(Jurnal Plastik Rekonstruksi, 2024.
Vol 11.
No 2, 50-.
RECONSTRUCTIVE
Article THE OUTCOME OF KEYSTONE FLAP FOR LOWER EXTREMITY DEFECTS: A SYSTEMATIC REVIEW Kevin Varian Marcevianto1.
Aditya Wardhana2, & Nandita Melati Putri2 Department of Surgery.
Faculty of Medicine Universitas Indonesia Ae Cipto Mangunkusumo Hospital.
Jakarta.
Indonesia Division of Plastic.
Reconstructive and Aesthetic Surgery.
Department of Surgery.
Faculty of Medicine Universitas Indonesia Ae Cipto Mangunkusumo Hospital.
Jakarta.
Indonesia
ABSTRACT
Introduction : Lower extremity defect poses a significant challenge in reconstructive surgery due to the limited usability of soft tissue.
The keystone flap which utilizes fasciocutaneous perforators, has emerged to be a potential technique in fixing soft tissue defects.
However, scientific evidence, specifically on its effectivity and complication rate in lower extremity defect is lacking.
Therefore, this systematic review aims to assess the outcome and potential complications correlated to the use of Keystone Flap in repairing lower extremity defect.
Method : This systematic review was done in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA).
Literature searching was conducted using four databases, which is PubMed Central.
Embase.
Scopus and Cochrane Library.
Result : A grand total of sixteen studies were included in the review.
Among it, fourteen studies were case series.
The others were cohort prospective and single arm interventional studies.
Out of the 662 keystone flaps used, a total of 129 complications .
5%,) were recorded, with the majority being infection or cellulitis .
%, n=.
, delayed healing .
5%, n=.
, wound dehiscence .
3%, n=.
, and partial flap loss or necrosis .
%, n=.
Conclusion: The keystone flap could be an alternative for lower extremity defect with a realtively low complication Key words: Keystone flap.
Lower extremity defect.
Reconstructive surgery.
Soft tissue repair.
Complications Latar Belakang: Defek ekstremitas bawah merupakan tantangan signifikan dalam bedah rekonstruksi karena keterbatasan jaringan lunak yang dapat digunakan.
Keystone flap, yang memanfaatkan perforator fasciokutaneus, telah muncul sebagai teknik potensial untuk memperbaiki defek jaringan lunak.
Namun, bukti ilmiah, khususnya terkait efektivitas dan tingkat komplikasinya pada defek ekstremitas bawah, masih terbatas.
Oleh karena itu, tinjauan sistematis ini bertujuan untuk menilai hasil dan potensi komplikasi yang berkaitan dengan penggunaan keystone flap dalam memperbaiki defek ekstremitas bawah.
Metodologi: Tinjauan sistematis ini dilakukan sesuai dengan pedoman Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA).
Pencarian literatur dilakukan menggunakan empat basis data, yaitu PubMed Central.
Embase.
Scopus, dan Cochrane Library.
Hasil: Sebanyak enam belas studi dimasukkan dalam tinjauan ini.
Empat belas di antaranya adalah case series, sementara sisanya merupakan studi kohort prospektif dan studi intervensi dengan satu kelompok.
Dari total 662 keystone flap yang digunakan, tercatat 129 komplikasi .
,5%), dengan mayoritas berupa infeksi atau selulitis .
%, n=.
, penyembuhan tertunda .
,5%, n=.
, dehiscence luka .
,3%, n=.
, dan kehilangan flap parsial atau nekrosis .
%, n=.
Kesimpulan: Keystone flap dapat menjadi alternatif untuk memperbaiki defek ekstremitas bawah dengan tingkat komplikasi yang relatif rendah.
Kata Kunci: Keystone Flap.
Defek Ekstremitas Bawah.
Bedah Rekonstruksi.
Perbaikan Jaringan Lunak.
Komplikasi Conflicts of Interest Statement:
The author.
listed in this manuscript declare the absence of any conflict of interest on the subject matter or materials discussed.
Received: 17-03-2024.
Revised: 26-08-2024.
Accepted: 16-09-2024 Copyright by Marcevianto.
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, & Putri.
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The outcome of keystone flap for lower extremity defectsA Jurnal Plastik Rekonstruksi.
Vol.
No.
2, 2024
INTRODUCTION
cutaneous sensitivity.
