Keystone and Pedicle Perforator Flaps in Reconstructive Surgery: New Modifications and Applications

Extended Anterolateral Thigh Flaps: Maximum Size for Covering Cancerous Defects

BACKGROUND

The anterolateral thigh perforator flap is frequently used for massive soft-tissue defect reconstruction. Cadaver perfusion examinations of isolated anterolateral thigh flaps have suggested a maximum skin area that may be vascularized based on the perforating vessels (ie, 250 cm 2 ). Therefore, this study aimed to evaluate a series of consecutive cases involving use of extended anterolateral thigh flaps for oncologic reconstruction of massive soft-tissue defects. To our knowledge, this is the largest study of extended anterolateral thigh flaps at a single center.

METHODS

Patients who underwent transfers of anterolateral thigh flaps exceeding 250 cm 2 at our institution between April 2018 and December 2022 were retrospectively identified. The operative data and results were analyzed.

RESULTS

Thirty-eight flaps in 36 cases were included. The 38 flaps consisted of 31 free flaps and 7 pedicled flaps. The average skin paddle size was 363 ± 101 cm 2 (range, 250-660 cm 2 ). The donor site was primarily closed in 7 flaps. The remaining 31 flaps required skin grafting to ensure donor-site closure. Neither total nor partial flap loss was observed. Four patients had wound dehiscence due to tightness. Three patients had surgical-site infections. Two patients had seromas. The postoperative courses of the 5 patients were complicated by partial skin graft loss at the donor sites.

CONCLUSIONS

The anterolateral thigh flap is versatile and reliable for the treatment of massive oncological defects. Even flaps much larger than 250 cm 2 can usually be harvested safely based on 2 to 4 perforators without special techniques, such as compound flaps or additional vessel anastomoses.

Does Preoperative Vascular Mapping Using Color-Doppler Ultrasound have a Role in the Success of Axial Nasolabial Flap?

Aim

The study was performed to compare the effects of preoperative vascular mapping on the clinical outcome of axial nasolabial flap.

Materials and Methods

A total of 26 patients (29 flaps) were alternately divided into two groups using simple block randomization method. In Group I patients, the conventional axial flap was marked. In Group II, USG-guided flap was designed with the help of Color-Doppler ultrasound. Patients were assessed for a minimum of 6 months and the postoperative flap outcome was quantified using a self-validated composite scoring system. Other parameters of patient morbidity including length of hospital stay, resurgery for reconstruction of secondary defects, postoperative complications were also measured and compared.

Results

The mean postoperative flap outcome score was significantly superior in Group II patients than Group I, at the beginning and at the conclusion of the study (intergroup p-value at postoperative-1-week = .001; at postoperative-1-month = .044; at postoperative-3-month = .139; at postoperative-6-month = .007). Additionally, reconstruction defects with the conventional nasolabial flap were associated with greater morbidity as compared to Group II (intergroup comparison-hospital stay and duration p = .001; complications p = .115; Redo Surgery p = .096).

Conclusion

Therefore, it can be concluded that flap selection based on known dominant perforators could be helpful in achieving favorable outcomes resulting in minimal postoperative morbidity while allowing complex surgical reconstructions.

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.

Indocyanine Green-Based Fluorescence Imaging to Guide Local Tissue Rearrangement of a Complex Morel-Lavallee Lesion About a Hip: A Technical Trick

VIDEO AVAILABLE AT

https://ota.org/education/ota-online-resources/video-library-procedures-techniques/icg-based-fluorescence-imaging.

Repair of buccal mucosa and floor of mouth defects using keystone design perforator island flap

OBJECTIVE

To assess the feasibility of utilizing the keystone design perforator island flap (KDPIF) for the repair of small to medium-sized defects in the buccal mucosa and floor of mouth (cT1-2 stage tumor).

