Reading Man Flap: A Nasal Reconstruction Technique.

BACKGROUND: Closure of the nasal skin defects that resulted from excision of the skin neoplasms represents a challenging problem in reconstructive surgery. Here, the use of the reading man procedure as a new alternative in reconstruction of the skin defects of the nose is presented. MATERIALS AND METHODS: In this procedure, 2 local flaps designed in an unequal Z-plasty manner are used. Defect coverage is achieved by transposing the first flap to the defect area, whereas the second flap is used for closure of the first flap's donor site. In last 10 years, this technique has been used for closure of the nasal skin defects that resulted from removal of skin cancers in 28 patients (15 men and 13 women) aged from 45 to 98 years. The defects were ranging between 1.5 and 3.1 cm in diameter. RESULTS: In all patients, a tension-free 1-stage closure was obtained. There was no patient with dog ear formation and/or distortion of the mobile anatomical structures, such as nasal tip, alar lobules, and nostrils. All patients healed without complications. A mean follow-up of 52 months (8 months to 6.5 years) revealed satisfactory cosmetic results in all patients. No tumor recurrence was observed. CONCLUSIONS: Using the advantage of extra tissue relaxation provided by an unequal Z-plasty, the reading man procedure seems to be a useful alternative for the closure of nasal defects with alike local skin. As a critical achievement, this procedure does not require excision of additional healthy tissue. Borrowing tissue from multiple directions, it avoids dog ear formation and distortion of the mobile anatomic structures.

A Basic Algorithmic Surgical Approach for Nicolau Syndrome.

BACKGROUND: Nicolau syndrome (NS) is a rare complication that develops after the administration of intramuscular diclofenac sodium. The etiology and surgical treatments of 11 patients with NS were evaluated and studies in the literature were examined. The aim of this study was to compose a basic algorithm for surgical approaches to treat NS. MATERIALS AND METHODS: Eleven patients were evaluated for NS between December 2013 and January 2018. Two patients did not accept treatment, and nine patients underwent surgical debridement of necrotic tissues. The tissue defects of five patients were closed with a fasciocutaneous flap and, in four patients, the defects were repaired primarily. RESULTS: No complications, such as wound infection, wound dehiscence, seroma, or flap necrosis, were encountered. Of the seven patients who received concurrent antibiotic therapy, no patient had any problems at their follow-up (2-30 months). The results were satisfactory from an aesthetic and functional point of view. CONCLUSION: NS was more frequent in women with a high body mass index and high fat in gluteal regions. We considered that any kind of medication could lead to NS. Different methods are discussed for treatment.

A New Cartilage-Sparing Procedure for Correction of the Prominent Ear Deformity: Dermal Anchor Technique.

BACKGROUND: Although the literature is replete with surgical techniques described for correction of the prominent ears, new techniques are still needed to minimize the recurrence rates and postoperative complications. OBJECTIVE: Here, the author presents a new and simple otoplasty procedure, namely, the dermal anchor technique (DAT), in which a wide planar adhesion between the opposing dermal surfaces of the deepithelized antihelical groove is used as a biological anchor for long-term maintenance of the antihelical fold without any cartilage manipulation. MATERIALS AND METHODS: For 12 years, this new procedure was used for correction of 76 prominent ears in 44 patients, with 17 being female and 27 being male. The ages of the patients ranged from 5 to 37 years. In 28 patients, the DAT was combined with conchal excision and/or concha-mastoid sutures as required, whereas it was used alone in the remaining 16 patients. The preoperative and postoperative distance between the ear and the head was measured at 4 points (superior helical point, superior conchal attachment, inferior conchal attachment, and lobules). RESULTS: All patients healed uneventfully. Except mild edema and pain, there was no postoperative problem. The mean follow-up time was 4½ years (4 months-10 years). During this time, there was no patient with surface irregularities and/or suture-related complications. Two patients required revision because of unilateral lateralization of the upper pole by time (recurrence rate, 2.63%). When the preoperative and postoperative superior helical point, superior conchal attachment, inferior conchal attachment, and lobule measurements for both ears of the patients who were operated on were compared, postoperative values were determined to be significantly decreased (P < 0.001). CONCLUSIONS: The DAT provides predictable and aesthetically satisfactory long-lasting results with a minimal risk of complications. Because it does not harm the cartilage tissue, it avoids the potential problems resulted from cartilage manipulations such as surface irregularities and chondritis. Covering the suture knots with a thick soft tissue layer, it eliminates the suture-related complications. Moreover, it offers a direct approach and does not require anterior dissection. Thus, it requires a shorter operative time, minimizes the risk of anterior skin necrosis and hematoma, and causes less postoperative pain, edema, and ecchymosis.