8 Most commonly, the defects often have a 3:1 long-to-short axis ratio.
Lower extremity defects often arise from trauma, tumors, or chronic illnesses.
1 Problems with these defects might arise, especially in the lower leg, due to the thin nature of the soft tissue, which lacks expandability.
2,3 For thigh defects as well as those in the proximal and middle thirds of the leg, local muscle flaps are used in traditional reconstructive procedures for lower limb 2 Because full-thickness skin transplants have significantly greater metabolic demands than split-thickness grafts, split-thickness grafts have traditionally been utilized as the preferred reconstructive technique for cutaneous lesions on the distal lower limbs that cannot be fully healed.
Utilizing these grafts has certain downsides, including morbidity at the donor site and the normal maturation-related graft manifestations of atrophy, depression, and hypopigmentation at the recipient site.
4 Lower extremity wound applications of grafts are associated with considerable risks of graft failure.
Fasciolocutaneous flaps, which are the current trend, are closely followed by perforator flaps in an effort to reduce difficulties at the donor site.
3 These types of flaps preserve muscle function and reduce complications at the donor site, representing a new trend in reconstruction.
The Keystone flap is a novel advancement flap that transfers nearby tissue with enough flexibility to addredss soft tissue abnormalities using sporadic fasciocutaneous perforators.
5 It can be used as a primary reconstructive option or as a supplementary technique for additional soft tissue coverage.
By being aware of the areas of high perforator density, the keystone flap can be founded on a number of random fasciocutaneous perforators without necessitating dissection of the primary feeding artery.
This technique requires minimal microsurgical expertise, shortens the surgical process, and reduces the risk of pedicle disruption and kinking.
The Keystone flap gets its name from the curvilinear trapezoid-shaped center stone of a Roman arch, which was first reported by Behan Two opposing V-Y flaps that are placed parallel to the defect's long axis make up the flap.
The defect should be elliptical in form, with the long axis running parallel to the cutaneous nerves, veins, and known perforators, in order to enhance vascularity and perhaps preserve The use of the keystone design perforator island flap in the lower extremities has been the subject of many studies.
2Ae5 However, scientific evidences regarding its usage for lower extremity defects are still lacking.
Therefore, this systematic review is aimed to examine the effectiveness and complications associated with keystone flaps in the repair of lower extremity defects.
METHOD
This study was reported in accordance with the principles stated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
9 The protocol of this systematic review was registered in the international prospective register of systematic reviews (PROSPERO) with registration number CRD42023442246.
Being a systematic review, ethical approval or patient consent was not necessary for this study.
Inclusion and exclusion criteria We included all published original studies that documented the utilization of keystone flaps for lower extremity defects.
We excluded duplicate studies, incomplete data of study, as well as review articles, technical report, editorials, commentaries, and letters.
If multiple publications covered the same study or aspects of a study, we checked that the data from a single study were not counted repetitively.
Articles not in English or Bahasa Indonesia were also excluded from the study.
Search strategy A systematic literature search was conducted in electronic databases, including PubMed Central.
Embase.
Scopus and Cochrane Library.
We tried to identify articles published from January 2003 .
he year of the initial description of the keystone flap techniqu.
until current year.
The search employed appropriate English-language keywords combined with Boolean logical operators.
No limitations were set on the search.
The identified studies were Copyright by Marcevianto.
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recorded in Microsoft Excel 2020 along with their relevant details.
Data extraction and study appraisal The authors conducted independent data The following information was extracted from the included studies: duration of study, country of study, study design, duration of follow up, number of subjects, sex, age, etiology of the defect, flap location, number of flaps performed, the type of technique performed, flap size, complications, and other specific outcomes.
The level of evidence for each article was determined according to the criteria outlined by the Oxford Centre for Evidence-Based Medicine.
Critical appraisal for each study was done according to the appropriate tool for each study The Newcastle Ottawa Scale was used for cohort studies.
It examines studies from its selection of cohorts, comparability of cohorts, and validity of outcomes.
11 The JBI Checklist for Case Series for was used for case series.
It is a 10number tool which examines studies from its methodology and reporting.
12 Finally, the Critical Appraisal of Intervention Studies by Guyatt & Rennie was used for interventional studies.
examines the validity, importance, and applicability of the results.
Figure 1.
PRISMA flow diagram of the literature RESULTS Search selection and characteristics Figure 1 shows the flow of literature search.