STUDY DESIGN

We conducted a retrospective analysis of eight patients who underwent KDPIF to address oral defects at the Affiliated Hospital of Qingdao University between June 2021 and September 2022. Patient information, including medical history, defect site, flap size, operative time, hospital stay, complications, and postoperative recovery of oral function, was comprehensively evaluated.

RESULTS

Eight patients (6 females and 2 males) underwent reconstruction using KDPIF. The mean operation time was 58.5 minutes (55-63 minutes), with an average length of stay of 3.5 days (3-5 days). None of the 8 cases (100%) exhibited flap splitting necrosis or infection. Moreover, no scar contracture was observed, and oral functions, including the degree of opening, type of opening, tongue mobility, speech function, and swallowing function, were successfully restored. One patient (12.5%) experienced bleeding from the incision on the first postoperative day, but following compression, hemostasis was achieved, and the incision healed well.

CONCLUSIONS

KDPIF demonstrates technical feasibility and suitability for repairing small to medium-sized buccal mucosa and floor of mouth defects (cT1-2).

A bipedicled keystone perforator island flap: Pedicle division technique with enhanced advancement potential for chronic wound coverage

Since the first description of the keystone perforator island flap (KPIF) in 2003, several modifications have been suggested to enhance its coverage ability. However, locoregional flaps have limited its use in chronic wounds due to decreased elasticity around the defect. We investigated the use of a bipedicled KPIF (bKPIF), which covers a defect while completely elevating the median part of the flap from the fascia. A retrospective chart review of 20 consecutive patients who underwent classical type I KPIF (n = 10) or bKPIF (n = 10) reconstruction from June 2020 to December 2022 was performed. Baseline characteristics, indications, operative details, healing time, and complications were analyzed and compared between the two groups. The average defect size was 30 cm2 in type I KPIF and 36.6 cm2 in bKPIF, and an average flap size of 86.5 cm2 was covered in type I KPIF, larger than bKPIF at 73.8 cm2. The flap/defect ratio was significantly lower in the bKPIF group (p < 0.02), with an average of only 55% pedicular area. The average advancement distance in the bKPIF group was 1.85 cm (standard deviation 0.78) greater than that in the type 1 KPIF group. There was no significant difference between the groups in terms of operation time, complete healing time, and complications. All ten bKPIFs were successful without any flap necrosis. Even though the mean pedicular area in the bKPIF group was nearly half compared with that in the type I KPIF group, it was sufficient to perfuse the entire flap without any major complications. This novel technique using bKPIF has potential clinical relevance, as evidenced by the enhanced ability to cover chronic defects with severe scarring. Lateralizing the hotspots to the bilateral corners of the flap is the mechanism that facilitates this potential.

Anterolateral Thigh Chimeric Flap: An Alternative Reconstructive Option to Free Flaps for Large Soft Tissue Defects

The anterolateral thigh (ALT) skin flap provides abundant, thin, pliable skin coverage with adequate pedicle length and calibre, and tolerable donor site morbidity. However, coverage of relatively large defects using the ALT flap alone is limited. We present our experience of using the ALT flap coupled with the vastus lateralis (VL) flap supplied by the same pedicle for large defect reconstruction. Between 2016 and 2020, ten patients with extensive lower-extremity or trunk defects were treated using the ALT/VL chimeric flap. The ALT portion was used to cover the cutaneous and joint defect while the VL part was used to resurface remnant defects, and a skin graft was performed. All flaps were based on the common descending pedicle, and branches to separate the components were individually dissected. All defects were successfully reconstructed using the ALT/VL chimeric flap. No surgery-related acute complications were observed, and the patients had no clinical issues with ambulation or running activities during the long-term follow-up period. With the separate components supplied by a common vascular pedicle, the ALT/VL chimeric flap allows us to reconstruct extensive defects with joint involvement or posterior trunk lesions. Thus, the ALT/VL chimeric flap may be a suitable alternative for extensive tissue defect reconstruction.

Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review

PURPOSE

The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects.

METHODS

A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap.

RESULTS

Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%).

CONCLUSIONS

Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

Minimizing donor-site morbidity following limbs' injuries with keystone perforator island flap reconstruction

Plastic surgeons strive to choose better techniques to reconstruct the defects of the limbs, minimizing the wound healing problems, improving the aesthetic and functional outcome with less complications. This study refers to the use of keystone perforator island flap in limbs' reconstruction, their harvesting technique to minimize donor-site morbidity, maximize the functional and cosmetic outcome, and will point on the most important indications and advantages. Between January 2014 and June 2020, a number of 28 cases were treated in our department, with simple or complex defects of the limbs. The database included patients' demographics, comorbidities, etiology, characteristics of the flap, surgical factors, follow-up period, flap outcomes. We performed 28 keystone perforator island flaps, 14 of Type I, 12 of Type IIA, 1 of Type III, 1 of Type IV, with an average size of 69 cm² (ranged from 1.25 cm² to 318 cm² ). Trauma was the major cause of the defects. One flap exhibited approximately 4% partial superficial necrosis. All donor sites healed without any adverse events. All patients were satisfied with the functional and aesthetic results. The keystone perforator island flaps provide a simple and effective method of wound closure by using tissues of similar texture, thickness, color. Preserving the main artery and the underlying muscle this flap reduces the donor site morbidity. The use of keystone perforator island flaps seems to be one of the most suitable choices whenever possible.

Reconstruction of Achilles region defects: A single-centre experience

BACKGROUND

Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes.

METHOD

In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre.

RESULTS

Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting.

CONCLUSION

Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

The Keystone Flap: A Multi-centric Experience in Elderly Patients Treatment

Soft tissue reconstruction in elderly patients must be rapid and reliable. The keystone island flap (KF) offers an effective solution, with low complication rates and quick recovery. This multi-centric study aims to show authors' experience with KFs in treating soft tissue defects of trunk and limbs. Patients with soft tissue defects suitable for KF reconstruction were recruited from March 2019 to December 2019. Active inflammation and previous surgeries in the same region were considered exclusion criteria. Complications that occurred during follow-up were recorded, and their incidence pattern was assessed with the Fisher test. Seventy-two patients with mean age of 76.2 years old were selected. They presented lesions in torso (46; 63.9%) or in upper (4; 5.6%) or lower (22; 30.6%) limb regions. Fifteen (20.8%) wounds were non-oncologic lesions, and the others were oncologic lesions, mostly non-melanoma skin cancers. KF type I was carried out in 42 (58.3%) cases, KF type II-A in 13 (18%) cases, double opposed type III KF in 16 (22.2%) patients, and 1 (1.4%) case required partial flap's undermining (IV KF). Mean post-operative recovery period was 4.3 days (range, 1-9 days). Post-surgical complications occurred in 15 (20.8%) cases, 7 (9.7%) of them were considered major complications. No statistically significant difference in complications' incidence, nor among different surgical sites nor among KF types, was registered. Reconstructive surgeons have to adapt their work to elderly patients. The KF allows rapid operative times, low morbidity rates, and short post-operative recovery time, thus appearing as a feasible solution.

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

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.

A Propeller Perforator Flap in the Distal Lower Extremity: An Alternative to Free Flap Coverage Near the Ankle

As perfusion assessment technologies and microsurgical techniques have evolved, plastic surgeons have become increasingly aggressive and creative in offering reconstructive solutions to limb salvage problems. In the distal lower extremity, pedicled perforator flap transfer has grown in popularity as compared to the historically reliable option of free tissue transfer. Pedicled perforator flaps typically avoid muscle harvest and restore the thin, supple soft tissue in the distal extremity, where there is a relative lack of redundancy of soft tissues. They also allow for a shorter operative time and recovery in otherwise complex wounds of the foot and ankle. This case report highlights the indications, nuance, and post-operative course of a patient who underwent peroneal perforator flap for coverage of a complex ankle wound in the setting of a calcaneal fracture.

