Keystone Flaps for Coverage of Defects in the Posterior Neck and Lower Occipital Scalp: A Retrospective Clinical Study

Abstract

The coverage of the posterior neck and lower occipital scalp defects should be approached carefully. Thick, stiff, and inelastic skin properties of these areas tend to make coverage of even small defects difficult. Herein, the authors present a retrospective review of our experience with posterior neck and lower occipital scalp reconstruction using the keystone flap (KF) and describe the expanding versatility of KF reconstruction. The medical records of 17 patients who underwent KF reconstruction to cover the posterior neck and lower occipital defect from April 2017 to May 2020 were reviewed. Clinical and operative data were collected. All defects were successfully covered with the KFs. The defect sizes ranged from 2.5 Â 3.5 cm to 6 Â 11 cm, and the flap sizes ranged from 3 Â 5.5 cm to 9 Â 18 cm. All flaps fully survived, although marginal maceration developed in one case; however, it healed with conservative management. The final results were favorable, and all patients were satisfied with their final outcomes. Consequently, the KF can be considered as a good reconstruction modality with few complications and provides an alternative to other reconstructive options for coverage of the posterior neck and lower occipital defects.

Latissimus Dorsi Muscle Flap for Scalp Reconstruction and Postoperative Ulceration Management

“…A similar consideration was mentioned by a previously reported scalp reconstruction case 16 . In case of small scalp defects, local keystone flaps could be useful to cover the posterior neck and lower occipital defects 17 . However, it is not suitable for this patient because further stretching of transferred LDM would decrease thickness of the flap and its ability of withstanding friction and compression.…”

Modified Keystone Perforator Island Flap for Tension-Reducing Coverage of Axillary Defects Secondary to Radical Excision of Chronic Inflammatory Skin Lesions: A Retrospective Case Series

“…Then, the final defect was created. The KPIF was designed based on the final defect size, surrounding tissue laxity, and relaxed skin tension lines (RSTLs) of the axilla [ 4 , 5 , 7 , 13 ]. We designed the KPIF to have a larger width than the defect at the side with sufficient tissue laxity and attempted to create the KPIF long axis, so that it was as parallel to the RSTLs as possible [ 4 , 5 , 7 , 13 ].…”

“…Small axillary defects can be reconstructed either via direct closure with undermining or healing with secondary intention; however, moderate defects should be covered with local flaps, and large or extensive defects should be covered with free flaps [ 5 ]. In terms of the depth of the defect, skin grafts can be applied for superficial defects, and flap techniques are useful for covering deep defects involving exposure of the underlying structures [ 7 ].…”

“…Among the numerous types of local flaps, the keystone perforator island flap (KPIF) technique devised by Behan in 2003 has demonstrated successful outcomes in a series of 300 cases. This reconstructive modality can be applied to cover various defects in most parts of the human body and is used by many reconstructive surgeons as a primary option or an alternative to other reconstructive methods [ 4 , 5 , 7 , 12 , 13 ]. The popularity of the KPIF technique is thought to be attributable to its distinct differences from other flaps, including its intuitive defect-adjustable design and easy reproducibility; even beginners can perform this technique with a minimal learning curve [ 4 , 5 , 7 , 13 ].…”

“…This reconstructive modality can be applied to cover various defects in most parts of the human body and is used by many reconstructive surgeons as a primary option or an alternative to other reconstructive methods [ 4 , 5 , 7 , 12 , 13 ]. The popularity of the KPIF technique is thought to be attributable to its distinct differences from other flaps, including its intuitive defect-adjustable design and easy reproducibility; even beginners can perform this technique with a minimal learning curve [ 4 , 5 , 7 , 13 ]. Several studies have reported the use of the KPIF for reconstructing axillary defects [ 2 , 14 ]; however, relatively more studies have compared KPIF reconstruction in other body areas.…”