A total of 66 records were initially identified from the databases.
8,14Ae29 Table 1 shows the number of hits acquired using the respective keywords used on each database.
After further screening and assessment, ultimately 16 studies were included.
One study was retrospective cohort studies, fourteen were a case series, and one was a single arm conventional study.
Furthermore, detailed characteristics of each study are described in Table 2 and Table 3.
Figure 2.
Complications of keystone flap In the sixteen studies, 662 keystone flaps were utilized in 639 patients with various types of defects.
The majority of the flaps, totaling 471 .
15%), were conducted on the lower limb.
The most frequent etiology of the defect was oncologic causes .
9%, n=.
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The outcome of keystone flap for lower extremity defectsA Jurnal Plastik Rekonstruksi.
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Table 1.
Keywords used for each database with corresponding hits Database PubMed EMBASE Scopus Cochrane Keywords .
ower extremity .
) AND .
eystone flaps .
) AND .
urgical reconstruction .
) lower limb' AND 'keystone flap' AND 'reconstructive lower AND extremity AND keystone AND flaps AND .
ower extremit.
AND .
eystone flap.
AND .
urgical Hits Table 2.
Study characteristics and population Author .
LoE Design Duration of Study Subjects Sex Age Etiology of Defect Moncrieff et Australia Prospective July 2003 Ae June Median:
Ae Primary cutaneous melanoma = 176 .
%) Stone et al.
Canada Case series Not Female = 123 .
Male = .
Female .
Male = .
59A18
Mohan et al.
United Kingdom & Australia Case series January 2020 Ae December 2014 Female .
Male = .
Ae Turin et al.
United States Case series December 2015 Ae March Female .
%) Male = 3 .
%) 5 A 12 Lanni et al.
United States Case series January 2012 Ae August Female .
Mean Ae.
Melanoma = 22 .
%) Dermatofibrosarcoma protuberans = 2 .
%) Full-thickness burn = 2 .
%) Basal cell carcinoma = 2 .
%) Squamous cell carcinoma = 2 Merkel cell carcinoma = 1 .
%) Angiosarcoma = 1 .
%) Malignant melanoma = 14 .
Soft tissue sarcoma = 12 .
Benign pathologic condition = 6 .
Nonmelanoma skin cancer = 4 .
Basal cell carcinoma = 1 .
Squamous cell carcinoma = 1 .
Melanoma = 1 .
Dermatofibrosarcoma protuberans = 1 .
Scalp wound secondary to craniotomy = 2 .
Basal cell carcinoma = 7 .
Squamous cell carcinoma = 4 .
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Author .
LoE Design Duration of Study Subjects Sex Age .
Male = .
Pripotnev & White25 .
Canada Case series 2 years Cogolludo et Spain Case series 2014 Ae Fang et al.
China 4 Case series September 2014Ae March Petukhova et United States 4 Case series 2016Ae Al-Mousawi et Italy 4 Case series May 2015 Ae May Srivastav et India 4 Case series October 2017 Ae December 2019 Kong et al.
South Korea 4 Case series Dec 2017 Ae June Guern et al.
France 4 Case series 2010 Ae Female .
Male = .
Female .
%) Male = 3 .
%) Female .
Male = .
Female .
Male = .
49Ae89 Female .
Male = .
Female .
%) Male = .
%) Female .
Male = .
Female .
%) Male = 8 .
%) 63 .
Ae 76 A 11.
Ae 1 A Etiology of Defect Melanoma = 29 .
Sarcoma = 9 .
%) Trauma = 3 .
%) Other = 8 .
Basal cell carcinoma = 22 .
Squamous cell carcinoma = 11 .
Melanoma = 5 .
Dermatofibroma = 1 .
Squamous cell carcinoma = 6 Basal cell carcinoma = 3 .
%) Dermatofibrosarcoma protuberans = 1 .
%) Trauma = 2 .
Benign/malignant tumour = 21 .
Chronic ulcer = 8 .
Squamous cell carcinoma = 39 .
Basal cell carcinoma = 33 .
Melanoma = 8 .
Atypical nevus = 3 .
Others = 3 .
Osteomyelitis type II = 7 .
Osteomyelitis type i = 5 .
Ae Trauma = 25 .
%) Tumor resection = 10 .
%) Abscess debridement = 15 Trauma = 5 .
Burns = 1 .
Ae Squamous cell carcinoma = 6 Basal cell carcinoma = 9 .
