Keystone Design Perforator Island Flap Research Articles

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

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

Keystone design perforator island flap: our experience for coverage of lower limb defects

The fusion of concept of perforasome and trapezoid design made Keystone design Perforator Island flap (KDPIF). This flap was first introduced by Behan in 2003 and since then many modifications were done. Keeping the principles of KDPIF, two modifications were done in this study. Aims: to determine reliability and advantages of KDPIF for lower limb defect coverage. Materials and Methods:15 cases were done in Plastic surgery department of Rajshahi Medical College Hospital from October 2020 to September 2022. Results: The largest wound measuring 11X 10 cm2 on thigh defect following wide local excision of sarcoma was covered by the largest dimension flap measuring 16X 11 cm2. In most of the cases (7 cases), Type IIA KDPIF was done. With co-morbidities, 14 flaps survived without any complications. Range operating time was 35-110 minutes. Conclusion: Due to its reliable vascularity and easy execution and good outcomes, KDPIF is one of the best choices for lower limb defect coverage. Bangladesh Journal of Medical Science Vol. 22 No. 04 October’23 Page : 920-925

Clinical Applications of Keystone Design Perforator Island Flap: A Single-Center Experience

Clinical Applications of Keystone Design Perforator Island Flap: A Single-Center Experience

Keystone flap for reconstruction of ulnar side defect of the hand: a case report

Soft tissue defects of the hand may present in various forms and are often challenging to treat. The goal of surgical hand reconstruction includes both functional and aesthetic aspects. The keystone-design perforator island flap is a multi-perforator advancement flap with a safe flap harvesting technique, reliable blood supply, minimal donor site morbidity, and a simple dissection process that obviates the need for microsurgical techniques. Our patient was an 85-year-old man with squamous cell carcinoma on the left-hand ulnar side. The patient had difficulty in ambulation and used the affected area of the hand to stand up. Thus, we planned reconstruction using an omega-variant type B keystone flap to further reduce tension during flap insetting and to provide sufficient padding that would protect against excessive pressure postoperatively. The flap and donor site were closed primarily, without any postoperative complications. The patient was satisfied with the outcome after 19-month follow-up.

Clinical application of keystone design perforator Island flap (KDPIF) in trunk defects: a retrospective study

The aim of this study was to evaluate the treatment outcomes of patients with trunk defects reconstructed by Keystone Design Perforator Island Flap (KDPIF). A total of 37 eligible cases with trunk defects were reconstructed by KDPIF from January 2017 to June 2020. Data were collected from electronic medical records, including aetiology, defect size and location, and type of KDPIF applied. Postoperative complications were recorded, and patient satisfaction was evaluated at the last clinical visit. There were 23 males and 14 females, and the average defect was 8.16 × 4.94 cm. Etiologies included decubitus ulcer (n=12), oncologic resection (n=11), infection (n=9) and others (n=5). Type III was applied in 19 cases, Type IIa in 13 cases, type IV in two cases and modified KDPIF in three cases. There were no major complications except delayed healing or wound dehiscence in three cases, which were managed by regular dressing or secondary surgical intervention. The average postoperative satisfaction score was 8.68 ± 1.13 points and all patients were satisfied with their cosmetic appearance and function at the last follow-up. Trunk defects can be successfully reconstructed by KDPIF, which results in satisfactory cosmetic and functional outcomes without major complications.

Outcomes of the Keystone Island Perforator Flap: A Systematic Review

The Keystone Design Perforator Island Flap (KDPIF), first described by Behan in 2003, has been demonstrated as a versatile, safe, and straightforward reconstructive option for various soft tissue defects. The purpose of this systematic review is to evaluate the indications, variations, and overall complication profile of the keystone flap in reconstructive surgery. A literature review was conducted in accordance with PRISMA guidelines using MeSH term "surgical flaps" with the keyword "keystone flap." Empirical studies with at least 15 patients who underwent keystone flap reconstruction were assessed for quantitative analysis. Outcomes of interest included patient demographics, indications, anatomic location, flap design, and complications. Database search produced 135 articles, of which 25 were selected for full-text review. Out of 23 studies selected qualitative analysis and 22 met criteria for quantitative analysis. Overall success rate of this flap was 98%. Wound complications were highest in extremity flaps. Several modifications of this flap were described. Keystone reconstruction demonstrates excellent success rates and versatility. However, further studies with more standard reporting are needed to determine guidelines for patient specific surgical planning.

Keystone Flap for Closure of Skin Cancer Defects on the Upper Extremity.

