array:24 [
  "pii" => "S1578219017303694"
  "issn" => "15782190"
  "doi" => "10.1016/j.adengl.2017.11.013"
  "estado" => "S300"
  "fechaPublicacion" => "2018-01-01"
  "aid" => "1735"
  "copyright" => "Elsevier España, S.L.U. and AEDV"
  "copyrightAnyo" => "2017"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Actas Dermosifiliogr. 2018;109:71-2"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 308
    "formatos" => array:3 [
      "EPUB" => 21
      "HTML" => 216
      "PDF" => 71
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0001731017303459"
      "issn" => "00017310"
      "doi" => "10.1016/j.ad.2017.05.015"
      "estado" => "S300"
      "fechaPublicacion" => "2018-01-01"
      "aid" => "1735"
      "copyright" => "AEDV"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "cita" => "Actas Dermosifiliogr. 2018;109:71-2"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 363
        "formatos" => array:3 [
          "EPUB" => 5
          "HTML" => 291
          "PDF" => 67
        ]
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">V&#237;deos de cirug&#237;a dermatol&#243;gica</span>"
        "titulo" => "Colgajo de keystone tipo <span class="elsevierStyleSmallCaps">i</span>"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "71"
            "paginaFinal" => "72"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Type <span class="elsevierStyleSmallCaps">I</span> Keystone Island Flap"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1565
                "Ancho" => 1625
                "Tamanyo" => 243426
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dise&#241;o del colgajo keystone tipo <span class="elsevierStyleSmallCaps">i</span>&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "H&#46;A&#46; Cocunubo-Blanco, A&#46; P&#233;rez-Bustillo, E&#46; Manrrique, M&#46;&#193;&#46; Rodr&#237;guez-Prieto"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "H&#46;A&#46;"
                "apellidos" => "Cocunubo-Blanco"
              ]
              1 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "P&#233;rez-Bustillo"
              ]
              2 => array:2 [
                "nombre" => "E&#46;"
                "apellidos" => "Manrrique"
              ]
              3 => array:2 [
                "nombre" => "M&#46;&#193;&#46;"
                "apellidos" => "Rodr&#237;guez-Prieto"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1578219017303694"
          "doi" => "10.1016/j.adengl.2017.11.013"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303694?idApp=UINPBA000044"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017303459?idApp=UINPBA000044"
      "url" => "/00017310/0000010900000001/v1_201801020548/S0001731017303459/v1_201801020548/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1578219017303700"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2017.11.014"
    "estado" => "S300"
    "fechaPublicacion" => "2018-01-01"
    "aid" => "1654"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "sco"
    "cita" => "Actas Dermosifiliogr. 2018;109:73"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 302
      "formatos" => array:3 [
        "EPUB" => 22
        "HTML" => 204
        "PDF" => 76
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Images in Dermatology</span>"
      "titulo" => "A Pink Tumor&#58; Angiolymphoid Hyperplasia With Eosinophilia"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:1 [
          "paginaInicial" => "73"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Un tumor rosado&#44; hiperplasia angiolinfoide con eosinofilia"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:6 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1338
              "Ancho" => 975
              "Tamanyo" => 173800
            ]
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "I&#46; P&#233;rez-L&#243;pez, A&#46; Mart&#237;nez-L&#243;pez, P&#46; Aguayo-Carreras, M&#46;J&#46; Naranjo-D&#237;az"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "P&#233;rez-L&#243;pez"
            ]
            1 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Mart&#237;nez-L&#243;pez"
            ]
            2 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Aguayo-Carreras"
            ]
            3 => array:2 [
              "nombre" => "M&#46;J&#46;"
              "apellidos" => "Naranjo-D&#237;az"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731017301722"
        "doi" => "10.1016/j.ad.2016.10.022"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017301722?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303700?idApp=UINPBA000044"
    "url" => "/15782190/0000010900000001/v1_201801020547/S1578219017303700/v1_201801020547/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1578219017303682"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2017.11.012"
    "estado" => "S300"
    "fechaPublicacion" => "2018-01-01"
    "aid" => "1696"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "sco"
    "cita" => "Actas Dermosifiliogr. 2018;109:69-70"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 418
      "formatos" => array:3 [
        "EPUB" => 23
        "HTML" => 288
        "PDF" => 107
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Resident&#39;s Forum</span>"
      "titulo" => "The Good and Bad News About New Drugs for Treating Alopecia Areata"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "69"
          "paginaFinal" => "70"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "FR-Luces y sombras de nuevos f&#225;rmacos en el tratamiento de la alopecia areata"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "D&#46; Morgado-Carrasco, E&#46; Rodr&#237;guez-Lobato, J&#46; Riera-Monroig, J&#46; Ferrando"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "D&#46;"
              "apellidos" => "Morgado-Carrasco"
            ]
            1 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Rodr&#237;guez-Lobato"
            ]
            2 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Riera-Monroig"
            ]
            3 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Ferrando"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731017302648"
        "doi" => "10.1016/j.ad.2017.05.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017302648?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303682?idApp=UINPBA000044"
    "url" => "/15782190/0000010900000001/v1_201801020547/S1578219017303682/v1_201801020547/en/main.assets"
  ]
  "en" => array:16 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Videos of Surgical Procedures in Dermatology</span>"
    "titulo" => "Type <span class="elsevierStyleSmallCaps">I</span> Keystone Island Flap"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "71"
        "paginaFinal" => "72"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "H&#46;A&#46; Cocunubo-Blanco, A&#46; P&#233;rez-Bustillo, E&#46; Manrrique, M&#46;&#193;&#46; Rodr&#237;guez-Prieto"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "H&#46;A&#46;"
            "apellidos" => "Cocunubo-Blanco"
            "email" => array:1 [
              0 => "hacb27&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "P&#233;rez-Bustillo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "E&#46;"
            "apellidos" => "Manrrique"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "M&#46;&#193;&#46;"
