The Keystone Flap in Dermatology: Clinical Experience with 18 Patients

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Aragón-Miguel, M. Gutiérrez-Pascual, A. Sánchez-Gilo, J. Sanz-Bueno, F.J. Vicente-Martin" "autores" => array:5 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Aragón-Miguel" "email" => array:1 [ 0 => "raquel.aragonm@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Gutiérrez-Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Sánchez-Gilo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Sanz-Bueno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "F.J." "apellidos" => "Vicente-Martin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre. Instituto de Investigación I+12, Madrid, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicación del colgajo de keystone en dermatología. Experiencia clínica en 18 pacientes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1167 "Ancho" => 1517 "Tamanyo" => 249599 ] ] "descripcion" => array:1 [ "en" => "Design and technique of the keystone flap. A, The flap design is marked. B, The lesion is excised. C, Dissection is performed without reaching the deep fascia. D, The defect is closed." ] ] ] "textoCompleto" => "IntroductionThe keystone flap was first described in 2003 by Behan<a class="elsevierStyleCrossRef" href="#bib0095">1</a> as an alternative to skin grafts and other flaps used to cover medium and large skin defects. The flap is a fasciocutaneous flap irrigated by vascular perforators. The name is borrowed from the architectural term keystone, referring to the central stone that supported the weight of Roman arches.We present our clinical experience in the use of this flap to cover medium-sized defects on the legs.Materials and MethodsIn this descriptive, retrospective study, 18 patients with malignant skin tumors on the legs underwent keystone flap reconstruction. The technique was performed in the University Hospital Rey Juan Carlos, in Mostoles (Madrid), Spain between July 2013 and May 2017. No patient was excluded from the study. The clinical and demographic characteristics of the patients are described, along with the histopathological findings of tumor biopsy, the defect size, and associated side effects.TechniqueWe performed 17 keystone flap reconstructions according to the classic Behan technique<a class="elsevierStyleCrossRef" href="#bib0095">1</a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>), and 1 according to the modified Moncrieff technique.<a class="elsevierStyleCrossRef" href="#bib0100">2</a> After application of mepivacaine 2% to the area as local anesthetic, local primary tumors were removed by fusiform excision and the flap was constructed, sparing the vascular perforators. From the anatomical area with greatest mobility, in most cases from the posterior compartment of the leg, a flap of the same width as the defect was marked. Each corner of the flap formed a 90° angle. The final shape of the flap was an arched trapezoid like a keystone. Simple suture was used with nonresorbable 3/0 and 2/0 stitches. In some cases, V-Y advancement of each end of the flap was needed for full closure.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In the case of the modified keystone flap procedure, partial dissection only was performed of the arch, leaving a central area of healthy skin that contributed to dermal vascularization.All surgical procedures were performed in the outpatient setting; admission to hospital was not required for any patients.As these flaps required substantial tension, a regimen of 7-10 days of antibiotics was started after surgery. Amoxicillin-clavulanic acid was the treatment of choice if there were no contraindications. Patients were recommended relative rest, and no antithrombotic prophylaxis was required.In all cases, the first dressing change was performed in hospital 48-72hours after surgery to ensure flap viability. The stitches were removed after 14-18 days. The duration of patient follow-up varied depending on the malignant tumor that had been excised.ResultsA total of 18 flap procedures were performed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Twelve of these were in women and 6 in men (ratio 2:1). The oldest patient was aged 95 years and the youngest 59 years, with a mean age of 77.83 years. The malignant tumors excised were as follows: 7 basal cell epitheliomas, 6 squamous cell carcinomas, and 5 malignant pigmented tumors (malignant melanoma, lentigo maligna, and lentigo maligna melanoma). All lesions were located on the legs.