Improving Outcomes in Anterolateral Thigh Flap Donor-Site Reconstruction Using Propeller Flaps: A Retrospective Comparative Study with Skin Grafting

BACKGROUND

 After anterolateral thigh (ALT) flap harvesting, skin graft of the donor site is commonly performed. When the defect width exceeds 8 cm or 16% of thigh circumference, it can determine lower limb function impairment and poor aesthetic outcomes. In our comparative study, we assessed the functional and aesthetic outcomes related to ALT donor-site closure with split-thickness skin graft compared with thigh propeller flap.

METHODS

 We enrolled 60 patients with ALT flap donor sites. We considered two groups of ALT donor-site reconstructions: graft group (30 patients) with split-thickness skin graft and flap group (30 patients) with local perforator-based propeller flap. We assessed for each patient the range of motion (ROM) at the hip and knee, tension, numbness, paresthesia, tactile sensitivity, and gait. Regarding the impact on daily life activities, patients completed the lower extremity functional scale (LEFS) questionnaire. Patient satisfaction for aesthetic outcome was obtained with a 5-point Likert scale (from very poor to excellent).

RESULTS

 In the propeller flap group, the ROMs of hip and knee and the LEFS score were significantly higher. At 12-month follow-up, in the graft group, 23 patients reported tension, 19 numbness, 16 paresthesia, 22 reduction of tactile sensitivity, and 5 alteration of gait versus only 5 patients experienced paresthesia and 7 reduction of tactile sensitivity in the propeller flap group. The satisfaction for aesthetic outcome was significantly higher in the propeller flap group.

CONCLUSION

 In high-tension ALT donor-site closure, the propeller perforator flap should always be considered to avoid split-thickness skin graft with related functional and aesthetic poor results.

Myelomeningocele defect reconstruction with keystone flaps: vascular rationale for the design and operative technique

BACKGROUND

Myelomeningocele is a frequently seen condition at tertiary care hospitals. Its treatment involves a variety of plastic reconstructive techniques. Herein, we present a series of myelomeningocele patients treated using keystone flaps.

METHODS

We gathered information regarding soft tissue reconstruction and the use of bilateral keystone flaps to treat myelomeningocele patients. We obtained data from clinical records and recorded the demographic characteristics of mothers and children with the condition. The size, level of defect, and complications detected during the follow-up were analyzed.

RESULTS

A series of seven patients who underwent bilateral keystone flaps for myelomeningocele closure was analyzed. There were no cases of midline or major dehiscence, flap loss, necrosis, surgical site infections, or cerebrospinal fluid leakage. No revision procedures were performed. Minor complications included one case with minimal seroma and three cases with areas of peripheral dehiscence that healed easily using conventional measures.

CONCLUSIONS

The use of keystone flaps is an adequate option for closure of dorsal midline soft tissue defects related to myelomeningocele. This technique offers predictable results with an acceptable spectrum of complications. Robust blood flow can be predicted based upon anatomical knowledge.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases

BACKGROUND

To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects.

METHODS

From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed.

RESULTS

The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing.

CONCLUSIONS

STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

In situ Adipogenesis in Biomaterials Without Cell Seeds: Current Status and Perspectives

