Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 133e139

Superior gluteal artery perforator flap in thereconstruction of pilonidal sinus

Tahsin Oguz Acarturk*, Cem K. Parsak, Gurhan Sakman, Orhan Demircan

Department of Plastic, Reconstruction and Aesthetic Surgery, Cukurova University School of Medicine, Adana, Turkiye

Received 9 February 2008; accepted 29 July 2008

KEYWORDSPilonidal sinus;Superior gluteal arteryperforator flap;Natal cleft;Sacral defect

* Corresponding author. Tel.: þ90 536427.

E-mail address: toacarturk@yahoo

1748-6815/$-seefrontmatterª2009Britdoi:10.1016/j.bjps.2008.07.017

Summary Background: Pilonidal sinus is a difficult disease to treat. Many treatment modal-ities from secondary-intention healing to various types of flaps have been used with eachhaving different rates of success.Materials and methods: A perforator flap based on the superior gluteal artery perforators wasdesigned at 45

�-angle to the defect created by the excision of the pilonidal sinus and was trans-

posed in 15 male patients with un-operated chronic pilonidal sinus. Defect and flap size, lengthof surgery, blood loss, time to mobilisation, hospital stay, time of return to work and rate ofcomplications were evaluated.Results: The average defect size in length, width and depth were 6.9 cm, 3 cm and 3 cm,respectively. The cutaneous part of the flaps was exactly the same size as the defect. Theaverage length of surgery was 45 min (sinus excision 10 min, flap harvest 15 min and closure20 min) with blood loss being less than 25 cm3. Patients were mobilised and discharged homethe morning after surgery (less than 24 h). The patients were able to return to normal dailyactivities after 3 days and to work 10 days after the surgery. There were no complicationsand no recurrences at an average of a 10-month follow-up.Conclusion: The superior gluteal artery perforator flap (SGAP) offers many advantages overrandom (better vascularity and flap safety) or larger flaps (decreased operating time anddonor-area morbidity) in the treatment of pilonidal sinus disease. We present our results withthe use of the SGAP flap, which is designed at a 45

�-angle to the defect created by the excision

of the pilonidal sinus. Compared to the previously described techniques, it has the advantageof closing defects of any size within a short surgical time and minimal blood loss. The hospitalstay, time to mobilisation and return to daily activities and work are shortened, in addition tozero complications and recurrence rates.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

2 609 6409; fax: þ90 322 338

.com (T.O. Acarturk).

ishAssociationofPlastic,Reconstruc

Pilonidal sinus is a disease of the sacro-coccygeal regionresulting from the penetration of shed hair shafts throughthe skin, leading to acute and chronic inflammation and

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

134 T.O. Acarturk et al.

infection.1 It is a disease of young adult males, although itcan also be seen in dark-skinned and hirsute females. Eventhough the incidence was reported to be 26 per 100 000,this number may be higher in certain areas of the worldamong people having more body hair.2 The depth of theintergluteal fold and curved anatomic plane of the sacro-coccygeal region is also hypothesised to contribute to thepathophysiology of the disease process. In chronic pilonidalsinus disease, there is recurrent infection and chronicinflammation leading to unstable scarring with gradualspreading of the disease into adjacent soft tissue. Thisresults in multiple sinus openings with continued drainage,leading to significant morbidity.

Various treatment modalities used in the treatment ofthe pilonidal sinus disease (PSD) include incision andcurettage, application of phenol, cryosurgery, excision andprimary closure, marsupialisation, excision with secondary-intention healing, excision with skin grafting, random flapsand musculo-fascio-cutaneous flaps.3,4,5,6,7,8,9,10 Limitedexcision of the sinus tract and diseased tissue with primaryclosure has a recurrence rate between 4% and 42% ina different series.11,12 The recurrent disease presents aneven greater challenge with regards to treatment. A widerexcision of the diseased tissue including some healthytissue has a higher chance of complete eradication of thedisease, but precludes primary closure. Various localrandom flaps have been described (Limberg, Duformental,Z-plasty and W-plasty) to close these defects.6,7,13,14

Although improved recurrence rates have been reportedcompared to earlier methods, the recurrence and compli-cations rates can still be around 6%, with wound compli-cation rates around 15%.14,15 In addition, the post-operativehospital stay and return to daily activities are greatlylimited. More importantly, these random flaps can only beused for small defects. Thus, the general surgeon is limitedby the size of the defect created and the ability for closure.For larger defects and recalcitrant disease, various mus-culo-fascio-cutaneous flaps have been described.8,9,10

Although cure rates are higher, they have the drawbacks ofextensive surgery, such as increased blood loss, extendedhospital stay and healing times.

