Application of Keystone flap in the repair of soft tissue defect of lower extremity_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

Aerken·Juman , Maimaiaili·Yushan , Abulaiti·Abula , REN Peng , CHENG Erlin ,  Aihemaitijiang·Yusufu

Department of Microreconstructive Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi Xinjiang, 830011, P.R.China;

Corresponding author：

Aihemaitijiang·Yusufu, Email: Ahmatjang@163.com

Keywords：

Keystone flap; microsurgical technique; soft tissue defect; lower extremity

DOI：

10.7507/1002-1892.202103134

Video：

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Objective To study the effectiveness of Keystone flap in the repair of soft tissue defect of lower extremity.Methods The clinical data of 27 cases with soft tissue defects of lower extremity treated by Keystone flap between January 2018 and June 2020 were retrospectively analyzed. There were 18 males and 9 females, with an average age of 43.9 years (range, 8-63 years). The cause of soft tissue defects included skin tumor in 3 cases, ulcer in 2 cases, soft-tissue infection in 8 cases, trauma in 7 cases, and donor site defect after free or pedicled flap transplantation in 7 cases. Defect size ranged from 2.0 cm×1.5 cm to 15.0 cm×9.5 cm. The types of Keystone flaps included type Ⅰ in 2 cases, type Ⅱa in 16 cases, type Ⅱb in 1 case, type Ⅲ in 6 cases, and Moncrieff modified type in 2 cases. The area of flap ranged from 3.0 cm×1.5 cm to 20.0 cm×10.0 cm. The donor site was directly sutured (26 cases) or repaired with skin grafting (1 case).Results The operation time was 45-100 minutes, with an average of 67.5 minutes; the hospitalization stay was 3-12 days, with an average of 8.5 days. Postoperative incision dehiscence occurred in 1 case, and flap marginal necrosis occurred in 2 cases, all of which were completely healed after dressing change; 1 case of incision was swollen and congested with tension blisters, which resolved spontaneously at 7 days after operation. The other flaps and the skin grafting survived and healed successfully, the wounds of recipient and donor sites healed by first intention. The healing time was 2-3 weeks (mean, 2.2 weeks). No pain occurred in all patients. All 27 cases were followed up 3-26 months (mean, 11.5 months). No obvious scar contracture and bloated skin flap were found. The texture and color of the skin in the recipient area were similar to those of the surrounding tissues and feel existed.Conclusion The Keystone flap is a feasible and efficient way to repair soft tissue defect of lower extremity. Furthermore, the skin color and texture is similar to the surrounding tissue after healing.

Citation： Aerken·Juman, Maimaiaili·Yushan, Abulaiti·Abula, REN Peng, CHENG Erlin, Aihemaitijiang·Yusufu. Application of Keystone flap in the repair of soft tissue defect of lower extremity. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(8): 1038-1042. doi: 10.7507/1002-1892.202103134 Copy

1.	Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg, 2003, 73(3): 112-120.
2.	Huang J, Yu N, Long X, et al. A systematic review of the keystone design perforator island flap in lower extremity defects. Medicine (Baltimore), 2017, 96(21): e6842. doi: 10.1097/MD.0000000000006842.
3.	Douglas CD, Low NC, Seitz MJ. The keystone flap: not an advance, just a stretch. Ann Surg Oncol, 2013, 20(3): 973-980.
4.	Moncrieff MD, Bowen F, Thompson JF, et al. Keystone flap reconstruction of primary melanoma excision defects of the leg-the end of the skin graft? Ann Surg Oncol, 2008, 15(10): 2867-2873.
5.	Moncrieff MD, Thompson JF, Stretch JR. Extended experience and modifications in the design and concepts of the keystone design island flap. J Plast Reconstr Aesthet Surg, 2010, 63(8): 1359-1363.
6.	Behan FC. The fasciocutaneous island flap: an extension of the angiotome concept. Aust N Z J Surg, 1992, 62(11): 874-886.
7.	Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg, 2009, 124(5): 1529-1544.
8.	Mohan AT, Rammos CK, Akhavan AA, et al. Evolving concepts of keystone perforator island flaps (KPIF): Principles of perforator anatomy, design modifications, and extended clinical applications. Plast Reconstr Surg, 2016, 137(6): 1909-1920.
9.	Byun IH, Kim CW, Park TH. The modified keystone flap for pressure ulcers: A modification of the keystone flap with rotation and advancement. Ann Plast Surg, 2019, 82(3): 299-303.
10.	Pauline P, Guillaune De Bonnecaze G, Chabrillac E, et al. Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft. Head Neck, 2020, 42(2): 217-223.
11.	Aragón-Miguel R, Gutiérrez-Pascual M, Sánchez-Gilo A, et al. The keystone flap in dermatology: Clinical experience with 18 patients. Actas Dermosifiliogr (Engl Ed), 2018, 109(6): 515-520.
12.	Lanni MA, Van Kouwenberg E, Yan A, et al. Applying the Keystone design perforator island flap concept in a variety of anatomic locations: A review of 60 consecutive cases by a single surgeon. Ann Plast Surg, 2017, 79(1): 60-67.
13.	Al-Mousawi A, Sanese G, Baljer B, et al. Use of the keystone perforator island flap in the treatment of chronic lower extremity wounds complicated by osteomyelitis. Injury, 2020, 51(3): 744-749.
14.	Cogolludo LC, Conde-Taboada A, González-Guerra E, et al. Keystone flap used on the legs: case series. Clin Exp Dermatol, 2019, 44(6): 691-693.
15.	Abraham JT, Saint-Cyr M. Keystone and pedicle perforator flaps in reconstructive surgery: New modifications and applications. Clin Plast Surg, 2017, 44(2): 385-402.
16.	Hallock GG. The use of smartphone thermography to more safely unmask and preserve circulation to keystone advancement flaps in the lower extremity. Injury, 2020, 51(Suppl 4): S121-S125.

1. Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg, 2003, 73(3): 112-120.
2. Huang J, Yu N, Long X, et al. A systematic review of the keystone design perforator island flap in lower extremity defects. Medicine (Baltimore), 2017, 96(21): e6842. doi: 10.1097/MD.0000000000006842.
3. Douglas CD, Low NC, Seitz MJ. The keystone flap: not an advance, just a stretch. Ann Surg Oncol, 2013, 20(3): 973-980.
4. Moncrieff MD, Bowen F, Thompson JF, et al. Keystone flap reconstruction of primary melanoma excision defects of the leg-the end of the skin graft? Ann Surg Oncol, 2008, 15(10): 2867-2873.
5. Moncrieff MD, Thompson JF, Stretch JR. Extended experience and modifications in the design and concepts of the keystone design island flap. J Plast Reconstr Aesthet Surg, 2010, 63(8): 1359-1363.
6. Behan FC. The fasciocutaneous island flap: an extension of the angiotome concept. Aust N Z J Surg, 1992, 62(11): 874-886.
7. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg, 2009, 124(5): 1529-1544.
8. Mohan AT, Rammos CK, Akhavan AA, et al. Evolving concepts of keystone perforator island flaps (KPIF): Principles of perforator anatomy, design modifications, and extended clinical applications. Plast Reconstr Surg, 2016, 137(6): 1909-1920.
9. Byun IH, Kim CW, Park TH. The modified keystone flap for pressure ulcers: A modification of the keystone flap with rotation and advancement. Ann Plast Surg, 2019, 82(3): 299-303.
10. Pauline P, Guillaune De Bonnecaze G, Chabrillac E, et al. Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft. Head Neck, 2020, 42(2): 217-223.
11. Aragón-Miguel R, Gutiérrez-Pascual M, Sánchez-Gilo A, et al. The keystone flap in dermatology: Clinical experience with 18 patients. Actas Dermosifiliogr (Engl Ed), 2018, 109(6): 515-520.
12. Lanni MA, Van Kouwenberg E, Yan A, et al. Applying the Keystone design perforator island flap concept in a variety of anatomic locations: A review of 60 consecutive cases by a single surgeon. Ann Plast Surg, 2017, 79(1): 60-67.
13. Al-Mousawi A, Sanese G, Baljer B, et al. Use of the keystone perforator island flap in the treatment of chronic lower extremity wounds complicated by osteomyelitis. Injury, 2020, 51(3): 744-749.
14. Cogolludo LC, Conde-Taboada A, González-Guerra E, et al. Keystone flap used on the legs: case series. Clin Exp Dermatol, 2019, 44(6): 691-693.
15. Abraham JT, Saint-Cyr M. Keystone and pedicle perforator flaps in reconstructive surgery: New modifications and applications. Clin Plast Surg, 2017, 44(2): 385-402.
16. Hallock GG. The use of smartphone thermography to more safely unmask and preserve circulation to keystone advancement flaps in the lower extremity. Injury, 2020, 51(Suppl 4): S121-S125.

Chinese Journal of Reparative and Reconstructive Surgery

Application of Keystone flap in the repair of soft tissue defect of lower extremity

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