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The largest lesion excised was 2.5cm in diameter (6.25cm2) and the smallest 0.8×0.7cm (0.56cm2), with a mean area of 2.98cm2. The maximum resulting defect size after flap design was 7.6×3cm (22.8cm2) and the minimum defect size was 3.2×2cm (6.4cm2), with a mean area of 12.74cm2.Regarding comorbidities in these patients, 13 (72.2%) had cardiovascular risk factors, 46.15% had diabetes, and 100% had hypertension. One patient had had at least one episode of ischemic heart disease and another had had cerebrovascular accident (15.38% of the total). Two patients had presented with an episode of thrombosis (deep vein thrombosis and pulmonary thromboembolism) and 4 patients (30.76%) were receiving treatment with acenocoumarol. One patient (7.69%) had a history of malignant neoplasm and only 3 patients had a history of chronic venous insufficiency or stasis dermatitis.During follow-up (median duration, 19 months), 7 patients (38.8%) had a surgical wound complication. In 27.7% of patients, partial dehiscence of the surgical wound was observed. In 11.1%, some sign of infection after finishing the prophylaxis regimen was observed. In these patients, antibiotic treatment was administered according to susceptibility testing after taking a sample for culture. Three of the 4 patients who were in treatment with acenocoumarol experienced postoperative bleeding. Although none of these bleeding events was severe, acenocoumarol was replaced by low molecular weight heparin therapy. Those patients who were receiving antiplatelet therapy alone did not require any changes to their regimen. No cases of partial of total flap necrosis were observed.Our patients experienced moderate postoperative pain that was controlled with usual analgesics. This pain resulted from the tension arising from skin displacement.The 18 flaps had good cosmetic and functional outcomes. Those that showed partial dehiscence closed satisfactorily by second intent. No repeat operations were required.DiscussionClosure of skin defects on the legs is a therapeutic challenge for dermatologists. In most cases, the patients are elderly with deterioration of peripheral vascularization and reduced skin mobility.The reconstructive techniques used for closure of medium-large sized defects on the legs are skin grafts and skin flaps. Rotation, advancement, or transposition flaps can be used on the legs. The main problem is the lack of skin mobility, which is associated with a substantial increase in the risk of necrosis. On the other hand, full thickness skin grafting requires prolonged immobilization of the patient; is associated with higher rates of total/partial necrosis and postoperative dressing changes; and, at times, worse cosmetic outcomes.<a class="elsevierStyleCrossRefs" href="#bib0100">2–5</a>Behan<a class="elsevierStyleCrossRef" href="#bib0095">1</a> therefore proposed the keyhole flap procedure as an alternative to these approaches. Vascular perforators pass through the muscular fascia, directly feeding the dermis and subcutaneous tissue. These vessels provide sufficient irrigation for the flap to survive and favor earlier wound healing.<a class="elsevierStyleCrossRefs" href="#bib0095">1,5</a>There are 4 main subtypes of keystone flap (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Type I is the standard one, used for medium-sized lesions. The 3 remaining types are modifications of the standard flap and are used to cover larger defects.<a class="elsevierStyleCrossRef" href="#bib0095">1</a> In 2008, Moncrieff et al.<a class="elsevierStyleCrossRef" href="#bib0100">2</a> designed the modified keystone flap. This approach was used in 1 of our cases. In this alternative, additional vascularization is provided through dermal vessels. In a series of 176 patients, the Moncrieff variant demonstrated a lower rate of complications than with the standard flap.<a class="elsevierStyleCrossRef" href="#bib0105">3</a> The other keystone flap variants are the yin-yang flap,<a class="elsevierStyleCrossRef" href="#bib0120">6</a> omega flap,<a class="elsevierStyleCrossRef" href="#bib0125">7</a> and modifications to subtypeIV which cover larger defects.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Keystone flaps should have certain specific characteristics to survive. The defect has to have the same width as the flap. This allows redistribution of skin tension and avoids dehiscence and necrosis. The main disadvantage of the standard keystone flap is that it is difficult to use in large defects. Although it is generally recommended for defects smaller than 3cm, it is important to take into account anatomical and individual patient characteristics, such as skin mobility or whether or not underlying diseases are present that may limit the use of this technique. In these cases, variants of the same procedure or other flaps or grafts could be used.<a class="elsevierStyleCrossRef" href="#bib0105">3</a>Their longitudinal orientation preserves the vascular perforators and lymphatic vessels, reducing the risk of distal lymphedema. In the modified Moncrief flap, the skin bridge preserves this venous and lymphatic return.<a class="elsevierStyleCrossRef" href="#bib0100">2</a>We have described keystone flaps for defects on the legs, but the literature has examples of other uses<a class="elsevierStyleCrossRef" href="#bib0130">8</a>: in ophthalmology for eyelid reconstruction,<a class="elsevierStyleCrossRef" href="#bib0135">9</a> in maxillofacial surgery for parotid defects,<a class="elsevierStyleCrossRef" href="#bib0140">10</a> in general and gynecological surgery for perineal and vulvar defects,<a class="elsevierStyleCrossRef" href="#bib0145">11</a> and in neurosurgery for defects in the dorsolumbar and lumbosacral area.