High-throughput screening and clinical importance of autophagy-associated genes in basal cell carcinoma.

Autophagy is a type II programmed cell death mechanism that plays a critical role in preserving cellular homeostasis through the regulation of protein, lipid, and organelle quality control. It has become gradually evident that autophagy plays a fundamental role in the initiation and progression of various types of human cancers. Nevertheless, its significance in non-melanoma skin cancers, particularly in basal cell carcinoma, has not been well documented and remains largely elusive. In this study, we aimed to illuminate the role of autophagy-associated signaling signatures during development and progression of basal cell carcinoma. For the study, a total of 72 autophagy-related genes were screened using a high-throughput qPCR approach integrating Fluidigm 96.96 Dynamic Array™ integrated fluidic circuits (IFC) and BioMark™ HD Real-Time PCR system, which enabled efficient and precise analysis of gene expression patterns. Results were analyzed using Fluidigm's Real-Time PCR Analysis software and 2-ΔΔCt formula was used for the calculation of expression changes. Notably, expression levels of INS, TMEM74 and IFNA2 genes were identified to be prominently altered in BCC comparted to adjacent healthy tissues. However, only IFNA2 expression showed statistically significant change in BCC. Consequently, these findings suggest that IFNA2 might play significant role in the regulation of autophagy in BCC development and progression and can be therapeutically targeted.

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 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 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.

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.

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.

Surgical treatment of extensive sacrococcygeal hidradenitis suppurativa with triangular closure technique.

BACKGROUND: Recurrence of the sacrococcygeal hidradenitis suppurativa (HS) can significantly be reduced by invasive local excision of all the abscess, sinuses, and scars which often result in large defects on this region. Although a number of surgical procedures have been described, closure of large sacrococcygeal defects resulting from excision of extensive HS still remains a challenge. PURPOSE: Here, we present the use of triangular closure technique as a new alternative in surgical treatment of extensive HS of sacrococcygeal region. MATERIALS AND METHODS: For more than 4 years, triangular closure technique has been used for skin coverage of the large sacrococcygeal defects resulting from excision of the HS in 16 patients (12 men and 4 women) aged between 18 and 52. The size of the defects range from 10 to 25 cm in the greatest dimension. RESULTS: In all patients, a successful tension-free closure of the defect was obtained. Except for 2 patients who had tip necrosis, all patients healed uneventfully. There was no patient with infection and wound dehiscence. A mean follow-up for 36 months (6 months-5 years) revealed no recurrence and an aesthetically acceptable scar formation in all patients. No patient required additional surgery. CONCLUSIONS: Triangular closure technique enables the surgeon to achieve a tension-free defect closure of remarkably large sacrococcygeal defects resulting from surgical excision of extensive HS. Using 2 well-vascularized fasciocutaneous flaps, it provides a durable coverage and soft tissue padding over sacrococcygeal and gluteal region with good cosmesis. With these advantages, triangular closure technique seems to be a useful, 1-stage, and safe reconstructive alternative for the closure of these challenging defects.

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.

The reading man flap for closure of large meningomyelocele defects.

BACKGROUND: Closure of the skin defect in myelomeningocele repair is an essential step that determines the quality of the surgical result. In large myelomeningoceles, however, adequate skin coverage may not be accomplished by direct closure or skin undermining. In such cases, the skin defect is best repaired using flaps. The aim of this study is to evaluate the reading man procedure for closure of large meningomyelocele defect. METHODS: In this procedure, after neurosurgical repair and closure of the placode, the defect surgically becomes a circle in shape. Then, the circular defect is closed by transposition of two skin flaps designed in an unequal Z-plasty manner. Over 5 years, the reading man procedure was used for closure of large meningomyelocele defects in seven patients (four females and three males), aged between 1.5 and 6 months. The defect size was 10.5×7.25 cm (8.5×5.3 and 12.6×9.5 cm) on average. The localisation of the lesions was thoracolumbar in two patients and lumbosacral in five patients. RESULTS: In all patients, a successful tension-free one-stage closure was obtained without dog-ear formation. Except for one patient with minimal tip necrosis, healing was uneventful without any complications. There was no patient with late breakdown of the wound during 1.5 years (8 months-4 years) of mean follow-up. CONCLUSIONS: The reading man procedure enables the surgeon to achieve a tension-free defect closure of considerably large meningomyeleocele defects. Using two well-vascularised fasciocutaneous flaps, it provides a durable coverage and soft tissue padding over the neural tissues with no suture seam at midline. With these advantages, the Reading Man Procedure seems to be a useful and safe alternative for closure of large meningomyelocele defects.

Island volar advancement flap for reconstruction of thumb defects.