For cosmetic and reconstructive purposes in the setting of small-volume adipose tissue damage due to aging, traumatic defects, oncological resections, and degenerative diseases, the current strategies for soft tissue replacement involve autologous fat grafts and tissue fillers with synthetic, bioactive, or tissue-engineered materials. However, they all have drawbacks such as volume shrinkage and foreign-body responses. Aiming to regenerate bioactive vascularized adipose tissue on biomaterial scaffolds, adipose tissue engineering (ATE) has emerged as a suitable substitute for soft tissue repair. The essential components of ATE include scaffolds as support, cells as raw materials for fat formation, and a tolerant local environment to allow regeneration to occur. The commonly loaded seeding cells are adipose-derived stem cells (ASCs), which are expected to induce stable and predictable adipose tissue formation. However, defects in stem cell enrichment, such as donor-site sacrifice, limit their wide application. As a promising alternative approach, cell-free bioactive scaffolds recruit endogenous cells for adipogenesis. In biomaterials without cell seeds, the key to sufficient adipogenesis relies on the recruitment of endogenous host cells and continuous induction of cell homing to scaffolds. Regeneration, rather than repair, is the fundamental dominance of an optimal mature product. To induce in situ adipogenesis, many researchers have focused on the mechanical and biochemical properties of scaffolds. In addition, efforts to regulate an angiogenic and adipogenic microenvironment in cell-free settings involve integrating growth factors or extracellular matrix (ECM) proteins onto bioactive scaffolds. Despite the theoretical feasibility and encouraging results in animal models, few of the reported cell-free biomaterials have been tested in humans, and failures of decellularized adipose tissues in adipogenesis have also been reported. In these cases, the most likely reason was the lack of supporting vasculature. This review summarizes the current status of biomaterials without cell seeds. Related mechanisms and influencing factors of in situ adipogenesis in cell-free biomaterials, dilemma in the development of biomaterials, and future perspectives are also addressed.

A systematic review and meta-analysis of perforator flaps in plantar defects: Risk analysis of complications

The purpose of this study was to identify the risk factors for complications of perforator flaps in plantar reconstruction. A systematic review was performed by searching the PubMed, Cochrane Library, MEDLINE, and EMBASE databases from their inception date up to October 2020. Only studies on reconstructing plantar defects with perforator flaps were included, and specific data were required for each patient in the included studies. A total of 14 studies involving 111 flaps were identified and included in the meta‐analysis. Our meta‐analysis identified two risk factors for postoperative complications: flap size over 50 cm² (risk ratio [RR] = 3.12; P = .02), diabetes mellitus foot (RR = 3.26; P = .03). No significant differences were found regarding heel defects (P = .34), single perforator (P = .57), age older than 60 years (P = .19), chronic aetiology (P = .13), trauma (P = .33), tumour resection (P = .60), ulcer (P = .84), and burn (P = .76). Although more high‐quality studies with adequate sample sizes are needed, this meta‐analysis indicated that flap size over 50 cm² and diabetes mellitus foot were significant risk factors for postoperative complications of perforator flaps in plantar reconstruction.

Perforator-Based Flaps for Defect Reconstruction of the Posterior Trunk

INTRODUCTION

Full-thickness soft tissue defects of the back remain challenging clinical problems for reconstructive surgeons. Among a vast variety of local flap options, perforator-based local flaps gain increasing popularity lately. Because mostly heterogeneous patient cohort comparison of different perforator flaps is difficult and decision-making algorithms are lacking.

METHODS

Patients, who received a local perforator-based soft tissue reconstruction between 2012 and 2019, were evaluated retrospectively. Patients' data were evaluated in terms of flap type and dimension, wound size and cause, surgery time, postoperative complications, and hospitalization. A focus was set on decision making concerning reconstructive techniques and flap choice for defect closure.

RESULTS

Thirty-six patients (17 women, 19 men) were included, who received 40 perforator-based local flaps to reconstruct extended defects of the posterior trunk. Mean patient age was 56.3 years and mean hospitalization was 29 days. Average time of flap surgery was 179.7 minutes. Mean flap size was 160.8 cm and average defect size was 110 cm. Defects occurred because of tumor resection (50%), orthopedic/trauma surgery (16.7%), or pressure sores (33.3%). Twenty-eight propeller flaps (PPFs, 70%) and 12 perforator-based VY-advancement flaps (P-VYF, 30%) were transferred. In 4 patients, a bilateral approach using more than one flap was necessary. Revision surgery was required in 9 patients (25%) because of postoperative hematoma (n = 3), postoperative wound infection (n = 3), partial flap necrosis (1× P-VYF) and 2 flap losses (2× PPFs).