<a class="elsevierStyleCrossRefs" href="#bib0150">12,13</a>The most extensive series published was that of Behan<a class="elsevierStyleCrossRef" href="#bib0095">1</a> in 2003. That series included 300 patients treated with this reconstructive technique in different anatomical areas. The success rate was 99.6% (success was understood to mean absence of major complications). Subsequently, multiple case series have been published. We review the most relevant that include reconstructions on the legs.<a class="elsevierStyleCrossRefs" href="#bib0160">14–18</a>In 2011, Khouri et al.<a class="elsevierStyleCrossRef" href="#bib0160">14</a> reported a series of 28 patients with 14 keystone flap procedures on the legs. They obtained a complication rate of 35.7% and only 1 of the 14 procedures had total flap necrosis. Rao and Janna<a class="elsevierStyleCrossRef" href="#bib0170">16</a> reported 20 patients who underwent keystone flap procedures on the legs. The complication rate was 15% and the success rate 95% with only 1 case of partial flap necrosis. Recently, in 2017, a series of 60 keystone flap procedures was published (41.7% on the legs) with an overall complication rate of 40%, most of which (76%) were on the legs.<a class="elsevierStyleCrossRef" href="#bib0175">17</a> These results show an overall complication rate on the legs (between 15% and 40%) similar to ours (38.8%). In our series, the success rate was 100% and we did not observe partial or total flap necrosis in any patient.We have only found 1 prospective study that compares keystone flaps with other skin flaps.<a class="elsevierStyleCrossRef" href="#bib0180">18</a> In 39 patients, keystone flap procedures were performed, while in 22, a rhomboid transposition flap procedure was performed. Patients with a range of anatomical sites were included. No statistically significant differences were observed in the rate of dehiscence between the 2 types of flap.The only comparative study of the class keystone flap variant and the modified variant was published by Moncrieff et al.<a class="elsevierStyleCrossRef" href="#bib0100">2</a> Those authors observed a lower incidence of major complications in the modified variant and an overall success rate close to 99% (only 2 of the 176 patients treated had total graft necrosis).In conclusion, the keystone flap procedure is a reconstructive option for medium-sized defects on the legs. It is an alternative to full-thickness skin grafts and classic flap procedures. The cosmetic and functional outcomes are good. It is associated with less secondary edema and lower morbidity, and decreases the risk of skin necrosis.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1066764" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1014532" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1066765" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1014533" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-09" "fechaAceptado" => "2018-02-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1014532" "palabras" => array:4 [ 0 => "Keystone flap" 1 => "Fasciocutaneous flap" 2 => "Skin defects" 3 => "Lower limbs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1014533" "palabras" => array:4 [ 0 => "Colgajo de keystone" 1 => "Colgajo fasciocutáneo" 2 => "Defectos cutáneos" 3 => "Miembros inferiores" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectivesThe keystone flap is a fasciocutaneous flap supplied by perforating arteries. It is used in dermatology to repair surgical defects in areas with low skin extensibility (the upper and lower limbs and the back). We review the clinical experience gained with keystone flap reconstruction at our hospital and report on the surgical outcomes. Material and methodsDescriptive retrospective study of patients with malignant skin tumors on the lower limbs who underwent keystone flap reconstruction. ResultsEighteen patients (mean age, 77.83 years) underwent keystone flap reconstruction using the Behan technique in 17 cases and the modified Moncrieff technique in one. Basal cell carcinomas accounted for 38.8% of the tumors excised, squamous cell carcinomas 33.3%, and malignant pigmented tumors 27.7%. Cardiovascular risk factors were observed in 72.2% of patients. Minor complications occurred in 38.8% of patients, and there were no cases of partial or total flap necrosis. ConclusionsWe consider the keystone flap to be a good alternative to other flaps and grafts for the surgical reconstruction of lower limb defects. The success rate was high, and the cosmetic and functional outcomes were good." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosEl colgajo de keystone es un colgajo fasciocutáneo cuya vascularización proviene de las arteriolas perforantes musculares. Su aplicación en dermatología es para cubrir defectos en zonas de piel poco distensible (miembros inferiores, superiores y de la espalda). Presentamos nuestra experiencia clínica y los resultados quirúrgicos del centro. Material y métodosEstudio descriptivo retrospectivo de pacientes con tumores cutáneos malignos en miembros inferiores en los que se realizó el colgajo de keystone. ResultadosSe operaron 18 pacientes con una edad media de 77,83 años. Se realizaron 17 mediante la técnica propuesta por Behan y uno con la técnica modificada de Moncrieff. El 38,8% de los tumores extirpados fueron carcinomas basocelulares, el 33,3% carcinomas epidermoides y el 27,7% tumores malignos pigmentados. El 72,22% presentaba algún factor de riesgo cardiovascular. Se observó un 38,8% de complicaciones menores y ningún caso de necrosis parcial o total del colgajo. ConclusionesConsideramos que el colgajo de keystone es una buena alternativa terapéutica a otros colgajos e injertos para la reconstrucción de defectos en miembros inferiores. Los resultados estéticos y funcionales son buenos, con una tasa de éxito elevada." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Aragón-Miguel R, Gutiérrez-Pascual M, Sánchez-Gilo A, Sanz-Bueno J, Vicente-Martin FJ. Aplicación del colgajo de keystone en dermatología. Experiencia clínica en 18 pacientes. Actas Dermosifiliogr. 2018;109:515–520." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1213 "Ancho" => 1517 "Tamanyo" => 314193 ] ] "descripcion" => array:1 [ "en" => "Design and technique of the keystone flap. A, The flap design is marked. B, Dissection is performed without reaching the deep fascia. C, The flap is advanced and brought to the defect. D, The defect is closed." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1167 "Ancho" => 1517 "Tamanyo" => 249599 ] ] "descripcion" => array:1 [ "en" => "Design and technique of the keystone flap. A, The flap design is marked. B, The lesion is excised. C, Dissection is performed without reaching the deep fascia. D, The defect is closed." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: ACVA, acute cerebrovascular accident; AF, atrial fibrillation; BCE, basal cell epithelioma; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DL, dyslipidemia; DM, diabetes mellitus; DVT, deep vein thrombosis; F, female; HF, heart failure; M, male; OSAS, obstructive sleep apnoea syndrome; PTE, pulmonary thromboembolism; RL, right leg; SCC, spindle-cell carcinoma." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tumor Type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histological Defect Size, cm (cm2) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5×2 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Malignant ovarian neoplasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5×2 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lentigo maligna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.2×2.2 (13.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DVT RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.9×1.7 (10.03) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL, DM, stasis dermatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6×2.5 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dehiscence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.6×3 (13.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DL, hypertension, DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dehiscence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6×2 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DL, hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.2×2 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.6×3 (22.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL, DM, ischemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5×2 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6×2.3 (13,8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5×2.2 (12.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL, DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7×1.8 (12.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral PTE with Sintrom, ACVD, thrombophilia, hyperhomocysteinemia, thrombophlebitis RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Postoperative bleeding, dehisence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.7×1.5 (8.55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, HF, AF with Sintrom, venous insufficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Postoperative bleeding, infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lentigo maligna melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6×3×0.5 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL, DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BCE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5×2 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DL, AF with Sintrom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Postoperative bleeding, dehisence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Legs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5×2.3 (16.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, DM, DL, popliteal vein insufficiency, COPD, OSAS, CKD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dehiscence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.7×2.5 (14.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension, AF with Sintrom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1819357.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological Characteristics of the Patients and Tumor Type, Size, and Complications." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subtype \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Standard flap, with no division of the deep fascia. Generally lesions of smaller size \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Type II.</td><td class="td" title="table-entry " align="left" valign="top">Deep fascia are divided to ensure mobility, with subdivisions into: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIa Secondary defect with primary closure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIb Defect closed by skin graft \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Double flap Large defects \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial flap rotation Vascularization originates from the fixed part of the flap \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1819356.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Subtypes of Keystone Flaps Proposed by Behan." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "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. 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" => "bib0100" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Keystone flap reconstruction of primary melanoma excision defects of the leg —the end of the skin graft?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.D. Moncrieff" 1 => "F. Bowen" 2 => "J.F. Thompson" 3 => "R.P. Saw" 4 => "K.F. Shannon" 5 => "A.J. Spillane" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-008-0018-8" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol." "fecha" => "2008" "volumen" => "15" "paginaInicial" => "2867" "paginaFinal" => "2873" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18629589" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0105" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The keystone island and pedicle flap: A handy local flap for soft tissue reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.D. Shipkow" 1 => "A. Mojallal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-008-0126-5" "Revista" => array:5 [ "tituloSerie" => "Ann Surg Oncol." "fecha" => "2008" "volumen" => "15" "paginaInicial" => "3625" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18726652" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0110" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The keystone flap for lower extremity defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Hu" 1 => "J.S. Bordeaux" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.2011.02236.x" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg." "fecha" => "2012" "volumen" => "38" "paginaInicial" => "490" "paginaFinal" => "493" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22141740" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0115" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The keystone fasciocutaneous flap in the reconstruction of lower extremity wounds" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.C. Martinez" 1 => "J.L. Cook" 2 => "C. Otley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.2011.02239.x" "Revista" => array:6 [ "tituloSerie" => "Dermatol Surg." "fecha" => "2012" "volumen" => "38" "paginaInicial" => "484" "paginaFinal" => "489" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22211312" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0120" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Yin-Yang flaps: The mathematics of two keystone island flaps for reconstructing increasingly large defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F.C. Behan" 1 => "W.M. Rozen" 2 => "S. Tan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "ANZ J Surg." 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"fecha" => "2011" "volumen" => "81" "paginaInicial" => "650" "paginaFinal" => "652" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22295410" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0130" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The keystone perforator island flap concept" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Behan" 1 => "M. Findlay" 2 => "C.H. 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"fecha" => "2015" "volumen" => "9" "paginaInicial" => "PC05" "paginaFinal" => "PC7" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26046021" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0175" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Applying the keystone design perforator island flap concept in a variety for anatomic locations. A review of 60 consecutive cases by a single surgeon" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.A. Lanni" 1 => "E. van Kouwenberg" 2 => "A. Yan" 3 => "K.M. Rezaj" 4 => "A. Patel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SAP.0000000000000995" "Revista" => array:6 [ "tituloSerie" => "Ann Plast Surg." 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Original Article

The Keystone Flap in Dermatology: Clinical Experience with 18 Patients

Aplicación del colgajo de keystone en dermatología. Experiencia clínica en 18 pacientes

R. Aragón-Miguela,

Autor para correspondencia

raquel.aragonm@gmail.com

Corresponding author.