We present our results with the use of superior glutealartery perforator (SGAP) flap that was designed at 45

�

angle to the defect created by the excision of the pilo-nidal sinus.

Materials and methods

Fifteen patients with a history of primary chronic PSD wereconsecutively treated using the same operative techniqueand the post-operative regimen between October 2006 andJune 2007. Patients having recurrent PSD, which wastreated with prior surgery, and patients having symptoms ofacute exacerbation of the disease with extensive inflam-mation were excluded from the study. All patients wereotherwise healthy males with a mean age of 26 (range 17e36 years). The duration of symptoms was between 1 and 6years (mean 2.5 years). On physical examination, thepatients had one or more draining sinuses with foul smell,dark-brown discolouration of the skin and formation of scartissue.

Surgical technique

Patients were placed in a prone, jack-knife position, andthe gluteal cheeks were spread using adhesive tape. Thesacro-coccygeal area was shaved, cleaned with povidoneiodine and draped in a sterile manner. Methylene blue wasinjected into the sinus tracts, and the area of excision wasmarked as a vertical ellipse to include at least 1 cm ofhealthy tissue circumferentially. Excision was performedwith a knife, and all tissues overlying the pre-sacral fasciawere removed. In some patients where the diseased or scartissue extended laterally, the excision continued into thebuttocks to completely eradicate the disease. Haemostasiswas achieved with bipolar cautery.

The length, width and the depth of the defect in itsgreatest dimensions were measured after the tapes wereremoved. A sterile Doppler ultrasound was used to locatethe SGAP 1 cm lateral from the supero-lateral edge of thedefect (Figure 1a, point P). A line was drawn at a 45

�angle

to the vertical dimension of the defect. The distance fromthe perforator to the distal part of the defect also formedthe distance to the distal end of the flap. The lateralmidline of the edge of the defect was determined(Figure 1a, point D). The maximum width of the defect wasdrawn as a line perpendicular to the long axis of the flap. Anelliptical flap was demarcated by connecting the markedpoints. An important point was the drawing of the proximalend in a semi-rectangular fashion to allow better closurewhen the flap was transposed into the defect. The flap wasraised from distal to proximal including the muscle fasciaby incising the surrounding skin and subcutaneous tissue allthe way down to the muscle fibres. At the proximal one-third of the flap, care was taken not to injure the mainperforator identified on Doppler and several accompanyingsmall perforators. In our first several cases, the flap waselevated on a single, dominant perforator, which wasskeletonised and dissected intramuscularly. As experiencewas gained, direct visualisation, skeletonisation and intra-muscular dissection of the perforator was found to beunnecessary and time consuming, as this did not facilitatethe mobilisation of the flap. However, the location wasconstantly checked by the use of Doppler subcutaneouslyand transcutaneously during the dissection. Since severalminor perforators were identified close to the majorperforator, these were also included in the flap withmeticulous dissection to provide better vascularity. Again,as experience was gained, individual dissection, visual-isation and skeletonisation of these perforators were foundto be unnecessary as the flaps could be transposed easilyonce freed sufficiently from the surrounding soft tissue.The location of these minor perforators was constantlychecked by frequent intra-operative trans-subcutaneousDoppler monitoring, even though they were not directlyvisualised. In addition, when some fat tissue was left inbetween these perforators, kinking on each other duringtransposition was prevented. Between the proximal and themid-medial edge of the flap (Figure 1a point A to D), severalsmall para-sacral nerves (Figure 1a point N) were identifiedand dissected out to be included in the flap. The flap wasthen transposed to the defect and sutured by buriedinterrupted dermal 2/0 vicryl sutures and a single contin-uous subcuticular 4/0 monocryl suture (Figure 1b). The

Figure 1 A) The perforators are identified and marked at the supero-lateral part of the defect [P]. The flap meridian is marked ata 45� angle to the meridian of the defect. The most supero-medial part of the flap is marked approximately 1 cm above the mostsuperior part of the defect. Point D is 50% of the length from A to B. Point D to G forms the greatest width of the flap and is the sameas the width of the defect. In addition, one or more nerves can be identified at around point D. B) The flap is transposed into thedefect, creating a defect at the donor site. First suture is placed at the distal part of the flap [BeC]. Second suture is placed at thesuperior part of that flap. Third is placed at the supero-lateral part of the flap [EeF] C) Point D is sutured to point EF.

