V-to-Y-plasty

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

The V-to-Y-plasty is an easy-to-learn technique commonly used in plastic surgical practice. In this technique, an incision is made in a triangular pattern, and the triangular-shaped flap is advanced to cover the defect in the Y shape. The double V-to-Y-plasty involves a fusiform-shaped incision with two triangular-shaped pedicles that are advanced to the center of the defect and closed in the shape of two Ys, with the upper arms connected. The V-to-Y-plasty is an island pedicle flap. Although most local flaps rotate into a wound from nearby tissues, bringing the blood supply with the intact portion of the flap, island pedicle flaps receive the blood supply from below, in the capillaries immediately beneath the dermis. This capillary supply must not be disrupted by undermining the tissue when creating an island pedicle flap. 
Although the V-to-Y-plasty is a common procedure in covering skin defects, it has limited use in areas of poorer subcutaneous blood flow, such as the lower extremities. It works very well on the face, neck, and back. The V-to-Y-plasty may also be used to repair fingertip amputation, in which case the V-to-Y-plasty flap technique works best when the injury leaves more pulp than nail bed. The V-to-Y-plasty technique preserves the normal contours of the dorsal finger, helps pad the fingertip, and preserves normal sensation. It allows most patients to regain sensation and two-point discrimination in the fingertip. The cosmetic results are usually excellent, with good contour and fingertip padding preserved. 
The V-to-Y-plasty may also be used to alleviate the tension caused by a contracted scar in the skin or on a skin structure. In this scenario, the arms of the Y are cut around the contracted scar and away from the skin area or structure being distorted. The V flap is not undermined or moved, but natural tissue recoils will pull the lesion so as to relieve tension in the skin. Then the Y-shaped suture line is created. 

Equipment

  • Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.

  • Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.

Figure 1
Figure 1

Indications

  • Closure of skin defects that require minimal skin removal, or where skin may be under tension from a variety of directions.

Contraindications (Relative)

  • Poor blood flow areas

  • Uncooperative patient

  • Wounds best closed by other methods

  • Presence of cellulitis, bacteremia, or active infection

The Procedure

Step 1

The layout of the double V-to-Y-plasty is based on the fusiform excision. Measure and mark the extent of the excision, including appropriate surgical margins (see Appendix D). Lay out the fusiform shape with the usual 3:1 length-to-width ratio, with the long axis parallel with the lines of least skin tension (see Appendix B: Lines of Lesser Skin Tension (Langer)). Square the ends of the planned triangular flaps. 

Step 2

Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). Incise the outline of the fusiform incision. Skin incisions are made through the full thickness of the skin. Do not undermine the flap itself, because the blood supply for this island pedicle flap comes from the pedicle beneath. The flap based on the fusiform shape usually has enough mobility to allow for closure of the defect. 
  • Pearl: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 3

Finish excising the lesion (with its surgical margins) by making two straight incisions perpendicular to the long axis of the fusiform. 

Step 4

Remove the specimen and place in a specimen container to send it for pathologic examination. Clamp or tie off any bleeding at the base of the excision. 
  • PITFALL: Bleeding from the flap base will impede healing and promote flap necrosis.

Step 5

Make sure the dermis around the pedicles is completely bisected. 
  • PITFALL: Do not undermine the flap itself, because the blood supply for this flap comes from the pedicle beneath. If the pedicle is undermined for any reason, convert the procedure to a fusiform excision.

Step 6

Start the closure by suturing the two straight margins together in the center of the defect using a simple interrupted suture or vertical mattress suture. See Simple Interrupted Suture and Vertical Mattress Suture Placement
  • Pearl: The use of loupe magnification may assist the performance of this technique; a 4-0 to 5-0 suture will produce fewer suture marks.

Step 7

Place corner sutures on both ends of the newly joined central island. See Corner Suture
  • PITFALL: Make sure to maintain the same depth in the dermis throughout each corner suture.

Step 8

Place two additional corner sutures at the tips of the triangular flaps and use simple interrupted sutures to finish closing the incisions. Dress with antibiotic ointment and a bandage. 

Step 9

For a fingertip repair, perform a digital block (see Digital Nerve Block Anesthesia) and débride any devitalized tissue. Smooth or trim any protruding bone using a rongeur. Create a triangular-shaped flap (as described previously) with the base of the flap at the cut edge of the skin where the amputation occurred. Advance the flap over the defected area and suture it to the nail bed with either 5-0 or 6-0 nylon sutures. Then suture the flap as described previously. 
  • Pearl: The flap should be as wide as the greatest width of the amputation.

Step 10

To alleviate the tension caused by a contracted scar, cut the arms of the Y around the contracted scar and away from the skin area or structure being distorted. The V flap is not undermined or moved but allowed to recoil to relieve tension in the skin. 
Then the Y-shaped suture line is created as described before. 
Step 10
Step 10

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

  • Tissue sloughing, usually due to excess tension or the blood supply being disrupted by undermining

  • Sensory changes, which often subside with time

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. 

Postprocedure Instructions

Have the patient keep the bandage on and the wound dry for the first 24 hours. After that, it can be cleaned with hydrogen peroxide or gently washed with soap and water as needed. An antibiotic ointment and bandage should be reapplied until the patient returns or for 2 weeks. Have the patient report signs of infection. Schedule a return appointment for suture removal (see Appendix J). 

Coding Information

These codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-to-Y-plasty, rotation flaps, advancement flaps, and double-pedicle flaps. When applied to traumatic wounds, the defect must be developed by the surgeon because the closure requires it, and these codes should not be used for direct closure of a defect that incidentally results in the configuration of one of the flaps or plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes. All of the following codes are for adjacent tissue transfer or rearrangement, and they refer to defects in the trunk or the following sites: scalp, arms, or legs (SAL); forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet (FCCMNAGHF); and eyelids, nose, ears, or lips (ENEL). 

Bibliography

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