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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Schematic of the design of the reading man flap&#46; The curved arrows indicate the direction of transposition of each of the flaps&#44; which once transposed&#44; leave a distribution of scars like that shown in the figure on the right&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The so-called <span class="elsevierStyleItalic">reading man flap</span> was described by Mutaf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 2008 as a new technique for covering circular defects&#46; It takes its name from the form of the defect with the Z-plasties&#44; which is reminiscent of the silhouette of someone reading &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The technique is based on development of an asymmetric Z-plasty&#46; It has been mainly used for reconstruction of facial defects&#46; Given its most important characteristic is that it guarantees tension-free closure&#44; we believe that it could be of great use for closure of defects at sites subject to flexion and tension movements&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case History</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 102-year-old man&#44; who was partially dependent for basic activities of daily living&#44; but with complete mobility in his arms and who could eat without assistance&#44; underwent a single surgical procedure in regimen of major outpatient surgery&#44; under local anesthetic and sedation&#44; for a circular squamous cell carcinoma in the radial dorsal region of the left wrist &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The resulting defect measured 4&#8239;cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; A reading man flap was designed for reconstruction of the defect&#44; which was sutured directly with silk 3&#47;0 stitches &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Daily dressing changes were done with chlorhexidine and soft bandaging&#44; and the stitches were removed after 10 days&#46; The patient was recommended not to lift weights or make forced movements with the arm for 15 days&#46; No postoperative complications were reported&#44; except for a small superficial necrosis at the vertex of the second flap&#46; However&#44; the esthetic and functional outcome at 3 months was very satisfactory &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">This reading man technique is based on the use of an asymmetric Z-plasty &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The central line&#44; tangential to the defect&#44; and perpendicular to the line of low skin tension&#44; should be 50&#37; longer than the diameter of the defect &#40;black line&#41;&#46; At the distal end&#44; a line is designed forming a 60&#176; angle with a length equal to the diameter of the defect &#40;red line&#41; and at the proximal end to the defect&#44; another tracer line opposite to the anterior of equal length is added&#44; forming a 45&#176; angle &#40;green line&#41;&#46; Subsequently&#44; a double transposition is performed by which the tumor defect is covered by the first rectangular-shaped flap &#40;F1&#41;&#46; This defect is in turn covered by transposition of the second triangular-shaped flap &#40;F2&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In the literature&#44; we encountered 14 articles that reported a total of 147 cases&#46; The main site where this technique was used is the face&#44; specifically the malar region&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> followed by the trunk&#46; At the latter of these sites&#44; the reading man flap has been used mainly for covering large defects after myelomeningocele interventions&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or pressure ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In such situations&#44; it is a very useful alternative to myocutaneous or perforating flaps&#46; However&#44; we did not find any publication that highlighted the advantages of this plasty at sites of flexion and tension as was the case in our patient&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The reported rate of complications is relatively low&#46; There have been a few reports of mild dehiscence and cases of dog ears and transient trapdoor effect have been reported due mainly to the first flap being too large&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Also of note is a case of partial distal necrosis at the vertex of the second plasy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Such complications seem to be more frequent when used at an extrafacial site&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This plasty has been compared with other transposition flaps such as the Limberg flap or the bilobed flap in models of artificial human skin and a lower suture tension&#59; less removal of healthy skin&#44; and a longer scar were demonstrated compared with the Limberg flap but with a similar scar area&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The reconstruction of defects to cover periarticular areas is a therapeutic challenge&#44; and transposition flaps are the most widely used&#44; above all&#44; bilobed flaps or Limberg flaps&#44; as they allow the tension of closure to be reduced compared with other types of reconstruction&#46; Good outcomes have been reported with the keystone-type flap in these areas<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; however&#44; most patients were younger and with a much less atrophied skin than was the case in our patient&#46; Other options&#44; such as complete skin graft&#44; have the drawback of subsequent contracture of the graft and therefore a greater risk of functional limitations&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; the reading man flap is a safe plasty that can be performed relatively easily&#46; The main advantage is that it can guarantee closure with low tension&#46; There is therefore a lower risk of necrosis&#44; dehiscence&#44; and poor wound healing&#44; with less distortion and traction of adjacent tissues&#44; and less removal of healthy skin&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Although the reading man flap was initially described to cover circular defects on the cheek&#44; and indeed it is a good option for this site&#44; we believe that the advantages mentioned with respect to other local plasties make it a particularly useful option in regions submitted to high tension such as large defects on the trunk or those in body areas with movements of flexion and tension&#44; such as the wrist in the case of our patient&#46; In these regions of flexion and tension in particular&#44; other reconstructive options such as grafts or Limberg plasties can generate more traction with a greater risk of functional deficit&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
The Reading Man Flap: An Alternative for Reconstructing Defects in Areas of Flexion and Extension
Colgajo del lector como alternativa reconstructiva en regiones sometidas a movimientos de flexoextensión
Í. Martínez de Espronceda Ezquerro
Autor para correspondencia
martinezespronceda@gmail.com

Corresponding author.
