Background Reconstruction of the skin defect after myelomeningocele repair is a crucial step that influences the quality of the surgical outcome. Keystone perforator flap is an islanded fasciocutaneous flap based on random regional perforators, which is advanced to adjacent defects. It has become a reliable method of locoregional reconstruction in various body parts with minimum morbidity. The aim of this study was to evaluate our clinical experiences in using keystone perforator flaps as an alternative surgical method for closure of large myelomeningocele defects. Methods In this study, the keystone island perforator flap was used for reconstruction of large myelomeningocele defect in 7 patients (5 males and 2 females) aged between 7 days and 4.5 months. The defect size was 5.9 cm × 6.5 cm on average (range, 4.5 × 5 cm to 7 × 9 cm). The localization of the lesions was lumbosacral in 6 patients and thoracolumbar in 1 patient. Results In all patients, tension-free closure was obtained and healing was successful without any complications, except 1 infection, which resolved with conservative wound management. There was no patient with late breakdown of the wound or associated cerebrospinal fluids fistula formation for a mean of 13 months (range, 4 months to 2 years). Conclusions The keystone perforator flap technique is an effective, reliable, and durable reconstructive option which enables the reconstructive surgeon to attain a tension-free closure of sizable meningomyeleocele defects with no late wound breakdown or associated cerebrospinal fluids fistula formation and negligible donor site morbidity.

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Introduction The keystone perforator flap has become a versatile alternative for reconstruction of cutaneous defects of various etiologies and in all age groups. However, it demands a notable incision area proportional to defect size and is more prone to excessive tension during defect closure. We present a novel modified rotation Hemi‐keystone flap that reveals its excellence in flap survival. Methods Between March and December 2021, a retrospective chart review was conducted of 40 patients who received rotation Hemi‐keystone flap for coverage of cutaneous defects by a single surgeon. The primary outcome was successful flap survival. Results We performed a total of 45 modified rotation Hemi‐keystone flaps for reconstruction of cutaneous wound defects. The location of the wound defects was in the head and neck (38%), extremities (35.7%), and trunk (26.2%). The most common cause of wound defect is tumor resection (45.2%). The mean wound defect dimensions were 3.5 cm × 3 cm. The mean follow‐up time was 6 months. There were no significant complications, with only one patient (2.4%) having minor wound dehiscence, which was treated by local wound care. Conclusions The current series presents a simple, reliable, and versatile modification of the traditional keystone flap that minimizes morbidity at the reconstruction site along with improvement of flap mobility for successful reconstruction of cutaneous defects in a tension‐free manner. The favorable outcome of this technique contributes to the inclusion of the rotation Hemi‐keystone flap as an excellent surgical option in the reconstruction of various soft tissue defects.

Introduction: Myelomeningocele is the most common form of neural tube anomalies. Early reliable skin coverage should be achieved to reduce central nervous system infections. The keystone flaps are gaining popularity for myelomeningocele defect reconstruction. However, the use of a traditional keystone flap is limited in very wide or transversely oriented myleomeningocele defects with inadequate lateral tissue laxity. In this study, we present our successful experience using modified rotation advancement keystone flaps for closure of the transversely oriented myelomeningocele defects. Patients and Methods: Between April 2019 and April 2020, the modified rotation advancement keystone flap was used for reconstruction of transversely oriented myelomeningocele defect in 7 patients (5 males and 2 females) with average age of 14 days. The localization of the lesions was lumbosacral in 5 patients and thoracolumbar in 2 patient. The average myelomeningocele defect width was 6.4 cm, whereas the average defect length was 5.7 cm. The following information was evaluated: the flap dimensions, operative time, and postoperative complications. Results: All patients had uneventful operations, except for 1 case of superficial epidermolysis over flap tip, which settled with conservative wound management. Immediate venous congestion was detected in 2 patients that completely resolved. Otherwise, all wounds healed without any evidence of complications. The mean follow-up was 4 months. Conclusions: Although the conventional keystone flap seems to have geometric constraints to close a transversally oriented myelomeningocele defect, the modified rotation advancement keystone flap serves as a superior alternative and effective option for closure transversally oriented defect.