A free radical scavenger (Tempol) and its effect on intimal hyperplasia of vein grafts in rats.

BACKGROUND: Reversed vein grafting exposes the vessel to a period of ischemia, reperfusion and subsequent reactive oxygen species, which may damage endothelial tissue, smooth muscle cell proliferation and later the development of intimal hyperplasia. Tempol is a free radical scavenger that permeates biological membranes. This study investigates the effects of a free radical scavenger (Tempol) on intimal hyperplasia of femoral vein grafts and the level of reactive oxygen species in rats. METHODS: Arterial defects created in the femoral artery of rats were repaired with ipsilateral femoral vein grafts. Tempol was administered to group T and saline to group C on a daily basis for a period of 28 days. Blood samples were measured. RESULTS: The veins were stained with H&E and Verhoeff's elastic stains. Binary comparison revealed a statistically significant difference for intimal and medial thicknesses (p<0.01). CONCLUSION: This study found that a free radical scavenger (Tempol) prevents the early development of intimal hyperplasia, most probably by inhibiting the infiltration of polymorph nuclear monocytes (PNM), with evidence of increased levels of antioxidant products and decreased levels of free oxygen radicals.

A New Surgical Technique for Closure of Pilonidal Sinus Defects: Triangular Closure Technique.

BACKGROUND We present a clinical experience with a new local flap procedure, namely the triangular closure technique, for reconstruction of sacrococcygeal skin defects resulting from excision of the pilonidal sinus. MATERIAL AND METHODS In this technique, the defect is surgically converted to a triangle in shape. Then, the triangular defect is closed by transposition of 2 skin flaps designed in an unequal z-plasty manner. Over 6 years, this technique has been used for closure of defects of chronic pilonidal sinus disease in 27 patients (6 females, 21 males). The size of the defect ranged between 3.5 cm and 12 cm in dimension. RESULTS A tension-free defect closure was obtained in all patients. All flaps except one healed with no complications. A mean follow-up of 3.62±1.77 months revealed aesthetically and functionally acceptable results with the obliteration of the natal cleft in all patients. No recurrence was observed in the follow-up period. CONCLUSIONS The triangular closure technique was found to be a useful technique for the treatment of pilonidal sinus with favorable results regarding the time before return to work.

A New Technique for Total Reconstruction of the Lower Lid.

BACKGROUND: Although several methods have been described for total lower eyelid reconstruction, it remains as a major challenge in reconstructive surgery. Here, we present a new technique, the Mutaf unequal Z-plasty procedure for reconstruction of defects of the lower eyelid. METHODS: In this technique, 2 skin flaps designed in an unequal Z-plasty manner are used to provide skin coverage. Except for 2 patients whose additional upper eyelid defects were closed with Fricke flap, all patients were reconstructed with Mutaf unequal Z-plasty procedure. The conjunctival and tarsal defects are reconstructed with composite chondrocutaneous from the ear, mucochondral grafts, harvested from the nasal septum. In over 12 years, this new technique was used in 24 patients, 13 men and 11 women, with total and subtotal lower eyelid defects that resulted from excision of basal cell carcinomas. The age range of the patients was between 45 and 72 years. RESULTS: There was no complication such as ocular irritation or postoperative epiphora because of ectropion or entropion; all patients healed uneventfully. A mean follow-up of 4.7 ± 2.15 years (between 1 and 9 years) revealed a functionally and cosmetically satisfactory total lower eyelid reconstruction in all patients. CONCLUSIONS: This new technique seems to be a useful alternative for reconstruction of total and subtotal lower eyelid defects. The procedure seems to be superior since it requires considerably shorter operating time with no risk of flap failure. Moreover, this technique offers an excellent color and textural match for the reconstruction of total and subtotal lower eyelid defects extending the infraorbital area.

