Reconstruction of the Defect at Temporal Hairline by a Scalp Keystone Island Flap: Clinical Experience on 14 Cases

How to Safely Use the Perforator-based Keystone Island Flap in the Scalp: Basal Cell Carcinoma of the Scalp With Local Invasion to Calvarium

Scalp reconstruction has always been a challenging problem for even the most experienced surgeon to provide good aesthetic and functional results. This is mainly because the scalp is less mobile and tight, requiring a much larger dissection for the size of the original defect. We hypothesized that the omega variant perforator-based keystone island flap at the subgaleal plane provides a versatile and easily reproducible reconstructive option for scalp reconstruction after wide skin cancer excision. We reviewed all patients who underwent reconstruction with the keystone flap or its modification to repair scalp defects following wide resection of skin cancer in the scalp abutting calvarium from May 2021 to July 2023. We designed the flap width 50% wider than original keystone flap design first introduced by Dr. Behan. We reconstructed medium- to large-sized scalp defects ranging from 2×2 to 5×5 cm 2 using an omega variant perforator-based keystone island flap. All patients were satisfied with the aesthetic outcomes without complications. Keystone flaps are a versatile option for reconstructing the scalp after cancer resection. This strategy obviates the need for skin grafting, myocutaneous flap or free flap after cancer removal in the scalp.

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.