Vulvar Reconstruction Using Keystone Flaps Based on the Perforators of Three Arteries

Abstract

Various flaps are used to reconstruct skin and soft tissue defects of the vulva following resection of malignancies. Whenever possible, reconstruction using local flaps is the standard treatment. Here, we describe vulvar defect reconstruction using keystone flaps. Standard keystone flaps are based on randomly located vascular perforators. However, we designed a keystone flap that includes perforators of three named arteries (the anterior labial artery of the external pudendal artery, cutaneous branches of the obturator artery, and posterior labial artery of the internal pudendal artery) and the pudendal nerve, which accompanies the internal pudendal artery. Four patients with squamous cell carcinoma and extramammary Paget's disease of the vulva underwent radical vulvectomy and keystone flaps including perforators of three arteries. Depending on the morphology of the defects, keystone flaps were used with different designs. For elliptical and unilateral vulvar defects, a standard keystone flap was designed, and for defects on both sides of the vulva, a double opposing keystone flap was used. For oval defects, the omega variant keystone flap was designed, and when the morphology of the defect needed rotation of the flap, a rotational keystone flap was designed. All the patients showed good function and sensation, with an acceptable cosmetic appearance.

How to Safely Use the Perforator-based Keystone Island Flap in the Scalp: Basal Cell Carcinoma of the Scalp With Local Invasion to Calvarium

“…6,7 The keystone flap has proven its simplicity and versatility over a few decades. 6,[8][9][10][11][12] Nevertheless, using a keystone flap in the scalp is rarely discussed previously. Most of the previous articles addressing keystone flap in the scalp are at the more mobile area, such as the junction of scalp and forehead or scalp and posterior neck, or temporal region, which is mainly supplied by definite source vessels such as superficial temporal artery/vein.…”

“…It has become an established and versatile tool in the plastic surgeon’s armamentarium to reconstruct different body regions with minimum morbidity 6,7 . The keystone flap has proven its simplicity and versatility over a few decades 6,8–12 . Nevertheless, using a keystone flap in the scalp is rarely discussed previously.…”

Vulvar Reconstruction with Keystone Flaps after Radical Vulvectomy

“…Each flap type presents different considerations, such as the need to identify specific perforators, abdominal flap sequelae, or prolonged recovery periods associated with certain flaps. 6 …”

“… 5 , 6 Additionally, the keystone flap yields aesthetic results similar to the resected skin, with excellent cosmetic outcomes and emotional impact for patients. 6 , 7 As can be seen in Figure 4 , showing an adequate evolution of the healing, without alteration of the anatomy and preserving the functionality of the area. Other authors who present their experience with keystone flap are Peiretti et al 9 and Lee et al 6 evidencing the positive results obtained with this reconstructive option.…”

“…conducted a review of various reconstructive options reported in the literature, including the gracilis flap, gluteal fold flap, medial thigh flap, anterolateral thigh flap, rectus abdominis musculocutaneous flap, V-Y flap, Limberg flap, DIEP flap, pudendal artery thigh flap, and lotus petal flap. Each flap type presents different considerations, such as the need to identify specific perforators, abdominal flap sequelae, or prolonged recovery periods associated with certain flaps 6. …”