BACKGROUND: The volar advancement flap of the thumb described by Moberg has been used for pulp defects up to 1 to 1.5 cm since its mobility is quite limited due to the stiff nature and fibrous connections of the regional skin with underlying structures. There have been several attempts to increase the mobility of this useful flap by adding V-Y and Z-plasty concepts into the technique. These modifications could provide a slight increase in the flap advancement and achieve closure of defects up to 2 cm in length at best. METHODS: In this study, we describe the island volar advancement flap of the thumb in which all attachments, except the neurovascular pedicle of the flap, were divided to provide maximum mobility and advancement. This technique was used in 12 patients for reconstruction of traumatic defects of the distal thumb up to 3 to 3.5 cm in length. RESULTS: The flaps healed uneventfully in all patients. There was no patient with flap failure. All patients were followed up for 2 to 6 years (4 years on an average). Our results revealed sensible and durable skin coverage with maximum preservation of the thumb length. CONCLUSIONS: The island volar advancement flap seems to be a safe and useful procedure for thumb reconstruction. Providing a 1.5 cm of extra flap advancement, this new procedure enables us 1-stage closure of considerably large defects and is a critical achievement in thumb reconstruction.

A new alternative for reconstruction of the inferior medial canthal and nasal sidewall defects.

BACKGROUND: Reconstruction of the inferior medial canthal and nasal sidewall defects presents some particular problems resulting from the unique anatomy of this region such as the multiple contours and sigmoidal relaxed skin tension lines, differences in skin color and texture, and the anatomic limitations presented by the adjacent structures including lower eyelids, eyebrows, and lacrimal drainage system. PURPOSE: In this study, the authors represent a new local flap as a new alternative for reconstruction of the defects of the inferior medial canthal region and nasal sidewalls. METHODS: In this technique, defect closure is achieved by using 2 cutaneous flaps designed in an unequal z-plasty manner. The first flap is used to cover the defect, whereas the second flap is used for closure of the first flap's donor site. From October 2006 to May 2010, a total of 16 patients 38 to 80 years old underwent medial canthal and nasal sidewall reconstruction by using this procedure. The defect size ranged from 2.0 to 3.2 cm in width. RESULTS: A tension-free defect closure was achieved in all patients. Except 1 patient who had slight pseudoepicanthus, there was no patient with distortion of the surrounding anatomic structures. During a mean follow-up period of 30 months (5 months to 3½ years), all patients were satisfied with the cosmetic and functional results. Except 1 patient who underwent reoperation for tumor recurrence, no patient required further surgery. CONCLUSIONS: The reading man procedure was found to be a successful technique for the closure of inferior medial canthal and nasal sidewall defects. It allows tension-free closure of considerably larger defects without any additional healthy tissue excision and and/or dog ear formation. Moreover, using z-plasty principle, it avoids distortions of the surrounding mobile anatomic structures.

A new technique for closure of infraorbital defects.

BACKGROUND: The infraorbital region is a unique facial subunit surrounded with several important structures, such as the lower eyelids, oral commissure, ala nasi, and the sideburns. The potential for distortion of these neighboring anatomic landmarks and the absence of natural creases where incisional scars can be camouflaged make reconstruction of large infraorbital defects a challenge. PURPOSE: A new local flap procedure for reconstruction of large infraorbital skin defects, named Mutaf triangular closure technique, is described. MATERIAL AND METHOD: In this procedure, 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 4 years, this technique has been used for closure of the infraorbital defects in 12 patients (7 men and 5 women), aged 28 to 83 years. The defect size ranged between 1.7 and 8 cm in diameter. RESULTS: A tension-free defect closure was obtained in all patients. All flaps healed with no complications. No patient had "dog-ear" formation, ectropion, scleral show, or distortion of the surrounding anatomic structures. A mean follow-up of 18 months (5 months-3.5 years) revealed an aesthetically acceptable scar formation in all patients. CONCLUSIONS: The Mutaf triangular closure technique seems to be a useful procedure for the closure of considerably large infraorbital defects with alike local tissue. It provides a tension-free closure without displacement and/or distortion of the neighboring mobile anatomic structures.

Correction of tethered upper lip deformity following bilateral cleft lip repair.

BACKGROUND: Shallow upper buccal sulcus, vertical shortness (whistling deformity), and limited mobility of the median part of the upper lip are among the most common secondary deformities following surgical repair of wide bilateral cleft lip. They are often encountered together as a triad of postoperative deformities with a common etiology. To date, there has been no surgical procedure to correct these 3 associated deformities in 1 stage. PURPOSE: In this article, we describe the triad above-mentioned 3 associated postoperative deformities as a single clinical entity, namely the tethered upper lip (TUL) deformity. Moreover, a new procedure for simultaneous correction of these 3 postoperative deformities in 1 stage is presented. MATERIAL AND METHOD: Over 4 years, this new technique was used in 9 patients, 7 males and 2 females, with the TUL deformity following bilateral cleft lip repair. The patients were aged from 1 to 3 years. RESULTS: All patients healed uneventfully. A mean follow-up of 18 months revealed a well-contoured upper lip with a sufficient depth of the upper buccal sulcus, an adequate oral sphincter function, and mobility in all patients. The scars placed on the mucosal surface were almost invisible. CONCLUSIONS: Our technique seems to be useful for 1-stage correction of all 3 components of the TUL deformity including shallow upper buccal sulcus, vertical shortness of the median part of vermilion, and limited upper lip mobility following surgical repair of the bilateral cleft lips.