Algorithmic approach to the prevention of unnecessary fasciotomy in extremity snake bite.

BACKGROUND: In the literature, there is a lack of a consensus about the occurrence of the compartment syndrome due to the snake bites. There are different concepts for the surgical treatment of the threshold value of the chamber pressure. There are many different classifications and assessment criteria for the snakebites. PURPOSE: There is not any appropriate classification in order to the assessment of extremity snake bites while making a decision for fasciotomy. We aimed to standardize the follow-up and decision making to perform fasciotomy with a new classification system for the snakebites using objective data. PATIENTS AND METHODS: The data of all patients were recorded prospectively between 2006 and 2011. A total of 97 patients (64 male, 33 female) with a mean age of 30.94±14.04 were followed-up. During the evaluation of the patients, we used a new classification system that was improved for the extremity bites. We classified the patients due to their signs into four groups as for the classification system. RESULTS: 40 patients with compartment like symptoms were carefully followed for 48-72h, and only three patients required fasciotomy where full recovery was achieved in 37 patients. Coverage of the defects was performed with full thickness skin grafting in 4 patients and cross finger flap in two patient. In two patients, the defects were located on the palmar aspect of the thumb. Thus, we applied Kite flap for skin coverage. Reverse dorsal digital artery flap was performed in eight patients and dorsal interosseous metacarpal flap in six patients. Four patients underwent an amputation. Two patients had web reconstruction due to first web contracture. CONCLUSIONS: We present a large series of snake bite injuries and propose a classification and treatment recommendations. Fasciotomy should only be done while the measurement of intra-compartment pressure is above 55mmHg as snakebite can mimic the compartment syndrome. LEVEL OF EVIDENCE: III-IV.

Consolidative Technique Otoplasty: Comprehensive Approach in Combining Techniques.

BACKGROUND: This study aimed to present the long-term results of the consolidative technique otoplasty (CTO). METHODS: Patient age, sex, duration of follow-up, and how the deformity (bilateral-unilateral) occurred were determined. The kind of anesthesia, duration of surgery, surgical techniques used during the operation were reported, and the preoperative and postoperative distances between the ear and head were measured at four points (SUP: The highest point of the helix; SCA: the concha superior sticking points; ICA: stick point of Concha at the inferior; and lobular). Early- and late-term complications were recorded in the postoperative period. RESULTS: A total of 63 (21M-42FM) patients whose average age of 21:41 ± 8.96 (7-41), 119 ears (Right: 58/Left: 61) were operated on with this technique between 2013 and 2015. Mean follow-up was 18:22 ± 9:42 months. Anterior scoring was performed for three patients; concha resection was performed in 17 patients. Fifty-five patients were operated on as primary otoplasties and eight were secondary otoplasties. When the preoperative and postoperative SUP, SCA, ICA, and lobule measurements for both ears were compared, the postoperative values were found to be significantly decreased (p < 0.001). CONCLUSIONS: This technique may be an alternative in the repairs of prominent ears, and it provides an intervention opportunity for all the anatomical structures. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Response to Comment on ''Effects of Reduction Mammaplasty Operations on the Spinal Column: Clinical and Radiological Response''.

NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .".

Reconstruction of Congenital Isolated Alar Defect Using Mutaf Triangular Closure Technique in Pediatric Patients.

Congenital isolated alar defects are extremely rare, occurring in approximately 1 in 20,000 to 40,000 live births. The patients are presented here of 2 pediatric patients operated on for congenital isolated alar defect. The reconstruction of congenital isolated alar defects was made in a 3-layered fashion. The skin defects were covered using the Mutaf triangular closure technique in which 2 cutaneous local flaps are designed in an unequal Z-plasty manner. Conchal cartilage graft was used between the skin and mucosal closure to replace the missing part of the lower lateral cartilage in these patients. The early results were promising in Patient 1, but sufficient improvement was detected in the alar cartilage postoperative follow-up period in Patient 2. Hence, this patient required revision 1 to 2 years postoperatively. This technique provides excellent aesthetic and functional results, except for this problem in Tessier 2 cleft patients. The use of the Stair step flap technique with Mutaf triangle closure technique achieved cosmetically and functionally excellent results in the reconstruction and repair of a large, irregular, narrow cleft, in the inadequate rotation of the lateral part of the lower lateral cartilage. However, because of this problem, evaluation of the long-term follow-up of patients is necessary.