, M. Gutiérrez-Pascualb, A. Sánchez-Gilob, J. Sanz-Buenob, F.J. Vicente-Martinb

a Servicio de Dermatología, Hospital Universitario 12 de Octubre. Instituto de Investigación I+12, Madrid, España

b Servicio de Dermatología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España

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    "titulo" => "The Keystone Flap in Dermatology&#58; Clinical Experience with 18 Patients"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Design and technique of the keystone flap&#46; A&#44; The flap design is marked&#46; B&#44; The lesion is excised&#46; C&#44; Dissection is performed without reaching the deep fascia&#46; D&#44; The defect is closed&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The keystone flap was first described in 2003 by Behan<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> as an alternative to skin grafts and other flaps used to cover medium and large skin defects&#46; The flap is a fasciocutaneous flap irrigated by vascular perforators&#46; The name is borrowed from the architectural term <span class="elsevierStyleItalic">keystone</span>&#44; referring to the central stone that supported the weight of Roman arches&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present our clinical experience in the use of this flap to cover medium-sized defects on the legs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">In this descriptive&#44; retrospective study&#44; 18 patients with malignant skin tumors on the legs underwent keystone flap reconstruction&#46; The technique was performed in the University Hospital Rey Juan Carlos&#44; in Mostoles &#40;Madrid&#41;&#44; Spain between July 2013 and May 2017&#46; No patient was excluded from the study&#46; The clinical and demographic characteristics of the patients are described&#44; along with the histopathological findings of tumor biopsy&#44; the defect size&#44; and associated side effects&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed 17 keystone flap reconstructions according to the classic Behan technique<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; and 1 according to the modified Moncrieff technique&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> After application of mepivacaine 2&#37; to the area as local anesthetic&#44; local primary tumors were removed by fusiform excision and the flap was constructed&#44; sparing the vascular perforators&#46; From the anatomical area with greatest mobility&#44; in most cases from the posterior compartment of the leg&#44; a flap of the same width as the defect was marked&#46; Each corner of the flap formed a 90&#176; angle&#46; The final shape of the flap was an arched trapezoid like a keystone&#46; Simple suture was used with nonresorbable 3&#47;0 and 2&#47;0 stitches&#46; In some cases&#44; V-Y advancement of each end of the flap was needed for full closure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In the case of the modified keystone flap procedure&#44; partial dissection only was performed of the arch&#44; leaving a central area of healthy skin that contributed to dermal vascularization&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All surgical procedures were performed in the outpatient setting&#59; admission to hospital was not required for any patients&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As these flaps required substantial tension&#44; a regimen of 7-10 days of antibiotics was started after surgery&#46; Amoxicillin-clavulanic acid was the treatment of choice if there were no contraindications&#46; Patients were recommended relative rest&#44; and no antithrombotic prophylaxis was required&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In all cases&#44; the first dressing change was performed in hospital 48-72<span class="elsevierStyleHsp" style=""></span>hours after surgery to ensure flap viability&#46; The stitches were removed after 14-18 days&#46; The duration of patient follow-up varied depending on the malignant tumor that had been excised&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 18 flap procedures were performed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Twelve of these were in women and 6 in men &#40;ratio 2&#58;1&#41;&#46; The oldest patient was aged 95 years and the youngest 59 years&#44; with a mean age of 77&#46;83 years&#46; The malignant tumors excised were as follows&#58; 7 basal cell epitheliomas&#44; 6 squamous cell carcinomas&#44; and 5 malignant pigmented tumors &#40;malignant melanoma&#44; lentigo maligna&#44; and lentigo maligna melanoma&#41;&#46; All lesions were located on the legs&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The largest lesion excised was 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;6&#46;25<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41; and the smallest 0&#46;8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;7<span class="elsevierStyleHsp" style=""></span>cm &#40;0&#46;56<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41;&#44; with a mean area of 2&#46;98<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#46; The maximum resulting defect size after flap design was 7&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm &#40;22&#46;8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41; and the minimum defect size was 3&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm &#40;6&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41;&#44; with a mean area of 12&#46;74<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding comorbidities in these patients&#44; 13 &#40;72&#46;2&#37;&#41; had cardiovascular risk factors&#44; 46&#46;15&#37; had diabetes&#44; and 100&#37; had hypertension&#46; One patient had had at least one episode of ischemic heart disease and another had had cerebrovascular accident &#40;15&#46;38&#37; of the total&#41;&#46; Two patients had presented with an episode of thrombosis &#40;deep vein thrombosis and pulmonary thromboembolism&#41; and 4 patients &#40;30&#46;76&#37;&#41; were receiving treatment with acenocoumarol&#46; One patient &#40;7&#46;69&#37;&#41; had a history of malignant neoplasm and only 3 patients had a history of chronic venous insufficiency or stasis dermatitis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">During follow-up &#40;median duration&#44; 19 months&#41;&#44; 7 patients &#40;38&#46;8&#37;&#41; had a surgical wound complication&#46; In 27&#46;7&#37; of patients&#44; partial dehiscence of the surgical wound was observed&#46; In 11&#46;1&#37;&#44; some sign of infection after finishing the prophylaxis regimen was observed&#46; In these patients&#44; antibiotic treatment was administered according to susceptibility testing after taking a sample for culture&#46; Three of the 4 patients who were in treatment with acenocoumarol experienced postoperative bleeding&#46; Although none of these bleeding events was severe&#44; acenocoumarol was replaced by low molecular weight heparin therapy&#46; Those patients who were receiving antiplatelet therapy alone did not require any changes to their regimen&#46; No cases of partial of total flap necrosis were observed&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our patients experienced moderate postoperative pain that was controlled with usual analgesics&#46; This pain resulted from the tension arising from skin displacement&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The 18 flaps had good cosmetic and functional outcomes&#46; Those that showed partial dehiscence closed satisfactorily by second intent&#46; No repeat operations were required&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Closure of skin defects on the legs is a therapeutic challenge for dermatologists&#46; In most cases&#44; the patients are elderly with deterioration of peripheral vascularization and reduced skin mobility&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The reconstructive techniques used for closure of medium-large sized defects on the legs are skin grafts and skin flaps&#46; Rotation&#44; advancement&#44; or transposition flaps can be used on the legs&#46; The main problem is the lack of skin mobility&#44; which is associated with a substantial increase in the risk of necrosis&#46; On the other hand&#44; full thickness skin grafting requires prolonged immobilization of the patient&#59; is associated with higher rates of total&#47;partial necrosis and postoperative dressing changes&#59; and&#44; at times&#44; worse cosmetic outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#8211;5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Behan<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> therefore proposed the keyhole flap procedure as an alternative to these approaches&#46; Vascular perforators pass through the muscular fascia&#44; directly feeding the dermis and subcutaneous tissue&#46; These vessels provide sufficient irrigation for the flap to survive and favor earlier wound healing&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">There are 4 main subtypes of keystone flap &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Type <span class="elsevierStyleHsp" style=""></span>I is the standard one&#44; used for medium-sized lesions&#46; The 3 remaining types are modifications of the standard flap and are used to cover larger defects&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> In 2008&#44; Moncrieff et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> designed the modified keystone flap&#46; This approach was used in 1 of our cases&#46; In this alternative&#44; additional vascularization is provided through dermal vessels&#46; In a series of 176 patients&#44; the Moncrieff variant demonstrated a lower rate of complications than with the standard flap&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> The other keystone flap variants are the yin-yang flap&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> omega flap&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> and modifications to subtype<span class="elsevierStyleHsp" style=""></span>IV which cover larger defects&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Keystone flaps should have certain specific characteristics to survive&#46; The defect has to have the same width as the flap&#46; This allows redistribution of skin tension and avoids dehiscence and necrosis&#46; The main disadvantage of the standard keystone flap is that it is difficult to use in large defects&#46; Although it is generally recommended for defects smaller than 3<span class="elsevierStyleHsp" style=""></span>cm&#44; it is important to take into account anatomical and individual patient characteristics&#44; such as skin mobility or whether or not underlying diseases are present that may limit the use of this technique&#46; In these