Superior gluteal artery 135

order of closure was as follows: (1) the distal edge of theflap was sutured to the distal edge of the defect (Figure 1cpoint C to B) (2) a suture was placed to the supero-lateraledge of the flap to bring it as lateral as possible (Figure 1cpoint E to F), (3) a suture was placed to bring the superioredge of the lower triangular flap just lateral to the superiorpart of the already transposed perforator flap (Figure 1cpoint D to F). The rest of the incisions were closedaccordingly. All of the flaps were performed by the sameplastic surgeon. No drains were used. A clean, steriledressing was placed on the surgical site.

Post-operative care

The patients were immediately allowed to lie on theoperated area (but no longer than 1 h at a time during thefirst 48 h). On the morning after surgery, the patients weremobilised and discharged. They were prescribed an oralfirst-generation cephalosporin for 5 days. They wereallowed to shower in 48 h and to clean the operated areawith soap and water and were advised to keep the area dryand clean afterwards. They were allowed to gradually sitafter 72 h and return to work 10 days after surgery.

Results

Defect and flap size

The average defect was 6.93 cm in length (range 5.5e11 cm), 3.13 cm in width (range 2e5 cm) and 3 cm in depth(range 1.5e5 cm). The average cutaneous area was23.18 cm2 (range 10e55 cm2). The cutaneous part of theflaps was designed exactly the same size as the defects(Figure 2aee). In two cases, extra adipose tissue was

included within the flap to facilitate filling of the asym-metric fat-tissue defect created by the excision of thepilonidal sinus. In one case, the distal half of the flap wasthinned in order to re-surface the gluteal defect withoutcreating a bulky tissue (Figure 3aee).

Time

The average operative time was 45 min (range 35e60 min).The average time for excision was 10 min (range 7e15 min),flap harvest took 15 min (range 7e25 min) and closure took20 min (range 15e25 min). As more experience was gainedin flap harvesting, operative times became shorter.

Blood loss

Blood loss was less than 25 cc, with the majority of the lossbeing during the excision of the pilonidal sinus.

Post-operative course

All patients were mobilised and were discharged homewithin 24 h of surgery. Patients were able to return tonormal daily activities within 3 days and to work within 10days. Once the oedema from the surgery subsided, the flapattained a better contour.

Complications

None of the patients had infection, haematoma, seroma,wound dehiscence or flap necrosis. Patients did notcomplain of pain or discomfort in the operated area. In thelong-term follow-up, the patients stated return of normalsensation to the area. The surgical scar in the region was

Figure 2 A) Instillation of a methylene blue into the sinus. B) Defect after excision of the pilonidal sinus. Note that right supero-lateral edge of the diseased tissue is excised asymmetrically. The dominant perforator is identified with the Doppler and flap isdesigned. C) Elevation of the flap. D) Transposition into the defect. E) The final appearance after closure.

136 T.O. Acarturk et al.

inconspicuous once the hair re-grew, and all patients weresatisfied with the procedure. There were no recurrences ata mean of 10-months follow-up (range 6e12 months).