Comparison of the result of consolidative technique otoplasty and incisionless otoplasty in the repairs of prominent ears.

We aimed to compare the long-term results of complications of consolidative technique otoplasty (CTO) and incisionless otoplasty (IO). The study consists of 156 patients who were operated between 2006 and 2015. According to surgical techniques, these patients were divided into two groups as IO group and CTO group. The distance between the head and the ear was assessed by measuring the four points preoperatively and postoperatively (SUP: most superior helical point, SCA: superior conchal attachment, ICA: inferior conchal attachment, and lobule). Early and late postoperative complications, operative time were recorded. 128 ears in IO group, 163 ears in CTO group were prominent. When postoperative SUP, SCA, ICA, lobule values for right and left ears in both groups were statistically evaluated, it was found that CTO technique has led to significantly greater improvement compared to the IO technique (p < 0.001). The success rate in IO technique and CTO technique was 72 and 96 %, respectively. Early complications were similar in both groups. The late period complication determined much more frequently was seen in the IO group. Concerning operative time, it was identified as significantly lower in the IO group (p < 0.001). The early-term outcomes of both techniques were similar; however, the complication rates due to suture material and needed for revision in IO technique were higher whereas CTO technique was more permanent with lower complication risks.

Improvements in Vertebral-Column Angles and Psychological Metrics After Abdominoplasty With Rectus Plication.

BACKGROUND: Substantial fluctuations in body weight can result in diastasis recti and weakening of the connections between the lateral abdominal muscles and the rectus sheath. OBJECTIVES: The authors sought to determine the postural and psychological effects of abdominoplasty with vertical rectus plication. METHODS: Forty women with substantial back and lumbar pain owing to abdominal lipodystrophy were evaluated in a prospective study. Preoperatively and 6 months postoperatively, patients underwent bidirectional radiography of the thoracic and lumbar regions. A visual analog scale (VAS), the Beck Depression Inventory (BDI), and the Nottingham Health Profile (NHP) were applied to assess physical, psychological, and quality-of-life changes following surgery. RESULTS: Significant improvements in posture, assessed in terms of lumbar lordosis, thoracic kyphosis, and the lumbosacral angle, were observed 6 months after abdominoplasty with rectus plication. Results of the VAS and BDI indicated significant improvements in pain and quality of life, respectively. Results of the NHP indicated significant postoperative improvements in fatigue, pain, and sleep. CONCLUSIONS: Abdominoplasty with rectus plication improves posture by tightening the thoracolumbar fascia. In selected patients, abdominoplasty can reduce back and lumbar pain, thereby improving quality of life.

The expression levels of the sirtuins in patients with BCC.

Basal cell carcinoma (BCC) is the most common tumor in humans. Reduced expression of sirtuins interferes with DNA repair, which may cause mutations and genomic instability, and eventually leads to tumor development. In the present study, we investigate the expression levels of SIRT genes in non-tumoral and tumor tissues of patients with BCC. A total of 27 patients (16 males, 11 females) with BCC were included in the study; the mean age was 65.40 ± 10.74 years and mean follow-up was 2.5 ± 0.5 years. There were multiple synchronous lesions in six patients, and the remaining 21 patients had a single lesion. Tumor and non-tumoral tissue samples were collected from all patients, and mRNA expression levels of SIRT1-7 (Sirt1.1, Sirt1.2, Sirt2, Sirt3, Sirt4, Sirt5, Sirt6, and Sirt7) were examined by real-time PCR. The results showed that expressions of SIRT1.1, SIRT1.2, SIRT4, SIRT5, SIRT6, and SIRT7 mRNAs were unchanged in tumor tissues of BCC patients compared with non-tumoral tissue samples. Importantly, the expressions of SIRT2 and SIRT3 mRNAs were significantly reduced in tumor tissue samples from BCC patients compared with non-tumoral tissues (P = 0.02 and P = 0.03, respectively). In light of the previous reports that have demonstrated a link between SIRT proteins and cancer, our findings suggest that SIRT2 and SIRT3 may plan important roles in BCC pathogenesis and could be candidate prognostic biomarkers for BCC.