CONCLUSIONS

Pedicled perforator flaps are a reliable option for soft tissue reconstruction of complex wounds of the posterior trunk. A flexible surgical strategy is mandatory, and the individual perforator anatomy has to be considered. In most cases, P-VYFs or PPFs are reliably possible and allow sufficient defect reconstruction. However, skin incisions should always be performed in a way that classic random pattern flaps are still possible. Even in large defects combined, local perforator flaps may lead to sustainable soft tissue reconstructions without functional donor site deficits.

Surgical management of hidradenitis suppurativa with keystone perforator island flap

INTRODUCTION

Hidradenitis suppurativa is a chronic, relapsing disease of the skin, characterized by apocrine gland and pilosebaceous complex infections, causing recurrent superficial nodules and abscesses, fistula formation, scarring and fibrosis. It is accepted that wide local excision and local coverage is the crucial treatment to prevent recurrence of the disease.

MATERIALS AND METHODS

All patients presenting for surgical treatment of hidradenitis suppurativa between 2014 and 2019 were identified from the hospital database. Only patients with hidradenitis suppurativa confined to the axillary, inguinal or sacrococcygeal regions in Hurley grade II and III were included. A total of 21 patients (11 male, 10 female) aged between 21 and 76 years were evaluated retrospectively. All of the 22 defects were reconstructed with keystone perforator island flap following wide local excision. We performed descriptive analysis of demographic data, comorbidities, topographic distribution of lesions, Hurley scoring, size of defect, specific type of reconstruction, complications, follow-up period, recurrences.

RESULTS

21 patients with localized axillary, inguinal or sacrococcygeal hidradenitis suppurativa were identified, and 22 keystone perforator island flaps were performed. All keystone perforator island flaps survived giving a durable cover to the affected regions. There were no complications. Functional and aesthetic results were satisfactory and there were no recurrences.

CONCLUSION

These findings confirm that the keystone perforator island flap procedure can be effective for immediate defect reconstruction after wide local excision of advanced hidradenitis suppurativa of the axillary, inguinal and sacrococcygeal regions and provides excellent aesthetic results.

Keystone flap: a safe coverage option in the handling of salvage for myelomeningocele

BACKGROUND

Myelomeningocele (MMC) is the most common and severe pathology of open spina bifida compatible with life. Its early closure is an urgent therapeutic objective to reduce the morbidity and mortality of neonates, being a surgical challenge with two major objectives: (1) achieve closure of the dural cerebrum-spinal fluid fistula and (2) ensure a stable and durable soft tissue coverage. The use of fasciocutaneous flaps in keystone design is shown as a safe and stable surgical option with excellent aesthetic results in patients with MMC and who presented failed primary closures.

METHODS

Two clinical cases of fasciocutaneous flaps in keystone design were described as a coverage option in patients with lumbosacral MMC, in whom the primary closure was unsuccessful and required a safe coverage as a priority.

RESULTS

Successful coverage of the lumbosacral defect was performed using keystone flaps in neonatal patients with MMC and previous manipulation of the soft tissues when attempting primary closure, but they have had dehiscence of the wound, with a large area of lumbosacral defect and sizeable defect/back ratio.

CONCLUSIONS

The use of keystone flaps is a useful, accessible, and versatile technique as a management option for lumbosacral coverage defects in MMC, achieving a stable and safe covering of the meninges, without cerebrum-spinal fluid fistulas, which also allows the primary closure of the soft tissues in the donor area. The safety of this type of flap when used as salvage in lumbosacral defects with previously handled and raised tissues could infer that it is reliable enough to be considered as a first surgical option in the initial management of MMC.

Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications

Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon's armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and "hot spot" principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction. Modifications in keystone perforator island flap increased degrees of freedom the reconstructive surgeon has for soft tissue coverage of large defects, with significant reliability, aesthetically pleasing results, and reduced donor site morbidity.

Keystone design perforator island flap in facial defect reconstruction

Facial defect coverage is a common subject in the field of reconstructive surgery. There are many methods for facial defect reconstruction, and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement. Among various options for facial reconstruction, the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture, which is consistent with the ideal goal of reconstruction (replacement of like-with-like). Keystone design perforator island flap (KDPIF), devised by Behan in 2003, has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity, robust vascular supply, and reproducibility. Several studies have reported KDPIF reconstruction of facial defects, such as large parotid defects, small-to-moderate nasal defects, and eyelid defects. However, KDPIF has been used relatively less in facial defects than in other body regions, such as the trunk and extremities. The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF, modifications, physiology, mechanism of flap movement, consideration of facial relaxed skin tension lines and aesthetics, surgical techniques, clinical applications, and precautions for successful execution of KDPIF reconstruction.

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

Background

The keystone perforator flap design has been gaining popularity for reconstruction of cutaneous defects due to its robust vascular supply and high rates of flap survival. However, the design requires significant tissue mobilization relative to the defect and is consequently technically demanding, time intensive, and has associated morbidity. We present a novel, simplified modification of the keystone flap that may increase its reconstructive applications.

Methods

A retrospective chart review was conducted of patients who underwent V-Y hemi-keystone advancement flap reconstruction of cutaneous defects by a single surgeon. Outcomes of interest included wound healing complications.

Results

Eighty-six consecutive V-Y hemi-keystone advancement flaps were performed with an overall complication rate of 7% (6/86). Reconstruction sites included lower extremities (75/86, 87.2%), upper extremities (9/86, 10.5%), and the trunk (2/86, 2.3%). Mean follow-up time was 26.3 weeks. Four out of 5 surgical site infections occurred on lower extremity wounds. There were no cases of complete or partial flap loss.

Conclusions

The current series presents a simplification of the traditional keystone flap that decreases surgical complexity and time required for successful reconstruction of cutaneous defects, especially in challenging wounds on the lower extremities. The complication rates were similar, or lower, than previously reported series of keystone flap reconstructions. The consistently favorable outcome of this technique supports the integration of the V-Y hemi-keystone advancement flap into reconstructive surgery.

Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature

INTRODUCTION

The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated.

METHODS

This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded.

RESULTS

There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation.

CONCLUSIONS

The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

Closure of radial forearm free flap donor site: A comparative study between keystone flap and skin graft

BACKGROUND

The aim was to investigate the feasibility of radial forearm free flap (RFFF) donor site closure by keystone flap (KF) and compare its outcomes to those of skin graft (SG) closure.

METHODS

One hundred and one patients who underwent RFFF for head and neck reconstruction were included (35 KF closure and 65 SG closure). Duration of wound healing and donor site complications was collected. After a minimal follow-up of 1 year, patients were questioned about functional and esthetic impairment.

RESULTS

Coverage of donor site by KF was successful in all cases. The duration of wound healing was longer after SG than after KF (32 days vs 18 days, P < .001). Healing complications, esthetic and functional results were not statistically different.

CONCLUSION

Forearm donor site closure by KF is a feasible alternative to the traditional SG. Its main advantages are the reduced wound healing time and the avoidance of a second donor site.

Keystone Flap: Overcoming Paradigms

Background:

The physiology and geometry of the keystone flap (KF) are the main factors that support its development. This study reports our experience using the KF and proposes the concept of pedicular area.

Methods:

A prospective cohort study was conducted from October 2014 to December 2016, in which 112 KF procedures were performed with an average follow-up time of 10 months. The conclusions drawn from clinical observations were compared with the findings of a literature review.