Discussion

Treatment goals in PSD

The main treatment goal in PSD is complete eradication ofthe disease with no recurrence. This can be provided byadhering to several principles and understanding thepathophysiology of the disease. The first and the mostimportant principle is wide excision of the diseased tissuewith good margins of confidence in order to eradicate thedisease and disease-prone tissue. Thus, the extirpativesurgeon (general surgeon or plastic surgeon) should havethe freedom and comfort of excising a large amount oftissue without the fear of creating a defect that cannot be

closed. Once a large defect is created that cannot be closedsafely with primary closure, flaps have to be used. Thesecond treatment principle is the obliteration and elevationof the natal cleft. A deep intergluteal fold causes sweating,bacterial growth and penetration of the hair shafts due toshear and friction movements of the buttocks. Thus, inorder to obliterate and flatten the deep intergluteal foldand shift the incisions from the midline, flaps can be used.This would avoid maceration and friction. When theseprinciples are taken into consideration, flaps offer lowerrecurrence compared to primary closure, second-intentionhealing, curettage and marsupialisation techniques. Inaddition, treatment with flaps compared to the latter threetechniques resulted in shorter hospital stay, faster healingtimes, fewer office visits, decreased cost and less patientdiscomfort.6,16,17 Thus, in many centres, flaps have becomethe treatment of choice for primary as well as complicatedrecurrent PSD.

Figure 3 A) Asymmetric defect (11� 5� 4.5 cm) after excision of the pilonidal sinus and tract extending into contralateralgluteal cheek. B) Superior gluteal artery perforator flap raised. C) The distal part of the flap which will cover the gluteal defect isprepared thinner and the proximal and middle part of the flap which will cover the deep cavitary lesion is prepared thick. D) Theflap is transposed to the defect. Note the gluteus maximus muscle is uninjured. E) Final appearance. Note that the natal cleft isflattened. The contralateral gluteal defect is contoured without any bulky tissue.

Superior gluteal artery 137

Random flaps

Many flaps have been tried in the closure of defects createdby the excision of pilonidal sinus. Random flaps are oftenused by general surgeons.6,7,13,14 Although better rates ofcure are reported compared to primary closure orsecondary-intention healing, rates of recurrence can stillbe high. Another main drawback is that random flaps canonly be used to close relatively small defects withoutjeopardising the closure of the donor area. Thus, extirpa-tive surgeons are still limited by the amount of defect theyanticipate to create. Limberg flap or its variants are themost commonly used and reported. However, use of theLimberg flap for larger defects would require extensivemobilisation of the gluteal tissue in order to transpose theflap as well as to close the recipient area. In addition, thedistal part of the flap, which corresponds to the deepmidline gluteal fold, is under tension. There have beenseveral reports on modifications of the Limberg flap todecrease the rate of recurrence and time of healing;however, these are still limited in size and difficult totranspose.13,14

Perforator flap

Perforator flaps based on perforating arteries are morereliable than random flaps in terms of vascularity, espe-cially in closing larger and deeper defects. In addition,perforator flaps have more freedom in transposition,without forming dog ears or contour abnormalities in thedonor area. The use of SGAP flap in the treatment of sacralpressure sores has been described.18,19 Garrido et al.reported the use of SGAP flap in the reconstruction ofpilonidal sinus in five cases with no recurrence.20 Their flapswere designed at 90

�e135

�angle to the vertical axis of the

defect. In order to transpose this flap into a midline defectwithout kinking, it should be mobilised with a singleperforator. Possibly, this single perforator artery needs tobe followed for a certain distance to identify its intramus-cular component in order to provide adequate transposition(as in the case of a propeller flap), thus increasing theoperative time (62 min in Garrido et al. compared to 45 minin the current series) and risking injury to the perforatorartery. The average length of hospital stay was 5 days, andthe patients had a wound dehiscence rate of 40%. Nessar

138 T.O. Acarturk et al.

et al. have used an elliptical fasciocutaneous flap from theinferior gluteal area and transposed it to the pilonidal sinusdefect at a 90

�angle.21 They reported that the flap should

be on a 2e1.5:1 ratio and stated that it has a limited reach.In their study, the size of the defects was not reported, nopatient photographs were shown and the recurrence ratewas 5%. Compared to our technique, their technique hasseveral major drawbacks. First, the flap was prepared fromthe inferior gluteal region placing the incisions right on topof the pressure-prone ischium, which would create prob-lems in healing once the patients begin to sit. Second, thedonor area for the flap is close to the anus, which wouldincrease the likelihood of contamination. Third, since theflap was not raised as a perforator flap, but was ratherbased on a width-and-length ratio, the retained skinpedicle would create a bothersome dog ear just next to theanal canal. Finally, because of the 90

�-angle design and the

flap not being a true perforator flap, it has a limited reachand a small size.