%) Melanoma = 9 .
%) BowenAos disease = 1 .
%) Copyright by Marcevianto.
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The outcome of keystone flap for lower extremity defectsA Author .
Torto et al.
Italy.
United Kingdom, and Peru Kumbla et al.
United States Ribeiro et al.
Brazil Jurnal Plastik Rekonstruksi.
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LoE Design Duration of Study Subjects 2 Single-arm March 2019 Ae December 2019 4 Case series JanuaryAe July 2018 4 Case series February 2017Ae January Sex Age .
Etiology of Defect Female .
%) Male = .
%) Not Female .
%) Male = .
Ae Oncologic wounds = 15 .
Non-oncologic wounds = 15 .
Mean Donor for anterolateral thigh free flap = 6 .
%) Mean Basal cell carcinoma = 1 .
Squamous cell carcinoma = 1 .
Melanoma = 4 .
Sarcoma = 3 .
Table 3.
Study intervention and outcome Author Moncrieff et Australia Duration of followup 3 months Technique Standard = 106 .
Modified = 65 .
Doubleopposing keystone = 5 .
Intervention Size (Fla.
Flap Flaps Location Performed Not Lower mentioned limb = 176 Stone et al.
Canada Mohan et al.
United Kingdom & Australia 33 weeks 30 days Type I = 12 .
Type IIA = 17 .
Type IIB = 1 .
Others = 2 .
2 cm 0 cm2 Single keystone flap = 30 .
%) Bilateral keystone flap = 12 .
%) 344 cm2 Range: 5Ae 1350 cm2 Lower limb = 24 Torso = 3 .
Upper limb = 5 .
Lower limb = 19 .
Upper limb = 19 .
Outcome Total flap loss: 1 .
Partial flap necrosis: 1 .
Incomplete excision: 2 .
Early local recurrence:
Infection: 2 .
DVT: 1 .
Transient neuralgia: 4 .
Minor wound problem:
Seroma: 1 .
Delayed healing: 3 .
%) Cellulitis: 2 .
%) Minor flap dehiscence:
Partial/total flap loss: 0 Majority of patients were discharge home following surgery Partial/total flap necrosis: 0 .
%) Delayed healing and wound dehiscence: 10 Copyright by Marcevianto.
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Author .
Turin et al.
United States Duration of followup 201 days Technique Original keystone flap = 6 .
%) Marcevianto.
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, & Putri.
Intervention Size (Fla.
Flap Flaps Location Performed Groin/hip s/buttock .
Perineum = 1 .
Trunk = 6 .
2 cm2 Lower limb = 6 Outcome Lanni et al.
United States 719 days Pripotnev & White25
Canada
2Ae3 weeks Cogolludo et
Spain
Not Majority were BehanAos type
IIA
Other methods used were Type i.
IV, between type i/IV 6 cm2 .
to 500 Original keystone flap = 39 .
%) Not Original keystone flap = 10 .
%) Not Lower limb = 25 .
Trunk = 20 .
Upper limb = 5 .
Head and neck = 10 .
Lower limb = 25 .
Upper limb = 8 .
Back = 4 .
Neck = 2 .
Lower limb = 10 The mean time to mobilization was 1.
The mean length of stay was 6.
8 days Cellulitis: 0 .
%) Flap necrosis: 0 .
%) Edema/swelling: 0 Delayed wound healing: 1 .
Shorter time needed to perform surgery There were no difficulties with ambulation and range of motion Numbness: 2 .
Wound healing problem: 16 .
DVT: 1 .
Infection: 7 .
Hypertrophic scarring:
Contour deformity: 3 Partial dehiscence: 2 .
Infection: 1 .
Seroma: 1 .
Flap necrosis: 0 .
%) Large hemorrhage: 0 Wound infections: 0 Edema/swelling: 0 Difficulty walking:
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The outcome of keystone flap for lower extremity defectsA Author .
Duration of followup Technique Jurnal Plastik Rekonstruksi.
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Intervention Size (Fla.
Flap Location Outcome Flaps Performed Fang et al.
China 6Ae24 Petukhova et United States 26 weeks Modified keystone flap / boat shaped flap by adding a V shape along the lateral arc = 31 3y5 to 10y15 cm2 Modified keystone flap / V-Y hemikeystone 5 A 4.
Lower limb = 5 .