            "apellidos" => "Rodr&#237;guez-Prieto"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servicio de Dermatolog&#237;a&#44; Complejo Asistencial Universitario de Le&#243;n&#44; Le&#243;n&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Dermatolog&#237;a&#44; Hospital Cl&#237;nico Universitario de Valladolid&#44; Valladolid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "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&#46;</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&#44; with associated stasis dermatitis and skin changes due to lipodermatosclerosis of the lower limbs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">First&#44; the flap is designed on the area adjacent to the defect that can provide the largest tissue contribution and greatest tissue mobility &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; After preparation of the surgical field with povidone iodine and local anesthesia with mepivacaine&#44; 2&#37;&#44; plus epinephrine&#44; the tumor is excised&#44; continuing down to but not including the fascia&#46; The skin of the flap is then incised using a scalpel and the subcutaneous tissue is liberated by blunt dissection using scissors&#44; taking care not to damage the perforating vessels&#46; 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&#46; Finally the distal border is sutured to the defect using silk or staples&#46;</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&#44; although it has also been employed at other sites&#44; such as on the genitalia and the face&#46; There are no absolute contraindications&#59; relative contraindications include peripheral artery disease and infection&#46; Particular benefits of this flap are its greater viability and the good cosmetic result&#46; Complications can arise from wound infection&#44; hematomas&#44; or necrosis due to damage to the perforating arteries if blunt dissection was not used or was too aggressive&#46; Alternatives to this type of flap are the horn-shaped fasciocutaneous flap&#44; island flap&#44; and full thickness skin graft&#46;</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&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> who defined 4 subtypes according to complexity of the flap&#46; 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&#46; Type <span class="elsevierStyleSmallCaps">ii</span> is used to cover larger defects of 2 to 5<span class="elsevierStyleHsp" style=""></span>cm&#44; and has 2 variants&#58; IIA&#44; in which the fascia is incised along the convex border of the flap&#44; and IIB&#44; in which&#44; in addition to the fascial incision&#44; a full thickness skin graft is used to cover the secondary defect&#46; Type <span class="elsevierStyleSmallCaps">iii</span> uses 2 keystone flaps&#44; making it a double keystone&#44; for defects of 5 to 10<span class="elsevierStyleHsp" style=""></span>cm&#46; And type <span class="elsevierStyleSmallCaps">iv</span>&#44; which consists of a rotational keystone flap that requires mobilization of sufficient subfascial tissue&#44; is used mainly to cover open fractures&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As with other fasciocutaneous flaps&#44; the keystone flap derives its blood supply from the axial and perforating vascular system of the legs&#44; thus guaranteeing its viability&#46; Its design allows it to cover large as well as deep defects&#44; preserving sensitivity and avoiding differences in skin color and texture&#46; Apart from its use in the limbs&#44; this flap has been employed for the reconstruction of defects at other sites&#44; such as the trunk&#44; cheek&#44; nose&#44; lower eyelid&#44; neck&#44; and anogenital region&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;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&#44; in contrast to skin grafts&#44; which almost always have a different appearance&#44; as they are derived from skin from a distinct anatomical site&#44; and may be depressed due to a lack of subcutaneous cellular tissue&#46; It should also be noted that full thickness skin grafts generally take longer to perform&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As can be seen in the video&#44; the keystone flap is not particularly difficult to perform and we consider it to be a very interesting&#44; safe&#44; and rapid option with very good functional and cosmetic results&#46;</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&#46;</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" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cocunubo-Blanco HA&#44; P&#233;rez-Bustillo A&#44; Manrrique E&#44; Rodr&#237;guez-Prieto M&#193;&#46; Colgajo de keystone tipo <span class="elsevierStyleSmallCaps">i</span>&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;71&#8211;72&#46;</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&#46;</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&#46;C&#46; Behan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "ANZ J Surg"
                        "fecha" => "2003"
                        "volumen" => "73"
                        "paginaInicial" => "112"
                        "paginaFinal" => "120"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12608972"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The keystone design perforator island flap&#46; Part II&#58; Clinical applications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P&#46; Pelissier"
                            1 => "H&#46; Gardet"
                            2 => "V&#46; Pinsolle"
                            3 => "M&#46; Santoul"
                            4 => "F&#46;C&#46; Behan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bjps.2007.03.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Plast Reconstr Aesthet Surg"
                        "fecha" => "2007"
                        "volumen" => "60"
                        "paginaInicial" => "888"
                        "paginaFinal" => "891"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17493885"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eyelid reconstruction&#58; Expanding the applications of the keystone perforator island flap concept"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46;W&#46; Loh"
                            1 => "W&#46;M&#46; Rozen"
                            2 => "F&#46;C&#46; Behan"
                            3 => "J&#46; Crock"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1445-2197.2012.06222.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "ANZ J Surg"
                        "fecha" => "2012"
                        "volumen" => "82"
                        "paginaInicial" => "763"
                        "paginaFinal" => "764"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23025685"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perineal keystone design perforator island flap for perineal and vulval reconstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46;C&#46; Behan"
                            1 => "W&#46;M&#46; Rozen"
                            2 => "S&#46; Azer"
                            3 => "P&#46; 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"
]
Share
Journal Information
Vol. 109. Issue 1.
Pages 71-72 (January - February 2018)
Visits
7219
Vol. 109. Issue 1.
Pages 71-72 (January - February 2018)
Videos of Surgical Procedures in Dermatology
Full text access
Type I Keystone Island Flap
Colgajo de keystone tipo i
Visits
7219
H.A. Cocunubo-Blancoa,
Corresponding author
hacb27@hotmail.com