A propeller flap is formed when a perforator flap israised on a single perforator and is turned 180

�to its linear

plane. In order to prevent kinking in the pedicle, all of theother perforators should be sacrificed, and the remainingperforator should be dissected intramuscularly. This is timeconsuming, may injure the single perforator and mayjeopardise the blood supply. Even flaps designed at anangle of more than 75

�may need propeller flap concepts for

adequate mobilisation. Instead in our design, when severalperforators were preserved at the base of the flap withsome fat tissue among them, transposition of 45� would notlead to kinking in the pedicle and yet result in adequatetransposition as well as increased vascularity. The fat tissuewould act as a cushion, and thus the vessels would nottouch each other. Additionally, in order to adequatelymobilise the flap, the skin and surrounding subcutaneoustissue should be completely cut and freed all the way to themuscle, including the muscle fascia. Therefore, this wouldresult in a perforator flap rather than a subcutaneous islandflap. This particular design of perforator flaps can be a clearadvantage over the more technically challenging propellerflap concept on some areas of the body.

Lumbosacral adipofascial flaps

In a case series of seven patients, Onishi et al. useda gluteal adipofascial turnover flap lateral to the pilonidalsinus defect.22 This flap was based on the medial sacralperforators and was able to completely fill the cavitarydefect together with primary closure. Although no recur-rences were reported, the authors strongly suggested thatthis flap to be used only in small defects, when the twoedges of the defect could be brought together by gentlefinger traction. Thus, in bigger defects, the use of this flapwould preclude primary closure of the midline skin. Thesame problem also arises in the series reported by Turanet al., where a lumbar adipofascial flap was used to oblit-erate the cavitary defect of the pilonidal sinus with primaryclosure of the skin.23 In their technique, a cavitary lesion atthe donor area was created, which resulted in the use ofdrains for as long as 4 days with increased duration ofhospital stay. In both reports, the gluteal fold still appearsto be deep, which would increase the likelihood of

recurrent PSD in addition to the risk arising from havinga midline incision.

VeY rotation advancement and gluteal muscle flap

Gluteal flaps either in the form of rotation, VeY advance-ment or a combination of the two with or without thegluteus muscle have been used in the treatment of pilonidalsinus, especially in recalcitrant cases.8e10 Large muscu-locutaneous flaps have the disadvantage of loss-of-musclefunction, increased operating time and blood loss,increased amount of scars and likelihood of increaseddiscomfort and pain after surgery.8 In addition, the finalincisions are placed in the midline at the deepest positionof the intergluteal fold.8,10 Sungur et al. have used a VeYrotation advancement flap to cover defects of the pilonidalsinus.10 The mean operating time was 80 min with 135 ml ofblood loss and 5 days in the hospital. Although there wereno recurrences in an average of 9 months, the final incisionwas in the deepest portion of the midline natal cleft, whichis known to increase recurrence. In addition, the donor areaof the flap was approximately 3 times larger than thedefect itself compared to exactly the same size in ourtechnique. In PSD, when the final line of closure lies in themidline, even large rotation or advancement flaps appearto act not as true flaps that place the incisions away formthe midline, but rather as large mobilisations of thesurrounding tissue with ‘primary closure’. Scholler et al.used a VeY fasciocutaneous advancement flap, where themost medial portion was de-epithelialised and turned intothe defect to obliterate the dead space and elevate thenatal cleft.9 They advocated the use of bilateral flaps whenthe defect is wider than 10 cm, which is unnecessary whena single perforator flap is used. In their study, the averagehospital stay was 7 days and return to work took 28 days.

The technique presented in the current article hasseveral advantages over prior reported techniques. It offersbetter vascularity with increased safety compared to therandom flaps and decreased operating time and donor-areamorbidity compared to larger flaps. It also results inelevation of the natal cleft and avoids a final midline inci-sion. The use of a perforator flap assures better vascularityand more freedom of rotation as well as safely increasesthe size of the flap that is being transposed. Our design ofthe 45

�-angle flap is superior to the earlier perforator flaps.