The Effect of Coenzyme Q10 (Ubiquinone) on Random Pattern Skin Flap Survival in Rat Model.

BACKGROUND: In this study, the effect of coenzyme Q10 (CQ10) on flap survival was investigated. METHODS: Fifty Wistar Albino rats were divided into 5 groups. The survival rates of the skin flaps were assessed 10 days after complete elevation of the flaps. Regions of survival and necrosis were drawn on transparent acetate sheets and scanned into a computer. Tissue samples were assessed histopathologically after staining with hematoxylin-eosin, vascular endothelial growth factor staining and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-Biotin Nick End-labeling staining. To evaluate the antioxidant effect of CQ10; malondialdehyde, nitric oxide levels were measured. RESULTS: Viable flaps area was found higher in groups 3 and 4 as compared to groups 1, 2, and 5. In terms of vascular proliferation, elevated angiogenesis was observed in pathological specimens of groups 3 and 4 as compared to groups 1, 2, and 5. Malondialdehyde levels in groups 3 and 4 were found to be significantly decreased as compared to groups 1, 2 and 5 (P < 0.05). Moreover, serum levels of CQ10 were found significantly increased in groups 3 and 4 (P < 0.05). CONCLUSIONS: In conclusion, CQ10 significantly improves flap viability in rat model, and the highest levels of serum CQ10 can be obtained by oral administration.

Effects of Reduction Mammaplasty Operations on the Spinal Column: Clinical and Radiological Response.

BACKGROUND: Women with macromastia suffer from bodily disproportions like increased spinal curvature owing to the mass effect caused by severely large breasts. In such cases, the erector spinae muscles generate an overcompensatory pressure to maintain a normal posture, resulting in neck, back, and lumbar pain. This study aimed to objectively show the improvement of physical symptoms after reduction mammaplasty and evaluate psychological and physical changes of patients. METHODS: Pre- and postoperative cervical, thoracic, and lumbar bidirectional (anteroposterior and lateral) radiographs were obtained from 40 patients who underwent reduction mammaplasty. Cervical lordosis, thoracic kyphosis, lumbar lordosis, and lumbosacral angles were evaluated. Body mass index, breast tissue volume, and excised tissue amount were recorded for each patient. Visual Analog Scores (VAS) were used to qualify the severity of neck, back, and lumbar pain, the Nottingham Health Profile (NHP) to evaluate quality of life (QoL), and the Beck Depression Inventory (BDI) to evaluate depression severity. RESULTS: Cervical lordosis, thoracic kyphosis, lumbar lordosis, and lumbosacral angle improved, and patients' neck, back, and lumbar pain decreased. The positive correlation between the excised glandular tissue amount and the decrease in neck, back, and lumbar pain was reflected in the results of VAS, NHP, and BDI tests. After reduction mammaplasty, depression symptoms caused by macromastia decreased. Parameters of QoL, including physical activity, socialization, fatigue, sleeping, and emotional reactions, significantly improved. CONCLUSION: Patients with macromastia should be considered for reduction mammaplasty before the onset of postmenopausal osteoporosis to improve QoL.

''The dermal internal brassiere flap,'' a new modification of inferior pedicle breast reduction technic.