Background: We sought to examine the efficacy of the Keystone Design Perforator Island Flap (KDPIF) for the reconstruction of skin cancer excision defects isolated to the upper extremity. In particular, to examine the size of defects repaired and the complications associated with the keystone flap procedure isolated to the upper extremity. Methods: This is a retrospective chart review including all patients older than 18 years of age who received a KDPIF procedure between February 2013 and February 2019 for the oncologic reconstruction of skin cancer defects isolated to the upper extremities by a single surgeon. All procedures were done according to the original description by Behan. Results: A total of 32 patients, 18 (56%) male and 14 (44%) female, received 35 keystone flaps between February 2013 and February 2019. The mean age of the males and females was 70.5 and 79.7 years of age, respectively. Thirty-five lesions suspicious for cancer were excised and 14 (40%) basal cell carcinoma (BCC), 11 (31%) squamous cell carcinoma (SCC), 9 (26%) melanoma, and 1 (3%) actinic keratoses diagnoses were histopathologically determined. Skin defect excisions varied from 3.53 cm2 to 31.42 cm2. No intraoperative or postoperative complications occurred. Conclusions: The keystone flap is a successful versatile flap procedure with a low or absent complication rate for the reconstruction of skin cancer excision defects of various locations (eg arm, hand, elbow, forearm, shoulder, and wrist), cancer pathologies, and sizes on the upper extremity. When needed, a Doppler may successfully identify adequate perforating blood vessels for the relatively larger flaps.

Closure of meningomyelocele defects using various types of keystone-design perforator island flaps.

BackgroundVarious methods have been described to close large meningomyelocele defects, but no technique has been proven superior to others. This study presents cases of meningomyelocele defect closure with a keystone-design perforator island flap.MethodsA retrospective study was performed on 14 patients with meningomyelocele defects closed using various types of keystone flaps.ResultsThe median age of the patients at surgery was 10.5 days (range, 1–369 days) and the average defect size was 22.5 cm2 (range, 7.1–55.0 cm2). The average operative time for defect closure was 89.6 minutes (range, 45–120 minutes). Type IV bilateral keystone flaps were used for four defects, type IV unilateral flaps for six defects, type IIA flaps for two defects, and type III flaps for two defects.ConclusionsAll the defects healed completely with no major complications. The keystone-design perforator island flap is a reliable, easy, and fast technique to close large meningomyelocele defects.

Commentary: Closure of Meningomyelocele Defects using Various Types of Keystone-Design Perforator Island Flaps

Commentary: Closure of Meningomyelocele Defects using Various Types of Keystone-Design Perforator Island Flaps

Double keystone flap for large lower thigh defect

<br>Large lower thigh defects are a reconstructive challenge. Keystone design perforator island flap in the lower thigh is not routinely performed as the skin here is less extensible. We present a case of a large anterolateral lower thigh defect wherein we used double keystone flaps from the remaining circumference of the thigh and grafted the donor site in the posterior thigh. Circumferential incision/scarring in the limbs risk damage of superficial lymphatico-venous circulation and distal edema. However, our case demonstrates an uneventful recovery and excellent aesthetic and functional outcome.<br>

A systematic review of the keystone design perforator island flap in the reconstruction of trunk defects.

The keystone design perforator island flap can be utilized in the repair of trunk defects. A systematic review was carried out to identify the complication rates of the use of this flap to treat such defects. The MEDLINE, Embase, Cochrane Library, and PubMed Central databases were searched for articles published between January 2003 and December 2018 that reported the use of keystone design perforator island flaps in the repair of trunk defects. Study selection was conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eight articles involving a total of 54 flaps satisfied the inclusion criteria. The most frequently reported cause of trunk defects was oncologic resection (64.4%). The overall complication rate was 35.2%, and complications included infection (11.1%), wound dehiscence (7.4%), delayed healing (7.4%), and partial flap loss (1.9%). The keystone design perforator island flap is associated with a high success rate and low technical complexity. Despite minor complications, keystone design flaps could be a preferred choice for trunk reconstruction.