First, the perforators do not need to be surgically identifiedor skeletonised to assure adequate transposition. Thus, lessdissection leads to faster surgery (45 min) and prevention ofinjury to the perforators. Second, inclusion of severalperforators of various calibres, rather than a single perfo-rator, provides better vascularity, but still allows safetransposition without kinking of the vascular pedicle.However, care should still be taken during the dissectionwhile approaching the proximal one-third of the flap. Third,a parasacral sensory nerve can be identified and includedwithin the flap to provide sensation to a pressure-pronearea. This flap design results in minimal undermining andtension-free closure of the donor area. The technique ofelevating a flap at a 45

�angle to the defect have been used

by this author in other sacral and lumbar wounds as large as18� 8 cm in size, with primary closure of the donor site(Acarturk, unpublished data). In addition, if necessary,

Superior gluteal artery 139

either extra adipose tissue can be added to the flap or partof the flap can be thinned to conform to the surface char-acteristics of the defect without jeopardising vascularity. Inliterature, our technique has the shortest hospital stay (lessthan 24 h), earliest mobilisation (less than 24 h), return todaily activities (3 days) and return to work (10 days). Inaddition, the blood loss is less than 25 cc, and no drains areused. More importantly, there are no complications and norecurrences.

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7. Manterola C, Barroso M, Araya JC, et al. Pilonidal disease: 25cases treated by the Dufourmentel technique. Dis ColonRectum 1991;34:649e52.

8. Rosen W, Davidson JS. Gluteus maximus musculocutaneous flapfor the treatment of recalcitrant pilonidal disease. Ann PlastSurg 1996;37:293e7.

9. Schoeller T, Wechselberger G, Otto A, et al. Definite surgicaltreatment of complicated recurrent pilonidal disease witha modified fasciocutaneous V-Y advancement flap. Surgery1997;121:258e63.

10. Sungur N, Kocer U, Uysal A, et al. V-Y rotation advancementfasciocutaneous flap for excisional defects of pilonidal sinus.Plast Reconstr Surg 2006;117:2448e54.

11. Sondenaa K, Nesvik I, Andersen E, et al. Recurrent pilonidalsinus after excision with closed or open treatment: final resultof a randomised trial. Eur J Surg 1996;162:237e40.

12. Iesalnieks I, Furst A, Rentsch M, et al. Primary midline closureafter excision of a pilonidal sinus is associated with a highrecurrence rate. Chirurg 2003;74:461e8.

13. Mentes BB, Leventoglu S, Cihan A, et al. Modified Limbergtransposition flap for sacrococcygeal pilonidal sinus. SurgToday 2004;34:419e23.

14. Cihan A, Ucan BH, Comert M, et al. Superiority of asymmetricmodified Limberg flap for surgical treatment of pilonidaldisease. Dis Colon Rectum 2006;49:244e9.

15. Ersoy OF, Karaca S, Kayaoglu HA, et al. Comparison of differentsurgical options in the treatment of pilonidal disease: retro-spective analysis of 175 patients. Kaohsiung J Med Sci. 2007;23:67e70.

16. Akca T, Colak T, Ustunsoy B, et al. Randomized clinical trialcomparing primary closure with the Limberg flap in the treat-ment of primary sacrococcygeal pilonidal disease. Br J Surg2005;92:1081e4.

17. Morden P, Drongowski RA, Geiger JD, et al. Comparison ofKarydakis versus midline excision for treatment of pilonidalsinus disease. Pediatr Surg Int 2005;21:793e6.

18. Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superiorgluteal artery perforator flap: an additional tool in the treat-ment of sacral pressure sores. Br J Plast Surg 1999;52:385e91.

19. Leow M,LimJ, Lim TC.The superior gluteal arteryperforator flapfor the closure of sacral sores. Singapore Med J 2004;45:37e9.

20. Garrido A, Ali R, Ramakrishnan V, et al. Reconstruction of thenatal cleft with a perforator-based flap. Br J Plast Surg 2002;55:671e4.

21. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilo-nidal sinus. Am J Surg 2004;187:300e3.

22. Onishi K, Maruyama Y. Sacral adipofascial turn-over flap for theexcisional defect of pilonidal sinus. Plast Reconstr Surg 2001;108:2006e10.

23. Turan A, Isler C, Basx SC, et al. A new flap for reconstruction ofpilonidal sinus: lumbar adipofascial turnover flap. Ann PlastSurg 2007;58:411e5.