Upper limb = 6 .
Trunk = .
Face = 2 .
Lower limb = 75 .
Upper limb = 9 .
Trunk = 2 .
Al-Mousawi et al.
Italy 16 months Srivastav et India Not Kong et al.
South Korea 4Ae7 Type I = 4 .
Type IIA = 3 Type IIB = 1 .
Type i = 1 .
Type IV = 2 .
Freestyle = 1 .
Not specified Modified keystone flap Omega variation (OV) = 1 .
Not Lower limb = 12 Not Lower limb = 30 Upper limb = 10 Torso = 10 Lower limb = 6 3y6 to 8y17 Shorter time needed to perform surgery Good functional results Superficial infection: 1 .
Partial flap necrosis: 1 .
Infection: 2 .
Dehiscence: 1 .
Infection dehiscence:
Hematoma: 0 .
%) Hemorrhage: 0 .
%) Flap failure: 0 .
%) High rates of flap Minimize incision area and increase efficiency Partial flap necrosis: 1 .
Wound discharge with recurrent osteomyelitis:
Partial flap necrosis: 2 Wound infection leading to dehiscence: 3 Marginal maceration: 1 .
Infection: 0 .
%) Hematoma: 0 .
%) Copyright by Marcevianto.
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Author .
Guern et al.
France Torto et al.
Italy.
United Kingdom, and Peru
Kumbla et
United States Duration of followup
6 months 6 months Not Technique Sydney
melanoma unit
(SMUM) = 1
OV SMUM =
Original keystone flap = 19 .
%) Simplified version = 6 Type I = 42 .
Type IIA = 13 Type i = 16 .
Type IV = 1 .
Not specified Marcevianto.
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Intervention Size (Fla.
Flap Location Flaps Performed 12 cm2 Lower limb = 25 Outcome Torso = 51 cm2 .
Ae244 Upper limb = 33.
3 cm2 .
Ae42 cm.
Lower limb = 32.
Ae 110 cm.
Lower limb = 22 .
Upper limb = 4 .
Torso = 46 .
Lower limb = 6 Ribeiro et Brazil Not Original keystone flap = 9 .
%) 6 cm2 Lower limb = 5 .
Torso = 3 .
Face = 1 .
Total flap necrosis: 1 Partial flap necrosis: 1 Partial flap dehiscence:
Partial flap necrosis: 7 .
Total flap necrosis: 0 Wound dehiscence: 5 .
Wound infection: 3 .
Seroma: 1 .
Partial wound dehiscence: 1 .
Average operative time 3 minutes Mean hospital stay was 7 days Dog ear: 1 .
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Table 4.
Critical appraisal of included cohort studies Study Domain Moncrieff et al.
Total Quality Good S: selection.
C: comparability.
O: outcome Conversion to Agency for Healthcare Research and Quality (AHRQ) standards:
A Good quality : 3 or 4 stars in selection domain AND 1 or 2 stars in comparability domain AND 2 or 3 stars in outcome/exposure domain A Fair quality : 2 stars in selection domain AND 1 or 2 stars in comparability domain AND 2 or 3 stars in outcome/exposure domain A Poor quality : 0 or 1 star in selection domain OR 0 stars in comparability domain OR 0 or 1 stars in outcome/exposure domain Table 5.
Critical appraisal of interventional study Question Validity Were participants randomized? Was randomization concealed? Were participants analyzed in the groups to which they were randomized? Were participants in each group similar with regard to known prognostic variables? Were participants aware of group allocation? Were clinicians aware of group allocation? Were outcome assessors aware of group allocation? Was follow-up complete? Importance How large was the treatment effect? How precise was the estimate of the treatment effect? Applicability Were study participants similar to my own situation? Were all clinically important outcomes .
arms and benefit.
considered? Torto et al.
N/A
N/A
N/A
N/A
N/A
N/A
Yes, 6 months N/A N/A Yes Yes Table 6.
Critical appraisal of case series .
Question Were there clear criteria for inclusion in the case series? Was the condition measured in a standard, reliable Stone et Yes Mohan et Yes Pripotnev & White25 Turin et Yes Lanni et al.
Cogolludo et al.
Srivastav et al.
