
were removed between 7th and 14th postoperative day regarding the
sutured part of the body. The follow-up period was 7 to 21 months
(mean, 13 months). Patients, including the ones who had operations
on their face, were satisfied with their scar appearance. Two-point
discrimination and Semmes-Weinstein monofilament sensory tests
were done during follow-up and no sensory impairment was seen.
Patients who were operated on under local anesthesia were dis-
charged from the hospital on the same day, and patients who had
general anesthesia were discharged between the first and fifth
postoperative day.
DISCUSSION
Defect closure is the principal combat area of plastic surgery.
Whether it is skin or muscle or bone, plastic surgery has various
methods in its armamentarium. Besides, the vital and functional im-
portance of defect reconstruction, cosmetic appearance, and patient
FIGURE 9. A, Plan of the lesion excision and bilateral V-Y
rotation advancement flap. B, Movement of the flaps. C, Closure
of the defect without any dog ear deformity.
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Annals of Plastic Surgery & Volume 71, Number 5, November 2013
FIGURE 10. A, Bone and soft tissue defect on the left parietal
region after gunshot injury. B, Elevation of the flap above the
periosteum, parietal branch of the superficial temporal artery is
visible inside the flap. C, Closure of the defect with simple
interrupted sutures. D, Postoperative first month.
comfort should not be neglected. Therefore, primary skin closure is
mostly preferred to secondary intention to increase patient’s satis-
faction by reducing the need for painful change of the dressing. In
addition, reconstruction with flap is preferred to direct closure, not
only when it is not possible to bring wound edges closer but also to
reduce flap’s tension. Relaxed suture line provides minimal enlarged
scar and ensure flap viability. There are numerous varieties of flaps;
local cutaneous flaps have the perfect color match and its operation
is easier and shorter than distant and free flaps. If attention is paid
to relaxed skin lines during flap design, future scar will be as small
and relaxed as possible.
Local cutaneous flaps are classified as random and axial with
regard to their blood source and also classified as rotational, ad-
vancement (single pedicle, bipedicle, and V-Y flaps), transpositional,
and interpolation according to their geometric design and type of
movement. Advancement flaps advance or linearly slide to cover a
tissue defect. They have the advantage of changing the place of a
portion of the scar that may have been produced by a linear closure.
V-Y advancement flap has been used successfully to cover soft tissue
defects. Various modifications of this flap have been described in
the literature.6Y11
In rotation flaps, adjacent tissue is rotated around a pivot point
(arcuate slide) to cover a defect. Rotation flaps fill 1 defect by creating
another defect that may be closed with less tension or distortion.
Tension is redirected and redistributed.12Y14
When the flap is rotated over a adjacent normal skin area to
cover the defect, it is called transposition flap (Rhomboid,15,16
Webster,17 Dufourmentel flap,18,19 Banner,20 bilobed,21 and tunneled
transposition flap). Like rotation flaps, transposition flap uses the
skin laxity at a site distant to the surgical defect and reorient the
tension of closure. Transposition flaps are generally smaller and more
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A Local Flap That Never Disappoints
mobile than rotation flaps. Resultant scars are geometric broken lines
that may be less conspicuous and could be hidden easily.
Local flaps generally depend on subdermal plexus (random
flap) that needs particular attention to their length/width ratio to keep
the flap viable. If an artery or vein is seen, all the effort must be spent to
include it into the flap that will provide surgeons to harvest larger flaps
with desired shape.
The V-Y rotation advancement flap’s skin incision is shorter
than classic V-Y advancement flap. Advancement helps to reduce the
tension on the pivot point of the classic rotation flap. Similarly, ro-
tation of the flap augments the advancement distance and provides
tension-free coverage of the defect. Because of its laterally placed
pedicle, it could be undermined totally. Despite its larger undermining
than classic V-Y advancement flap, its tension-free closure prevents
dead space. Anyway, in all cases, we used suction or Penrose drains
and we profited from it by not facing any hematoma and seroma
formation. Classic V-Y flap is generally elevated on a known artery, if
it is harvested in a random manner, flap viability is jeopardized re-
gardless of its size. In contrary, V-Y rotation advancement flap gives
freedom to harvest the flap from any area of the body without being
concerned about the presence of an artery inside the pedicle. Its lateral
sided pedicle that contains subdermal plexus, subcutaneous tissue
and, in some cases fascia, provides excessive blood perfusion.
We have already experienced the versatility of V-Y rotation
advancement flap in pilonidal sinus.4 We observed that this flap did
not affect the sensation of the gluteal region. With this study, we could
generalize this finding to whole body because we have not seen any
sensory impairment, pain, or numbness.
Although this flap is not restricted as much as other local flap
types by the general principles of flap surgery (length/width ratio,
tension on the pedicle, dead space under the flap, etc), we used it on
every part of the body easily, from scalp to heel. We did not have any
specific indication or contraindication for this flap. Regardless of the
location, the size, and the depth of the defect, we reconstructed all of
them in the same manner. We found that some criteria such as
patient’s age, general condition, or presence of chronic diseases (eg,
diabetes mellitus and vascular diseases) that could be contraindica-
tion for some local or free flaps, do not interfere with the viability
of the V-Y rotation advancement flap. Because of its simplicity to
teach and its flexibility to practice, if a local flap is needed in our
clinic, V-Y rotation advancement flap is the first choice that comes to
our minds whether the surgeon is a resident or a professor.
CONCLUSIONS
V-Y rotation advancement flap is a very convenient flap that
could be performed by any plastic surgeon, regardless of experi-
ence, in every part of the body, whatever the size of the defect is. It
restores the defect with a perfect color match and leaves an aes-
thetically acceptable scar. With its surgical flexibility and durability,
V-Y rotation advancement flap disappoints neither the surgeon nor
the patient.
REFERENCES
1. Argamaso RV. V-Y-S-plasty for closure of a round defect. Plast Reconstr Surg.
1974;53:99Y101.
2. Borman H, Maral T. The gluteal fasciocutaneous rotation-advancement flap
with V-Y closure in the management of sacral pressure sores. Plast Reconstr
Surg. 2002;109:2325Y2329.
3. Demir Z, Veliddeoglu H, Celebioglu S. V-Y-S plasty for scalp defects. Plast
Reconstr Surg. 2003;112:1054Y1058.
4. Sungur N, Kocer U, Uysal A, et al. V-Y rotation advancement fasciocuta-
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5. Sungur NKY, Yildiz K, Dölen UC, et al. Bilateral V-Y rotation advancement
flap for fingertip amputations. Hand. 2012;7:79Y85.
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Sungur et al Annals of Plastic Surgery & Volume 71, Number 5, November 2013

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pressure sores. Ann Plast Surg. 2001;46:421Y425.
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640Y644.
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flap. Ann Plast Surg. 2001;46:5Y8.
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urfacing. Arch Otolaryngol Head Neck Surg. 1991;117:77Y82.
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cutaneous alar rotation flap. Plast Reconstr Surg. 2009;123:1088Y1095.
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defects in the lower one-third of the nose. Plast Reconstr Surg. 1996;98: 163Y166.
15. Chasmar LR. The versatile rhomboid (Limberg) flap. Can J Plast Surg. 2007;
15:67Y71.
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17. Webster RC, Davidson TM, Smith RC. The thirty degree transposition flap.
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‘‘LLL’’ diamond-shaped L rotation-flap]. Ann Chir Plast. 1962;7:60Y66.
19. Dufourmentel C. [Stag-beetle flap. Sliding island flap with plasty in VY]. Ann
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