, M. Azcona Rodríguez, J. Sarriugarte Aldecoa-Otalora, M.E. Iglesias Zamora
Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona
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    "titulo" => "The Reading Man Flap&#58; An Alternative for Reconstructing Defects in Areas of Flexion and Extension"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Schematic of the design of the reading man flap&#46; The curved arrows indicate the direction of transposition of each of the flaps&#44; which once transposed&#44; leave a distribution of scars like that shown in the figure on the right&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The so-called <span class="elsevierStyleItalic">reading man flap</span> was described by Mutaf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 2008 as a new technique for covering circular defects&#46; It takes its name from the form of the defect with the Z-plasties&#44; which is reminiscent of the silhouette of someone reading &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The technique is based on development of an asymmetric Z-plasty&#46; It has been mainly used for reconstruction of facial defects&#46; Given its most important characteristic is that it guarantees tension-free closure&#44; we believe that it could be of great use for closure of defects at sites subject to flexion and tension movements&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case History</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 102-year-old man&#44; who was partially dependent for basic activities of daily living&#44; but with complete mobility in his arms and who could eat without assistance&#44; underwent a single surgical procedure in regimen of major outpatient surgery&#44; under local anesthetic and sedation&#44; for a circular squamous cell carcinoma in the radial dorsal region of the left wrist &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The resulting defect measured 4&#8239;cm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; A reading man flap was designed for reconstruction of the defect&#44; which was sutured directly with silk 3&#47;0 stitches &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; Daily dressing changes were done with chlorhexidine and soft bandaging&#44; and the stitches were removed after 10 days&#46; The patient was recommended not to lift weights or make forced movements with the arm for 15 days&#46; No postoperative complications were reported&#44; except for a small superficial necrosis at the vertex of the second flap&#46; However&#44; the esthetic and functional outcome at 3 months was very satisfactory &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">This reading man technique is based on the use of an asymmetric Z-plasty &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The central line&#44; tangential to the defect&#44; and perpendicular to the line of low skin tension&#44; should be 50&#37; longer than the diameter of the defect &#40;black line&#41;&#46; At the distal end&#44; a line is designed forming a 60&#176; angle with a length equal to the diameter of the defect &#40;red line&#41; and at the proximal end to the defect&#44; another tracer line opposite to the anterior of equal length is added&#44; forming a 45&#176; angle &#40;green line&#41;&#46; Subsequently&#44; a double transposition is performed by which the tumor defect is covered by the first rectangular-shaped flap &#40;F1&#41;&#46; This defect is in turn covered by transposition of the second triangular-shaped flap &#40;F2&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In the literature&#44; we encountered 14 articles that reported a total of 147 cases&#46; The main site where this technique was used is the face&#44; specifically the malar region&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> followed by the trunk&#46; At the latter of these sites&#44; the reading man flap has been used mainly for covering large defects after myelomeningocele interventions&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or pressure ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In such situations&#44; it is a very useful alternative to myocutaneous or perforating flaps&#46; However&#44; we did not find any publication that highlighted the advantages of this plasty at sites of flexion and tension as was the case in our patient&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The reported rate of complications is relatively low&#46; There have been a few reports of mild dehiscence and cases of dog ears and transient trapdoor effect have been reported due mainly to the first flap being too large&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Also of note is a case of partial distal necrosis at the vertex of the second plasy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Such complications seem to be more frequent when used at an extrafacial site&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This plasty has been compared with other transposition flaps such as the Limberg flap or the bilobed flap in models of artificial human skin and a lower suture tension&#59; less removal of healthy skin&#44; and a longer scar were demonstrated compared with the Limberg flap but with a similar scar area&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The reconstruction of defects to cover periarticular areas is a therapeutic challenge&#44; and transposition flaps are the most widely used&#44; above all&#44; bilobed flaps or Limberg flaps&#44; as they allow the tension of closure to be reduced compared with other types of reconstruction&#46; Good outcomes have been reported with the keystone-type flap in these areas<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; however&#44; most patients were younger and with a much less atrophied skin than was the case in our patient&#46; Other options&#44; such as complete skin graft&#44; have the drawback of subsequent contracture of the graft and therefore a greater risk of functional limitations&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; the reading man flap is a safe plasty that can be performed relatively easily&#46; The main advantage is that it can guarantee closure with low tension&#46; There is therefore a lower risk of necrosis&#44; dehiscence&#44; and poor wound healing&#44; with less distortion and traction of adjacent tissues&#44; and less removal of healthy skin&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Although the reading man flap was initially described to cover circular defects on the cheek&#44; and indeed it is a good option for this site&#44; we believe that the advantages mentioned with respect to other local plasties make it a particularly useful option in regions submitted to high tension such as large defects on the trunk or those in body areas with movements of flexion and tension&#44; such as the wrist in the case of our patient&#46; In these regions of flexion and tension in particular&#44; other reconstructive options such as grafts or Limberg plasties can generate more traction with a greater risk of functional deficit&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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