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Question way for all included in the case series? Were valid methods used for identification of the condition for all included in the case series? Did the case series have consecutive inclusion of Did the case series have complete inclusion of Was there clear reporting of the demographics of the participants in the study? Was there clear reporting of the clinical information of the participants? Were the outcomes or follow-up results of cases clearly reported? Was there clear reporting of the sitesAo/clinicsAo Was statistical Stone et Mohan et Pripotnev & White25 Turin et Lanni et al.
Cogolludo et al.
Srivastav et al.
Yes Yes Unclear Yes Yes Yes Unclear Yes Yes Unclear Yes Yes Yes Yes Yes Unclear Unclear Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Not Not Not Yes Not Not Copyright by Marcevianto.
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Table 6.
Critical appraisal of case series (Continu.
Question Were there clear criteria for inclusion in the case Was the measured in a reliable way for all included in the case Were valid methods used of the condition for included in the case Did the case series have inclusion of Did the case series have inclusion of Was there clear reporting of the of the participants in the study? Was there clear reporting of the clinical information of Fang et Petukhova et al.
Kong et Guern et Kumbla et al.
Ribeiro et Yes AlMousawi et al.
Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Unclear Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Unclear Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Copyright by Marcevianto.
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Question Were the outcomes or follow-up results of cases clearly Was there clear reporting of the sitesAo/clinicsAo Was statistical Fang et Petukhova et al.
AlMousawi et al.
Kong et Guern et Kumbla et al.
Ribeiro et Yes Yes Yes Yes Yes Yes Unclear Not Not Not Not Not Not Not There were complications in 19.
5% .
of cases, with the most common being infection .
%, n=.
, delayed healing .
5%, n=.
, and wound dehiscence .
3%, n=.
Only 0.
3% .
of cases reported complete flap necrosis, while partial flap necrosis was reported in 2% .
of Figure 2 and Table 2 provide further details on these complications.
Critical appraisal The studies were critically appraised according to their study designs.
Table 4 contains the critical appraisal of the cohort study.
Meanwhile.
Table 5 and Table 6 details the critical appraisal of the interventional study and case series studies respectively DISCUSSION The studies included are mostly case series studies .
out of 16 studie.
Based on Oxford Centre for Evidence-Based Medicine criteria, these studies are designated as level 4 evidence.
Meanwhile, the rest of the studies include one cohort and one single-arm interventional studies which are designated as level 2b.
Upon conducting a thorough critical appraisal, the cohort study by Moncrieff et al.
was found to be good in quality.
Out of the fourteen case series studies, only Lanni et al.
performed statistical analysis, while the majority did not.
Most studies have included all participants with consecutive sampling and clearly reported the demographics and outcomes.
However, some studies did not clearly state the inclusion criteria.
In several studies, it was not stated whether the condition was measured in a standard and reliable manner for all participants, and whether valid methods were utilized for identifying the The sole interventional study included in this study was doubtful in validity as it was a non-randomized Although randomization was done, follow-up was still completely done in 6 months.
While no statistical analysis was conducted in the study, the study results were still deemed applicable.
Across all studies, there was a total of 639 However, only 633 had their sex reported, which was composed by 315 males and 318 females.
The other 6 subjects were from the case series by Kumbla et al.
Central tendency of the age was reported with mean or median.
The youngest mean age was 38.
5 years (Srivastav et ) in which 50% of defect was caused by trauma.
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The outcome of keystone flap for lower extremity defectsA Jurnal Plastik Rekonstruksi.
Vol.
No.
2, 2024
The oldest mean age was around 76 years which was reported by Cogolludo et al.
and Torto et al.
The defects in both studies were mostly caused by oncologic wounds.
One study only reported the age range.
Pripotnev & White reported an age range of 49Ae89 in 37 subjects, with a majority of defects caused by malignancy.
The majority of defects, totalling 504 .
cases, were caused by cancer-related diseases.
Cancer can lead to deformities as tumours grow physically, with benign bone tumours and tumour-like lesions commonly associated with limb length discrepancies.
The discrepancy may be attributed to the disturbance of bone growth and development due to the presence of a tumour, particularly in younger patients.
30 The primary objective in managing this condition is tumour removal, which can be achieved through various procedures such as excision with wide margins or radical removal.
31 While tumour removal surgery aims to be conservative, secondary surgery may still be necessary postoperation to address any resulting deformities.
Guern et al.
demonstrated that keystone flaps are effective in repairing defects related to cancer 18 Although the majority of lower limb deformities included in this review were caused by tumors, other etiologies, including trauma and burns, can also lead to deformities.
