Ideas and Innovations

The Cone Flap: A New and Versatile

Fasciocutaneous Flap
Wilfredo Caldern, F.A.C.S., Patricio Andrades, M.D., Patricio Leniz, M.D., Ph.D.,
Jos Luis Pieros, M.D., Sergio Llanos, M.D., Ricardo Roa, M.D., and Osvaldo Irribarren, M.D.
Santiago, Chile
Fasciocutaneous flaps have enjoyed consid-
erable success in both the clinical and experi-
mental fields.
1,2
One of the most difficult areas
of the body to repair is the distal lower extrem-
ity, especially when bone is exposed. In these
cases, local myocutaneous flaps, muscular
flaps, microsurgery, and cross-leg flaps have
historically been utilized to obtain a durable
closure.
3
Fasciocutaneous flaps have been dem-
onstrated to be reliable, simple, and fast surgi-
cal solutions for moderate distal lower extrem-
ity defects.
413
From our point of view, the
problem with these flaps is how to close the
donor site. The purpose of this report is to
show our experience with a novel procedure
for direct closure of the donor site of fasciocu-
taneous flaps using a combined technique of a
rotation flap and a classic V-Y advancement
flap.
PATIENTS AND METHODS
From August of 2000 through June of 2002,
25 patients were operated on by the staff of the
Department of Plastic Surgery of the Hospital
del Trabajador, in Santiago, Chile. All the pa-
tients were men (age range, 20 to 52 years)
with exposed bone (tibia) in the distal portion
of the leg, with traumatic defects ranging from
2 to 5 cm in diameter and no osteomyelitis.
1
Success in the lower extremity was followed by
application to other parts of the body, includ-
ing the elbow (two patients), plantar region
(four patients), great toe (one patient), arm
(one patient), nose (one patient), and calvaria
(two patients). In total, this represents a series
of 36 cases. All patients were evaluated clini-
cally and photographically at 1-year follow-up.
The surgical technique consisted of a rota-
tion fasciocutaneous flap to cover the primary
defect and a V-Y fasciocutaneous flap to close
the donor site (Fig. 1). To obtain good ad-
vancement of the V-Y flap, we cut the fascia to
the underlying muscle, all around the V flap.
This allowed for good flap advancement and
complete coverage of the defect created by the
rotation flap. Both flaps are classified as Cor-
mack and Lamberty type A.
14
RESULTS
All the flaps survived completely, despite su-
tures under tension in some patients. All of the
patients with lower extremity flaps walked after
5 days with elastic support. There was no skin
necrosis in our series. The wounds healed well,
without dehiscence, and scarring was minimal.
There was no significant long-term edema or
pain, and postoperative sensation remained in-
tact (Figs. 2 through 4).
DISCUSSION
When a skin defect is present in the distal
portion of the leg, closure is not easy because
this area is marginally perfused, the skin is thin
and tight, and the defect is frequently associ-
ated with an underlying fracture. The surgical
options for skin coverage of the distal leg may
include muscular, myocutaneous, neurocuta-
neous, fasciocutaneous, and free flaps.
3
Fascio-
cutaneous flaps have been demonstrated to be
safe and reliable in the coverage of small de-
From the Department of Burn and Plastic Surgery, Hospital del Trabajador and the Plastic and Reconstructive Surgery Unit, Clinical Hospital
J. J. Aguirre, University of Chile School of Medicine and Diego Portales University. Received for publication November 3, 2003; revised February
12, 2004.
DOI: 10.1097/01.PRS.0000138754.97774.08
1539
fects in this area.
68
Their vascularity has been
studied extensively,
9
and they have the great
advantage of preserving sensitivity.
4,5
Unfortu-
nately, they are not useful in larger defects,
they are less resistant to infection than muscu-
lar flaps are,
2
and they always leave a complex
donor-site defect.
Usually, the donor-site defect of a fasciocu-
taneous flap is repaired with a partial-thickness
skin graft. This type of repair leave poor skin
coverage, with frequent ulceration, loss of sen-
sitivity, skin retraction, pigmentation, and hy-
pertrophic scars.
15
A good option for avoiding
these complications is to use another flap for
donor-site coverage.
1618
A fasciocutaneous flap
for closure of this donor site is preferable be-
cause it has better vascular security and a better
FIG. 1. Cone flap design. (Left) Original defect and rota-
tion flap design. (Center) Rotation of flap and V-Y advance-
ment flap design for secondary defect coverage. (Right) Final
result.
FIG. 2. (Above, left) Small defect of the lower leg and bone exposure. (Above, center and right) Intraoperative views
of cone flap elevation. (Below) Immediate and long-term results are shown.
1540 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004
mobilization rate. In addition, it decreases the
use of other, lower-quality or more complex
coverage options, and it offers better aesthetic
results and restored sensitivity. In this respect,
the V-Y advancement flap has been the most
used for these purposes.
1921
A local fasciocutaneous flap alone can be
used in small lower extremity defects that per-
mit primary closure of the donor site. The
cone flap expands this indication to larger
lesions under the same principles. It should
not be used in small defects because one flap
could be enough. It is also not indicated in
large defects because they are usually associ-
ated with infection and comminuted fractures
and no skin is available. For these reasons, the
best indications are medium-size defects (5 to
10 cm) with adequate surrounding tissue, sim-
ple underlying fractures, and lower grades of
contamination.
In this work, we present a new alternative for
donor-site closure of a rotation flap with a V-Y
advancement flap. We named it the cone flap
because of the final shape that results after the
surgery. It is a simple and easy-to-learn tech-
nique that is useful in the coverage of small to
medium-size defects in the distal leg and other
locations. Preserving all the fasciocutaneous
characteristics, the cone flap has a low compli-
cation rate and adequate long-term results.
The disadvantages are the suture tension and
the fact that it is not indicated in larger or
infected defects. We recommend this easy tech-
nique, as we have improved our surgical times
and complication rates with good patient
acceptance.
Wilfredo Caldern, M.D.
Hospital del Trabajador
Ramn Carnicer 185-5 Piso
Providencia, Santiago, Chile
ghtwco@gw.achs.cl
ACKNOWLEDGMENT
We thank Dr. Luis Vasconez for reviewing and improving
our manuscript.
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FIG. 3. Another distal medium-size leg defect (above)
treated with the cone flap technique. (Center) Rotation flap,
V-Y flap design, and (below) long-term results are shown.
Vol. 114, No. 6 / THE CONE FLAP 1541
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FIG. 4. (Left) Medium-size lesion on the right foot. (Center panels) Cone flap design, intraoperative and immediate postop-
erative views. (Right) Long-term results.
1542 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004