Keystone design perforator island flaps for coverage of non-oncological periarticular defects surrounded by the zone of injury

ObjectivePeriarticular defect coverage remains challenging because multi-vector tension forces affect wound tensile strength. This study presents our experience with keystone design perforator island flap (KDPIF) reconstruction of non-oncological periarticular defects surrounded by the zone of injury and describes the expanding versatility of KDPIF reconstruction for periarticular defects.MethodsFrom June 2017 to July 2019, 12 patients aged 8 to 84 years underwent KDPIF reconstruction to cover periarticular defects. All defects resulted from non-oncological causes and were surrounded by the zone of injury. We reviewed the patients’ medical records and clinical photographs to collect and analyze clinical and operative data.ResultsThe defect size ranged from 0.8 × 1.2 to 7 × 10 cm2. The flap size ranged from 1.5 × 3 to 15 × 18 cm2. All flaps survived completely. All patients showed favorable functional outcomes without significant limitation in joint range of motion during the follow-up period (range, 4–12 months). The mean observer scar assessment scale summary score and patient scar assessment scale total score were 17.667 ± 5.921 and 20.167 ± 6.478, respectively.ConclusionKDPIF reconstruction is a simple and effective surgical option for coverage of non-oncological periarticular defects surrounded by the zone of injury.

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.

Keystone-design perforator island flaps for the management of complicated epidermoid cysts on the back

Complicated epidermoid cysts (ECs) occur commonly on the back, but few reports have described their management. We present our experience in managing patients with ECs on the back using a keystone-design perforator island flap (KDPIF) reconstruction, thereby focusing on reduction and redistribution of wound tension. Altogether, 15 patients (average age, 48.067 ± 14.868 years) underwent KDPIF reconstructions after complete excision of complicated ECs on the back. We retrospectively reviewed the medical records and clinical photographs of all patients. Final scar appearance was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). All patients had ruptured ECs, while 6 patients also had cellulitis of the surrounding tissues. All defects, after complete excision of ECs and debridement of surrounding unhealthy tissues, were successfully covered with KDPIF. The mean ‘tension-change’ at the defect and donor sites was −4.73 ± 0.21 N and −4.88 ± 0.25 N, respectively (p < 0.001). The mean ‘rate of tension-change’ at the defect and donor sites was −69.48 ± 1.7% and −71.16 ± 1.33%, respectively (p < 0.001). All flaps survived with no postoperative complications. The mean observer scar assessment scale (OSAS) summary score and patient scar assessment scale (PSAS) total score were 14.467 ± 5.069 and 15.6 ± 6.512, respectively. Overall, we suggest that KDPIF reconstruction is a good surgical modality for the management of complicated ECs on the back.

Using the keystone design perforator island flap in large myelomeningocele closure.

Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure. The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography. No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up. The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.

Long-term follow-up for keystone design perforator island flap for closure of myelomeningocele

We have previously reported a small series on the closure of large myelomeningocele (MMC) defects with a keystone design perforator island flap (KDPIF) in a paediatric neurosurgical centre in Australia. We are now presenting an updated longer term follow-up of an expanded series demonstrating longer term durability of this vascularized flap for large myelomeningocele defects. The prospective data from the Monash Neurosurgical Database were used to select all cases of MMC between December 2008 and September 2016. Retrospective analysis of the neurosurgical database revealed an additional three patients who underwent KDPIF closure at the Monash Medical Centre for MMC repair at birth. Wound healing was satisfactory in all six cases. With delayed follow-up, there was no associated skin flap separation, skin flap dehiscence, skin flap necrosis, cerebro-spinal fluid leak, however two infections were encountered, both resolved with conservative management including antibiotics and simple washout. In this expanded case series with increased longevity of follow-up, the keystone design perforator island flap remains a robust alternative for closure of large myelomeningocele defects.

The Keystone Flap-A Case Series Demonstrating Practical Design, Use, and Applications.

The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions. This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used. Defects varying in size from 6 to 63 cm2 were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss. The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon.

The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

A systematic review of the keystone design perforator island flap in lower extremity defects.

Background:The keystone design perforator island flap is useful for the reconstruction of lower extremity defects. We performed a systematic review with the objective of identifying complication rates associated with using the keystone design perforator island flap to treat such defects.Methods:The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from January 2003 to August 2016 for articles describing keystone design perforator island flaps in lower extremities. The study selection was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Results:Nine articles that involved a total of 282 keystone design perforator island flaps satisfied the inclusion criteria. In these articles, the most common cause of lower extremity defects was oncologic resection (89.0%). Most such defects were in the middle third of the lower leg (32.7%). Complications occurred in 9.6% of patients; these complications included partial flap loss (1.1%) and complete flap loss (0.7%).Conclusion:Given its high success rate and low technical complexity, if applicable, the keystone design perforator island flap should be the preferred approach for lower extremity reconstruction.

Avoiding Skin Grafts: The Keystone Flap in Cutaneous Defects.

Therapeutic, IV.