BACKGROUND: The inferior pedicle mammaplasty is particularly applied to large breasts with a long sternal notch to nipple distance. The present study reports modifications developed to solve the bottoming-out deformity, the lack of upper pole fullness and the wound healing problems seen at the reverse T-zone, known disadvantages of the inferior pedicle reduction mammaplasty, and evaluates postoperative sensation. METHODS: A total of 110 patients with a mean age of 32 underwent the same technique. In this technique, two pairs of quadrangular and triangular flaps were planned from the skin of resection sites. The triangular dermal flaps and quadrangular flaps were suspended from the periosteum of the 2nd and 4th ribs, respectively. The distance from the nipple to inframammary fold was measured at the postoperative 1st month and 1st year. In the postoperative period, a nipple-inframammary fold distance increase of over 2 cm was determined as bottoming-out deformity. Sensation evaluations were performed by subjective and objective tests. RESULTS: The mean sternal notch to nipple distance was 35.00 cm. After operation, the mean distance between the sternal notch and the nipple was 20.00 cm. NAC examination revealed normal sensation in all patients. Whereas the preoperative mean areolar threshold value was 36.70 g/mm(2), the postoperative first-year mean areolar pressure threshold value was 35.50 g/mm(2) (p < 0.0001). The preoperative mean nipple pressure threshold value was 25.30 g/mm(2), whereas the postoperative first-year mean nipple pressure threshold value was 26.00 g/mm(2) (p = 0.5471). The postoperative first-month mean sternal notch to nipple distance value of the patients was 20.00 cm, whereas the postoperative first-year mean sternal notch to nipple distance value of the patients was 20.00 cm, (p = 0.0648). The postoperative first-month mean nipple to submammary fold distance value of the patients was 10.50 cm, the postoperative first-year mean nipple to submammary fold distance value of the patients was 11.00 cm (p < 0.0001) There were no patients determined as having bottoming-out deformity. No breast asymmetry was encountered at the late follow-up period. All patients, except the scarred ones, were satisfied with the results. CONCLUSION: In this study, we achieved an internal fascial reconstruction using a pair of triangular and quadrangular dermal flaps suspended to the rib periosteum. We believe that our modifications will contribute to decreasing the disadvantages of the inferior pedicle breast reduction technique. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A novel tumor suppressor gene in basal cell carcinoma: inhibition of growth factor-2.

In loss of heterozygosity (LOH) studies at the chromosome 4q22-35 region, it was shown that the amount of deletion was high in basal cell carcinoma (BCC). It has been proposed that genes located in this chromosomal region could be tumor suppressor genes in BCC. It has been thought that deletions in the ING2 gene located in the same region can play a role in the pathophysiology of BCC and that deletions occurring in this region may influence the level of ING2 expression in BCC. Tumoral and non-tumoral tissues from 75 patients with BCC (45 men and 30 women) were included to the study. Lesions were excised by a surgical margin of 0.5 cm. After excision, RNA was isolated from tumoral and non-tumoral tissue samples. ING2 messenger RNA (mRNA) expression level was determined in tumoral and non-tumoral tissues by the real-time polymerase chain reaction (RT-PCR). It was detected that ING2 mRNA expression level decreased in tumoral tissues when compared to non-tumoral tissues from BCC patients (p = 0.0001). It was found that expression levels of this gene were comparable among patients with primary, recurrent, or multiple BCC. It is thought that ING2 gene expression level could contribute to the development of BCC but not be associated with the stage and the prognosis of the tumor.

The spider procedure: a new Z-plasty-based local flap procedure.

BACKGROUND: Using neighboring similar skin, local flap procedures provide optimal aesthetic and functional results in reconstruction of skin defects. Therefore, a number of local flap procedures have been described. However, as skin defects present limitless variations in size and shape, new flap procedures are still needed. Here, we describe a new Z-plasty-based local flap technique, "the spider procedure," for closure of the skin defects. METHODS: In this procedure, first, the existing defect is surgically converted to a triangle in shape. Then, using a modified 5-flap Z-plasty pattern, the flaps are outlined. By transposing the elevated flaps in a Z-plasty manner, a tension-free closure is achieved by means of tissue relaxation provided by opposing Z-plasties. Over 9 years, this technique has been used for closure of various skin defects in 42 patients (19 men and 23 women) aged 17 to 57 years. This procedure was used for facial defects in 20 patients, abdominal defects in 6, upper extremity defects in 7, and lower extremity defects in 9 other patients. The defect size ranged between 1.5 and 17 cm in diameter. RESULTS: A tension-free defect closure was obtained in all patients. Except 2 patients with minor flap tip necrosis who underwent secondary healing, all patients healed uneventfully and no patient required revision surgery in our series. There was no patient with dog-ear formation. A mean follow-up of 2 years (6 months-9 years) revealed an aesthetically acceptable scar formation in all patients. CONCLUSIONS: On the basis of our clinical results, the spider procedure seems to be a useful alternative for the closure of various skin defects in all regions of the body. Using the advantage of extra tissue relaxation provided by opposing Z-plasties, it enables a surgeon to obtain tension-free closure of considerably large skin defects without dog-ear formation.