Extensive Mine-Shrapnel and Gunshot Wound Closure Using Keystone Island Perforator Flaps

Abstract

Background:During military operations, one aspect of a plastic surgeon’s work is to restore extensive and deep wound defects in a short period of time and provide a high degree of functional recovery to the damaged area. Because many injuries caused by military operations cannot be closed using a primary suture, the specialist has to select another surgical approach to close the wound defect. Surgeons must select methods that not only cover the extensive wound defect in 1 step but also allow skin coverage that is anatomically, functionally, and visually similar to the surrounding tissues to reduce the length of the hospital stay and ensure optimal functional recovery of the damaged organ.Methods:From 2014 to 2015, 25 patients underwent 36 reconstructions at our center after receiving mine-shrapnel and gunshot wounds. All reconstructions occurred during the acute period and used keystone island perforator flaps. The authors’ wound management technique was characterized by an aggressive surgical and antibiotic therapy protocol.Results:In all cases, after surgical debridement, the mine-shrapnel and gunshot wound defects were completely closed in 1 stage during the acute period. The working time in the operating room to perform the transposition of the flap ranged from 45 to 90 minutes, with an average of 68 minutes. All displaced flaps were similar in structure and color to the surrounding tissues and did not change the contours of the body. The adequate restoration of skin allowed patients to begin early recovery of functional activity.Conclusions:Local keystone island perforator flaps can be considered one of the primary methods of plastic closure of extensive defects caused by mine-shrapnel and gunshot wounds at different anatomical locations, providing that the tissue surrounding the defect is intact and usable as a donor resource.

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

“…One article was a prospective cohort study; [ 7 ] all other included articles were case series. [ 5 , 6 , 8 – 13 ] The mean age of enrolled patients was 52.4 ± 6.4 years (range, 2–82 years), and the average follow-up duration was 15.3 ± 8.4 months.…”

“…There were 2 articles reporting more than 1 keystone flap on the same patient. [ 10 , 13 ] Multiple keystone flaps on the same patient or on the same leg might affect the complication rate. Stone et al [ 10 ] reported 32 keystone flaps in 30 patients, with 2 patients having bilateral lower leg flaps.…”

“…[ 17 ] In comparison, the keystone flap procedure is faster and more straightforward. [ 3 ] Most of the authors of the included studies mentioned that keystone flaps required a short operating time, [ 5 , 8 – 13 ] and 3 articles reported average operating time that was less than 2 hours (104, [ 8 ] 45.5, [ 9 ] and 68 minutes [ 11 ] ). A literature review indicated that the average operating time for pedicled propeller flaps and free flaps is more than 2 hours.…”

“…For each article, a level of evidence defined by the Oxford Centre for Evidence-Based Medicine was determined (Table 1 ). [ 5 – 13 ]…”

Keystone Flap: Overcoming Paradigms

“…Short surgical times 36,37,42,50,55 without complex intrasurgical or postsurgical monitoring, a single operative field, and a more “stable” perfusion 50 are some of the additional advantages of KF that reduce morbidity, mortality, and intrahospital stay. 31,33 This differs from the microvascular options that require a wide learning curve and large resources for its execution.…”