Closure of defects of the malar region.

BACKGROUND: Reconstruction of the skin defects of malar region poses some challenging problems including obvious scar formation, dog-ear formation, trapdoor deformity and displacement of surrounding anatomic landmarks such as the lower eyelid, oral commissure, ala nasi, and sideburn. PURPOSE: Here, a new local flap procedure, namely the reading man procedure, for reconstruction of large malar skin defects is described. MATERIALS AND METHODS: In this technique, 2 flaps designed in an unequal Z-plasty manner are used. The first flap is transposed to the defect area, whereas the second flap is used for closure of the first flap's donor site. In the last 5 years, this technique has been used for closure of the large malar defects in 18 patients (11 men and 7 women) aged 21 to 95 years. The defect size was ranging between 3 and 8.5 cm in diameter. RESULTS: A tension-free defect closure was obtained in all patients. There was no patient with dog-ear formation, ectropion, or distortion of the surrounding anatomic structures. No tumor recurrence was observed. A mean follow-up of 26 months (range, 5 mo to 3.5 y) revealed a cosmetically acceptable scar formation in all patients. CONCLUSIONS: The reading man procedure was found to be a useful and easygoing technique for the closure of malar defects, which allows defect closure without any additional excision of surrounding healthy tissue. It provides a tension-free closure of considerably large malar defects without creating distortions of the mobile anatomic structures.

A new technique for reconstruction of a congenital isolated alar defect.

Congenital isolated alar defect (CIAD) is an extremely rare anomaly causing a remarkable aesthetic deformity. Up to today, only 6 previous cases have been reported, and there has been no technique approved as a criterion standard for the reconstruction of this anomaly yet. Here, we present a patient with a wide unilateral CIAD reconstructed with a new procedure, namely Mutaf's triangular closure technique. A 16-year-old adolescent boy was admitted to our clinic with a CIAD of 1.4 cm x 1.8 cm located on the left side. The reconstruction of the defect was done in a 3-layered fashion. The skin defect was covered by using the Mutaf's triangular closure technique in which 2 cutaneous local flaps designed in an unequal Z-plasty manner were used. The mucosal closure was achieved with a single mucosal transposition flap elevated from the superolateral alar region. A septal cartilage graft was placed between the skin and mucosal closure to replace the missing part of the lower lateral cartilage. Flaps healed with no complication. At 1 year after surgery, there was a cosmetically and functionally excellent result with almost symmetrical nostrils and minimal scar formation. Providing an aesthetic and anatomic reconstruction with alike local tissues, Mutaf's triangular closure procedure seems to be a useful option for reconstruction of the CIADs.

The anatomic replication technique (ART): a new approach in saddle nose correction.

Correction of major saddle nose deformities is one of the greatest challenges in nasal surgery. Here, a new approach for the correction of major saddle nose deformities in which the missing parts of the nasal skeleton are replaced with their anatomic replicas sculptured from an autogenous osteocartilagineous rib graft is presented. Since 1998, this new technique has been used in 17 patients (11 females and 6 males) with major saddle nose deformities. The age range was between 19 and 37 years. The etiology of saddle nose deformity was iatrogenic in 11 and traumatic in 2 patients. In the remaining 4 patients, saddle nose was a part of ethnic facial features. During a mean follow-up of 2 years, the sculptured nasal frame maintained its form and resistance. There was no patient with recurrent nasal collapse or airway obstruction. The nasal tip was naturally mobile in all patients. Replacing the missing parts of the nasal skeleton with their anatomic replicas created from autogenous tissues, this new technique restores all anatomic and functional features of the nose. It efficiently corrects saddle nose deformity and eliminates associated functional deficiencies.

The "reading man" procedure: a new technique for the closure of circular skin defects.

BACKGROUND: As most of the skin lesions tend to grow in a circular pattern, the resultant defects after surgical removal of these lesions are often circular. Although a number of local flap procedures have been described, alternative techniques are still needed for the closure of circular defects. PURPOSE: Here, a new surgical technique for the closure of circular skin defects is presented. This technique basically uses the extra skin relaxation gained with an unequal Z-plasty maneuver in favor of the defect closure. The procedure is named as "the reading man" because its surgical design resembles the silhouette of a man who is reading a book held in his hand. MATERIAL AND METHODS: In this technique, 2 flaps designed in an unequal Z-plasty manner are used. The first flap is transposed to the defect area whereas the second flap is used for closure of the first flap's donor site. For 3 years, this technique has been used for closure of the circular skin defects in 27 patients (19 men and 8 women) aged from 2 months to 68 years. The defect size was ranging between 1.5 and 14 cm in diameter. RESULTS: A tension-free defect closure was obtained in all patients. All flaps healed with no complications. There was no patient with dog ear formation. A mean follow-up of 15 months (6 months-3 years) revealed an esthetically acceptable scar formation in all patients. CONCLUSION: The reading man procedure was found to be a useful and an easy going technique for the closure of circular skin defects located on various anatomic regions. It enables surgeon to obtain a tension-free closure of considerably large skin defects with minimal scarring and additional healthy skin excision.