The Keystone Island Perforator Flap in Reconstruction of Large Myelomeningocele Defects

Abstract

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.

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

“…Eight previous studies have discussed the use of KDPIFs for meningomyelocele defect closure [15,[18][19][20][21][22][23][24]. All of those studies also demonstrated satisfactory experiences in using KDPIFs for meningomyelocele closure.…”

“…Among 28 patients who underwent rotation/advancement flap closures, Gursoy et al [27] noted an average operative time of 86.25 minutes for single flaps, 115.45 minutes for double flaps, and 170.38 minutes for four-flap closures. In previous studies using keystone flap closures for meningomyelocele, Gutman et al [15], Donaldson et al [18], Park et al [19], Hifny and Hamdan [24] reported average operative times of 223, 236, 225, and 86 minutes, respectively. Our study showed an average of 89.6 minutes, with 70.6 minutes on average for unilateral key- This series demonstrated that KDPIFs were successfully implemented as locoregional fasciocutaneous flaps in the reconstruction of large meningomyelocele defects.…”

“…Donaldson et al [18] reported that two out of six patients had wound complications after surgery. Both Formentin et al [23] and Hifny and Hamdan [24] reported that one patient out of seven had complications. To our knowledge, our study is the largest clinical case series of keystone flaps for meningomyelocele defect closure with 14 patients with no major complication such as CSF leaks.…”

“…All previous studies mainly used type III keystone flaps. Hifny and Hamdan [24] used type II keystone flaps in two patients and Gomez and Barrera [22] used type IV keystone flaps in two patients. In our study, we presented various types of keystone flaps to close defects with different sizes, and we proposed an algorithm for the reconstruction of meningomyelocele defects using keystone flaps based on the size of the defects and the proportion of the width of the defect to the width of the patient's back (Fig.…”

A New Dissection Ladder Approach for Perforator Vessels in Infant Meningomyelocele Soft Tissue Reconstruction

“…We suggested that this practice is too conservative and may cause severe complications of perforator kinking and flap loss. 7 Multiple studies worked on assessing the reliability of only one artery perforator as lumbar artery perforators or intercostal artery perforators. In comparison to our study, we worked on freestyle perforator pattern that allows more choices for designing the flap donor marking.…”