Corresponding author.
, A. Pérez-Bustillob, E. Manrriqueb, M.Á. Rodríguez-Prietoa
a Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain
b Servicio de Dermatología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Additional material (1)
Full Text
Introduction

We present a video showing the type I 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.

First, the flap is designed on the area adjacent to the defect that can provide the largest tissue contribution and greatest tissue mobility (Fig. 1). 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.

Figure 1.

Design of the typei keystone flap.

(0.23MB).

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.

Discussion and Conclusions

The keystone flap was first described in 2003 by Behan,1 who defined 4 subtypes according to complexity of the flap. Type i does not penetrate the muscle fascia and is useful for defects of up to 2cm. Type ii is used to cover larger defects of 2 to 5cm, 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 iii uses 2 keystone flaps, making it a double keystone, for defects of 5 to 10cm. And type iv, which consists of a rotational keystone flap that requires mobilization of sufficient subfascial tissue, is used mainly to cover open fractures.

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.2–4

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.

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.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
F.C. Behan.
The keystone design perforator island flap in reconstructive surgery.
ANZ J Surg, 73 (2003), pp. 112-120
[2]
P. Pelissier, H. Gardet, V. Pinsolle, M. Santoul, F.C. Behan.
The keystone design perforator island flap. Part II: Clinical applications.
J Plast Reconstr Aesthet Surg, 60 (2007), pp. 888-891
[3]
I.W. Loh, W.M. Rozen, F.C. Behan, J. Crock.
Eyelid reconstruction: Expanding the applications of the keystone perforator island flap concept.
ANZ J Surg, 82 (2012), pp. 763-764
[4]
F.C. Behan, W.M. Rozen, S. Azer, P. Grant.
Perineal keystone design perforator island flap for perineal and vulval reconstruction.
ANZ J Surg, 82 (2012), pp. 381-382

Please cite this article as: Cocunubo-Blanco HA, Pérez-Bustillo A, Manrrique E, Rodríguez-Prieto MÁ. Colgajo de keystone tipo i. Actas Dermosifiliogr. 2018;109:71–72.

Copyright © 2017. Elsevier España, S.L.U. and AEDV
Download PDF
Idiomas
Actas Dermo-Sifiliográficas
Article options
Tools
Supplemental materials
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?