Results:

One hundred twelve flaps were performed in 89 patients (45 men and 44 women) with an average age of 64 years (range, 3–89 years). The flap survival rate was 100%. The term pedicular area (PA) was coined to describe a flap segment that remains attached to its bed without vascular detriment and whose location can be randomly selected. In this study, the PA could be reduced up to a 10%, which means that over 90% of each flap was dissected without any harm.

Conclusions:

The KF is a safe, cost-effective technique with better results when compared with other reconstructive procedures. Although research is still needed to better understand the physiological adaptations of KF, the clinical evidence supports its use in many reconstructive scenarios.

Relaxed skin tension line-oriented keystone-designed perforator island flaps considering the facial aesthetic unit concept for the coverage of small to moderate facial defects

A variety of reconstructive options including skin grafts, loco-regional flaps, and free flaps exist for the coverage of facial defects. Each technique has advantages and disadvantages. In this study, we present our experience with relaxed skin tension line (RSTL)-oriented, keystone-designed perforator island flap (KDPIF) reconstructions, in consideration of the facial aesthetic unit concept for coverage of small to moderate facial defects.Between May 2016 and February 2018, 17 patients (11 men and 6 women), with an average age of 63.53 years (range: 37-83 years) underwent KDPIF reconstructions to cover facial defects. We performed the KDPIF reconstructions in consideration of the RSTLs and facial aesthetic unit concept. We retrospectively reviewed the defect causes, locations, and sizes, and flap sizes, types, and survivals, as well as the complications. Cosmetic outcomes were evaluated using the Harris 4-stage scale from 3 independent plastic surgeons' point of view, and postoperative satisfactory surveys from all patients.All defects were successfully covered with KDPIF. The defect sizes varied from 1.5 × 1.5 cm to 3 × 3.5 cm. The flap sizes varied from 1.5 × 3 cm to 3 × 5.5 cm. All flaps fully survived and there were no postoperative complications. The average subjective patient satisfaction score was 8.29 (range: 7-10) and the objective cosmetic outcomes were favorable (fair, good, or excellent).Considering its simplicity and safety, the KDPIF is a good reconstruction option with few complications and high reproducibility. The RSTL-oriented KDPIF reconstruction is a good reconstructive option for covering small to moderate facial defects with superior aesthetic outcomes.

Preoperative planning for advanced modelling of anterolateral thigh flaps in the treatment of severe haemifacial atrophy in Parry-Romberg and Goldenhar syndrome

Background

Technological advancement in medical science is constantly innovating solutions to the varied and complex challenges of surgery. Digital diagnostics and prospective microsurgery are rapidly evolving. Three-dimensional (3-D) imagery and computed tomography (CT) scanning can determine accurate dimensions of many defects. Subsequently, a thorough understanding of micro-vasculature and application of microsurgical techniques allows modelling of flaps to obtain an accurate transplant resulting in an aesthetic outcome following the very first operation.

Methods

Two patients with Parry–Romberg syndrome and one patient with haemifacial microsomia (Goldenhar syndrome) were treated with anterolateral thigh (ALT) flaps to restore facial volume, contour, and symmetry. In each case, a different approach in planning and performing the intervention was applied:

The patient in the first case had a full-thickness ALT flap transplant with significant overcorrection.

The patient in the second case had reconstruction with a partially thinned ALT flap guided by a clinically formed template made per manual measurements.

The patient in the third case had reconstruction with a precise primary thinned ALT flap with a template made according to data obtained from superimposed 3-D photographs and CT scans.

Results

All flaps survived. In cases 1 and 2, a corrective intervention was required to achieve acceptable facial symmetry. In case 3, a very good aesthetic result was achieved immediately after the first operation.

Conclusions

Digital methods of 3-D analysis offer great opportunities in creating a precise operative plan, and modern surgical techniques make it feasible to implement it intra-operatively. Overall, these methods shortened the rehabilitation time by avoiding further revision surgeries.