Videos of Surgical Procedures in Dermatology
Type I Keystone Island Flap
Colgajo de keystone tipo i
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"apellidos" => "Rodríguez-Prieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo de keystone tipo <span class="elsevierStyleSmallCaps">i</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1565 "Ancho" => 1625 "Tamanyo" => 245408 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Design of the type<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">i</span> keystone flap.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present a video showing the type <span class="elsevierStyleSmallCaps">I</span> keystone flap technique used in a 79-year-old woman to reconstruct the surgical defect resulting from the excision of a squamous cell carcinoma on her leg, with associated stasis dermatitis and skin changes due to lipodermatosclerosis of the lower limbs.</p><p id="par0010" class="elsevierStylePara elsevierViewall">First, the flap is designed on the area adjacent to the defect that can provide the largest tissue contribution and greatest tissue mobility (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After preparation of the surgical field with povidone iodine and local anesthesia with mepivacaine, 2%, plus epinephrine, the tumor is excised, continuing down to but not including the fascia. The skin of the flap is then incised using a scalpel and the subcutaneous tissue is liberated by blunt dissection using scissors, taking care not to damage the perforating vessels. The proximal border is sutured to the defect with silk or staples and a V-Y double advancement is performed at each of the lateral vertices. Finally the distal border is sutured to the defect using silk or staples.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The keystone flap is mainly used for surgical defects on the lower limbs or trunk, although it has also been employed at other sites, such as on the genitalia and the face. There are no absolute contraindications; relative contraindications include peripheral artery disease and infection. Particular benefits of this flap are its greater viability and the good cosmetic result. Complications can arise from wound infection, hematomas, or necrosis due to damage to the perforating arteries if blunt dissection was not used or was too aggressive. Alternatives to this type of flap are the horn-shaped fasciocutaneous flap, island flap, and full thickness skin graft.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion and Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">The keystone flap was first described in 2003 by Behan,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> who defined 4 subtypes according to complexity of the flap. Type <span class="elsevierStyleSmallCaps">i</span> does not penetrate the muscle fascia and is useful for defects of up to 2<span class="elsevierStyleHsp" style=""></span>cm. Type <span class="elsevierStyleSmallCaps">ii</span> is used to cover larger defects of 2 to 5<span class="elsevierStyleHsp" style=""></span>cm, and has 2 variants: IIA, in which the fascia is incised along the convex border of the flap, and IIB, in which, in addition to the fascial incision, a full thickness skin graft is used to cover the secondary defect. Type <span class="elsevierStyleSmallCaps">iii</span> uses 2 keystone flaps, making it a double keystone, for defects of 5 to 10<span class="elsevierStyleHsp" style=""></span>cm. And type <span class="elsevierStyleSmallCaps">iv</span>, which consists of a rotational keystone flap that requires mobilization of sufficient subfascial tissue, is used mainly to cover open fractures.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As with other fasciocutaneous flaps, the keystone flap derives its blood supply from the axial and perforating vascular system of the legs, thus guaranteeing its viability. Its design allows it to cover large as well as deep defects, preserving sensitivity and avoiding differences in skin color and texture. Apart from its use in the limbs, this flap has been employed for the reconstruction of defects at other sites, such as the trunk, cheek, nose, lower eyelid, neck, and anogenital region.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A further advantage of the keystone flap is that the use of skin adjacent to the surgical defect preserves skin appearance and thickness, in contrast to skin grafts, which almost always have a different appearance, as they are derived from skin from a distinct anatomical site, and may be depressed due to a lack of subcutaneous cellular tissue. It should also be noted that full thickness skin grafts generally take longer to perform.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As can be seen in the video, the keystone flap is not particularly difficult to perform and we consider it to be a very interesting, safe, and rapid option with very good functional and cosmetic results.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion and Conclusions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cocunubo-Blanco HA, Pérez-Bustillo A, Manrrique E, Rodríguez-Prieto MÁ. Colgajo de keystone tipo <span class="elsevierStyleSmallCaps">i</span>. Actas Dermosifiliogr. 2018;109:71–72.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1565 "Ancho" => 1625 "Tamanyo" => 245408 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Design of the type<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">i</span> keystone flap.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 81301409 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The keystone design perforator island flap in reconstructive surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.C. 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Grant" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1445-2197.2012.06021.x" "Revista" => array:6 [ "tituloSerie" => "ANZ J Surg" "fecha" => "2012" "volumen" => "82" "paginaInicial" => "381" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23305061" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000001/v1_201801020547/S1578219017303694/v1_201801020547/en/main.assets" "Apartado" => array:4 [ "identificador" => "6209" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Videos of Surgical Procedures in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000001/v1_201801020547/S1578219017303694/v1_201801020547/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303694?idApp=UINPBA000044" ]
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| 2023 July | 106 | 31 | 137 |
| 2023 June | 82 | 18 | 100 |
| 2023 May | 135 | 29 | 164 |
| 2023 April | 125 | 22 | 147 |
| 2023 March | 91 | 33 | 124 |
| 2023 February | 91 | 32 | 123 |
| 2023 January | 76 | 37 | 113 |
| 2022 December | 89 | 40 | 129 |
| 2022 November | 52 | 25 | 77 |
| 2022 October | 60 | 24 | 84 |
| 2022 September | 57 | 77 | 134 |
| 2022 August | 67 | 35 | 102 |
| 2022 July | 43 | 42 | 85 |
| 2022 June | 24 | 24 | 48 |
| 2022 May | 123 | 37 | 160 |
| 2022 April | 135 | 46 | 181 |
| 2022 March | 97 | 56 | 153 |
| 2022 February | 108 | 42 | 150 |
| 2022 January | 122 | 51 | 173 |
| 2021 December | 102 | 54 | 156 |
| 2021 November | 93 | 52 | 145 |
| 2021 October | 92 | 66 | 158 |
| 2021 September | 79 | 46 | 125 |
| 2021 August | 73 | 38 | 111 |
| 2021 July | 56 | 35 | 91 |
| 2021 June | 70 | 51 | 121 |
| 2021 May | 59 | 54 | 113 |
| 2021 April | 151 | 119 | 270 |
| 2021 March | 121 | 48 | 169 |
| 2021 February | 70 | 83 | 153 |
| 2021 January | 64 | 53 | 117 |
| 2020 December | 57 | 46 | 103 |
| 2020 November | 41 | 49 | 90 |
| 2020 October | 34 | 19 | 53 |
| 2020 September | 48 | 20 | 68 |
| 2020 August | 36 | 36 | 72 |
| 2020 July | 27 | 28 | 55 |
| 2020 June | 49 | 44 | 93 |
| 2020 May | 17 | 16 | 33 |
| 2020 April | 25 | 15 | 40 |
| 2020 March | 25 | 16 | 41 |
| 2020 February | 7 | 0 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 3 | 0 | 3 |
| 2019 May | 2 | 1 | 3 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 4 | 0 | 4 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 5 | 0 | 5 |
| 2018 November | 29 | 0 | 29 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 5 | 0 | 5 |
| 2018 February | 55 | 27 | 82 |
| 2018 January | 68 | 36 | 104 |
| 2017 December | 2 | 7 | 9 |
Show all
