V-Y Hemi-keystone Advancement Flap: A Novel and Simplified Reconstructive Modification

The Keystone Flap: A Game Changer That Promises New Horizons in Reconstructive Surgery

BACKGROUND

Since its first description emerged in 2003, the keystone flap has garnered the attention of the international scientific community due to its high safety profile and the suitably low complication rate associated with the reconstructive process.

MATERIALS AND METHODS

In this study, data were obtained from the performance of 72 keystone flaps to cover soft-tissue defects after the excision of neoplastic processes, excisions, and injuries occurring in polytrauma. The study was conducted in the Department of Plastic Surgery, "Bagdasar-Arseni" Emergency Hospital, Bucharest, and two plastic surgeons in the department performed the surgical procedures.

RESULTS

The statistical analysis revealed a remarkably low complication rate (3.22%), excellent functional and esthetic results, and a short hospitalization time. No intraoperative complications were identified during this study. The degree of satisfaction obtained after reconstructive surgery was exceptionally high, with a score of 9.47 on a 10-point rating scale (0 = poor results, 10 = excellent results) from the patient's perspective and 9.51 out of 10 for the surgical team.

CONCLUSIONS

The keystone flap is the optimal solution for reconstructing soft-tissue defects of variable sizes and shapes. It is associated with a low length of hospitalization, a low complication rate, and high patient satisfaction.

Modified Keystone Perforator Island Flap Techniques for Small- to Moderate-Sized Scalp and Forehead Defect Coverage: A Retrospective Observational Study

We aimed to demonstrate the effective application of keystone perforator island flap (KPIF) in scalp and forehead reconstruction by demonstrating the authors' experience with modified KPIF reconstruction for small- to moderate-sized scalp and forehead defects. Twelve patients who underwent modified KPIF reconstruction of the scalp and forehead from September 2020 to July 2022 were enrolled in this study. In addition, we retrospectively reviewed and evaluated the patient's medical records and clinical photographs. All defects (size range, 2 cm × 2 cm to 3 cm × 7 cm) were successfully covered using four modified KPIF techniques (hemi-KPIF, Sydney Melanoma Unit Modification KPIF, omega variation closure KPIF, and modified type II KPIF) with ancillary procedures (additional skin grafts and local flaps). All flaps (size range, 3.5 cm × 4 cm to 7 cm × 16 cm) fully survived, and only one patient developed marginal maceration that healed with conservative management. Furthermore, through the final scar evaluation with the patient satisfaction survey and Harris 4-stage scale, all patients were satisfied with their favorable outcomes at the average final follow-up period of 7.66 ± 2.14 months. The study showed that the KPIF technique with appropriate modifications is an excellent reconstructive modality for covering scalp and forehead defects.

Customized reconstruction with rotation Hemi-Keystone flap

INTRODUCTION

The keystone perforator flap has become a versatile alternative for reconstruction of cutaneous defects of various etiologies and in all age groups. However, it demands a notable incision area proportional to defect size and is more prone to excessive tension during defect closure. We present a novel modified rotation Hemi-keystone flap that reveals its excellence in flap survival.

METHODS

Between March and December 2021, a retrospective chart review was conducted of 40 patients who received rotation Hemi-keystone flap for coverage of cutaneous defects by a single surgeon. The primary outcome was successful flap survival.

RESULTS

We performed a total of 45 modified rotation Hemi-keystone flaps for reconstruction of cutaneous wound defects. The location of the wound defects was in the head and neck (38%), extremities (35.7%), and trunk (26.2%). The most common cause of wound defect is tumor resection (45.2%). The mean wound defect dimensions were 3.5 cm × 3 cm. The mean follow-up time was 6 months. There were no significant complications, with only one patient (2.4%) having minor wound dehiscence, which was treated by local wound care.

CONCLUSIONS

The current series presents a simple, reliable, and versatile modification of the traditional keystone flap that minimizes morbidity at the reconstruction site along with improvement of flap mobility for successful reconstruction of cutaneous defects in a tension-free manner. The favorable outcome of this technique contributes to the inclusion of the rotation Hemi-keystone flap as an excellent surgical option in the reconstruction of various soft tissue defects.

Modified Keystone Perforator Island Flap for Tension-Reducing Coverage of Axillary Defects Secondary to Radical Excision of Chronic Inflammatory Skin Lesions: A Retrospective Case Series

Axillary defect coverage is often challenging after radical excision of chronic inflammatory skin lesions, such as complicated epidermoid cysts and hidradenitis suppurativa. This retrospective case series aims to demonstrate our experience with axillary reconstruction using the modified keystone perforator island flap (KPIF) technique, emphasizing its tension-reducing effects. All patients who presented for axillary reconstruction after radical excision of chronic inflammatory skin lesions between May 2019 and December 2020 were identified using the medical record database. Eleven patients ranging in age from 17 to 71 years underwent modified KPIF axillary reconstruction. Four types of modifications (modified type II KPIF, omega variation closure, Sydney melanoma unit modification, and hemi-KPIF) were used. All defects (size range, 2.5 × 3 cm² to 8 × 13 cm²) were successfully covered using these modified KPIF techniques. All flaps (size range, 3.5 × 3.5 cm² to 11 × 30 cm²) fully survived without complications. All patients exhibited favorable functional outcomes, and no cases of recurrence or limitations in joint range of motion were observed during the follow-up period (range, 4–5 months). Modified KPIF techniques may represent a reliable, effective alternative reconstructive modality for managing axillary defects.