Rotation Advancement Keystone Flap for Closure of Large Myelomeningocele Defects

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.

Myelomeningocele Defects Reconstruction With Various Types of Keystone Flaps: An Algorithmic Approach Based on Defect Shape

The keystone flap has become an established option that has been utilized recently to close significant myelomeningocele defects. Although the keystone flaps can be adapted to repair myelomeningocele defects of different sizes, the shape of the defect is also an essential factor to consider. In this study, the authors proposed an algorithmic approach for reconstructing significant meningomyelocele defects utilizing different types of keystone flaps based on the shape of the resulting defect. From September 2016 to March 2022, the authors retrospectively reviewed the medical records of 28 patients with meningomyelocele who underwent repair with the keystone flaps. The mean age was 28 days (3 days to 4.5 months). Twenty-one meningomyelocele defects were in the lumbosacral (75%) and 7 in the thoracolumbar regions (25%). The defect sizes ranged from 3.5×5 cm (area, 13.4 cm 2 ) to 9×7 cm (area, 49.5 cm 2 ), with an average of 26.2 cm 2 . Ten meningomyelocele defects were a vertically oriented oval shape, 16 defects were a transversely oriented oval shape, and 2 defects were circular. In addition, unilateral keystone flap was used in 7.1% of the patients (2 patients), bilateral keystone flap in 28.6% (8 patients), and rotation advancement keystone flaps in 64.3% (18 patients). According to these findings, an algorithm was created based on the defect shape. This algorithmic approach is used as a decision-making guide to select the correct type of keystone flaps to repair myelomeningocele according to the defect shape.

Closure of Giant Dorsal Lumbosacral Myelomeningocele in Children Using Double Expanded Flaps: A Case Report and Literature Review

INTRODUCTION

Myelomeningocele (MMC) is the most common neural tube defect that can occur due to neural tube's failure to fuse properly during embryonic life. To prevent this, expanded flaps can be used for closure of large MMCs.

PRESENTATION OF CASE

A 4-year and 6-month girl was diagnosed with multiple congenital anomalies including hydrocephalus, dorsal lumbosacral MMC, and congenital tethered cord syndrome. Preoperative evaluation showed no lower limb movements and the size of the sacrococcygeal region was about 10 cm × 8 cm × 15 cm mass, prominent thoracic kyphosis, and no obvious urogenital or limb anomalies. The large dorsal lumbosacral MMC was treated with a double expanded flap to reconstruct, the soft tissue defect following the neurosurgical reconstruction.

DISCUSSION

The expanded flap was deemed as viable as all wounds were healed without any complications, such as dehiscence, leakage of cerebrospinal fluid, or infection. The technique described in the case report offers an effective method of closure.

CONCLUSION

This flap can be an effective method for reconstruction of large dorsal lumbosacral MMC defects that might improve outcomes and minimize complications. It also ensures minimal wound tension and breakdown.