While these conditions have different mechanisms in creating deformities, keystone flaps have proven useful in correcting resulting deformities.
Therefore, it is reasonable to assume that the use of Keystone Flap could aid in fixing leg deformities caused by various etiologies.
Across 16 studies, 662 keystone flaps were used to cover a range of defects in 639 patients.
Follow-up was done in a timeframe of two weeks to two years.
The majority of these flaps .
were performed on the lower limbs.
The majority of flaps utilized the BehanAos keystone flap technique, with only three studies opting for a modified version of the keystone flap.
In their research.
Fang et al introduced a modified keystone flap known as the "boat-shaped flap" that features a V shape along the lateral arc.
28 In order to seal the defect and minimize tissue incision.
Petukhova et al.
designed a simplified V-Y hemi-keystone advancement flap that entails cutting the curvilinear part of the flap on one 30 In a research by Kong et al, small to moderate-sized defects were covered using a modified keystone flap with the omega variant (OV) and Sydney melanoma unit modification (SMUM).
A total of 129 complications out of 662 total flaps .
5%) were recorded, with the majority being infection or cellulitis .
%), delayed healing .
5%), wound dehiscence .
3%), and partial flap loss or necrosis .
%).
Infections are common in surgical procedures, with a study indicating that 5Ae20% of post-operative patients experience some form of infection, of which up to 60% is highly Preventing post-operative infection, including in keystone flap procedures, involves prioritizing proper hygiene, using correct equipment, informing patients, and being wellprepared.
32 Petukhova et al stated that most infections occurred on lower extremities, indicating that healing is more difficult on the lower extremities due to minimal skin laxity, skin fragility, and decreased vascular supply.
30 While infection, delayed healing, and dehiscence are considered minor complications, partial loss or necrosis is considered major.
14 Another important complication that island flap procedures, including keystone flap, should be cautious about is total flap loss or necrosis.
The study's results in Table 3 showed that total flap necrosis occurred in only 2 .
3%) cases, indicating its relative rarity.
This finding aligns with a review conducted by Rini et al.
, which suggests that keystone flap has the lowest risk of total flap necrosis compared to other island flap This could be attributed to its shorter operative time, lower technical difficulty, and reduced donor-site morbidity.
33 Typically, keystone flap surgery requires 20-90 minutes, depending on the wound's size and complexity, and patients usually stay for 3 days postoperation before recovery.
16 However, these values may change during complications, emphasizing the importance of preventing complications to achieve better patient outcomes, improved mobilization, and shorter hospital The main limitation of this review lies in the limited variety of study types included.
The majority of studies incorporated were in the form of case series studies.
Inclusion of other study types could enhance the analysis and provide a more comprehensive perspective.
Moreover, there were also a few studies excluded due to language barrier, which may potentially affect the final data gathered.
Another limitation lies in the review being restricted to lower extremity As keystone flap are applicable to other body parts, it may be beneficial to broaden the scope to explore its effectivity in other body parts as well.
By addressing these limitations and Copyright by Marcevianto.
Wardhana.
, & Putri.
P-ISSN 2089-6492.
E-ISSN 2089-9734 iC DOI: 10.
14228/jprjournal.
This work is licensed under a Creative Commons License Attribution-Noncommercial No Derivative 4.
Jurnal Plastik Rekonstruksi.
Vol.
No.
2, 2024
Marcevianto.
Wardhana.
, & Putri.
incorporating a wider range of study types and body regions, future research can aid in the strengthening of evidence surrounding efficacy of keystone flap.
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JBI Database CONCLUSION Based on the findings of our systematic review, the keystone flap method can be considered as an alternative of safe and effective operative procedure for managing lower extremity defects, exhibiting a relatively low rate of complications.
Notably, the majority of complications identified were minor, suggesting they can be managed with relative ease.
These favorable outcomes highlight the viability of keystone flap in reconstructing lower extremity Correspondence regarding this article should be addressed to:
Kevin Varian Marcevianto.
Department of Surgery.
Faculty of Medicine Universitas Indonesia Ae Cipto Mangunkusumo Hospital.
Jakarta.
Indonesia.
Postal address: RSCM A Building, 4th floor.
Diponegoro Street 71st.
Central Jakarta.
Indonesia.
E-mai:
varian21@office.
ACKNOWLEDGEMENT
N/A
REFERENCES