cases&#44; variants of the same procedure or other flaps or grafts could be used&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Their longitudinal orientation preserves the vascular perforators and lymphatic vessels&#44; reducing the risk of distal lymphedema&#46; In the modified Moncrief flap&#44; the skin bridge preserves this venous and lymphatic return&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">We have described keystone flaps for defects on the legs&#44; but the literature has examples of other uses<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a>&#58; in ophthalmology for eyelid reconstruction&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> in maxillofacial surgery for parotid defects&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> in general and gynecological surgery for perineal and vulvar defects&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> and in neurosurgery for defects in the dorsolumbar and lumbosacral area&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The most extensive series published was that of Behan<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> in 2003&#46; That series included 300 patients treated with this reconstructive technique in different anatomical areas&#46; The success rate was 99&#46;6&#37; &#40;success was understood to mean absence of major complications&#41;&#46; Subsequently&#44; multiple case series have been published&#46; We review the most relevant that include reconstructions on the legs&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#8211;18</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In 2011&#44; Khouri et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> reported a series of 28 patients with 14 keystone flap procedures on the legs&#46; They obtained a complication rate of 35&#46;7&#37; and only 1 of the 14 procedures had total flap necrosis&#46; Rao and Janna<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> reported 20 patients who underwent keystone flap procedures on the legs&#46; The complication rate was 15&#37; and the success rate 95&#37; with only 1 case of partial flap necrosis&#46; Recently&#44; in 2017&#44; a series of 60 keystone flap procedures was published &#40;41&#46;7&#37; on the legs&#41; with an overall complication rate of 40&#37;&#44; most of which &#40;76&#37;&#41; were on the legs&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> These results show an overall complication rate on the legs &#40;between 15&#37; and 40&#37;&#41; similar to ours &#40;38&#46;8&#37;&#41;&#46; In our series&#44; the success rate was 100&#37; and we did not observe partial or total flap necrosis in any patient&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">We have only found 1 prospective study that compares keystone flaps with other skin flaps&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> In 39 patients&#44; keystone flap procedures were performed&#44; while in 22&#44; a rhomboid transposition flap procedure was performed&#46; Patients with a range of anatomical sites were included&#46; No statistically significant differences were observed in the rate of dehiscence between the 2 types of flap&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The only comparative study of the class keystone flap variant and the modified variant was published by Moncrieff et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> Those authors observed a lower incidence of major complications in the modified variant and an overall success rate close to 99&#37; &#40;only 2 of the 176 patients treated had total graft necrosis&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; the keystone flap procedure is a reconstructive option for medium-sized defects on the legs&#46; It is an alternative to full-thickness skin grafts and classic flap procedures&#46; The cosmetic and functional outcomes are good&#46; It is associated with less secondary edema and lower morbidity&#44; and decreases the risk of skin necrosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-08-09"
    "fechaAceptado" => "2018-02-25"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1014532"
          "palabras" => array:4 [
            0 => "Keystone flap"
            1 => "Fasciocutaneous flap"
            2 => "Skin defects"
            3 => "Lower limbs"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1014533"
          "palabras" => array:4 [
            0 => "Colgajo de keystone"
            1 => "Colgajo fasciocut&#225;neo"
            2 => "Defectos cut&#225;neos"
            3 => "Miembros inferiores"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The keystone flap is a fasciocutaneous flap supplied by perforating arteries&#46; It is used in dermatology to repair surgical defects in areas with low skin extensibility &#40;the upper and lower limbs and the back&#41;&#46; We review the clinical experience gained with keystone flap reconstruction at our hospital and report on the surgical outcomes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descriptive retrospective study of patients with malignant skin tumors on the lower limbs who underwent keystone flap reconstruction&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eighteen patients &#40;mean age&#44; 77&#46;83 years&#41; underwent keystone flap reconstruction using the Behan technique in 17 cases and the modified Moncrieff technique in one&#46; Basal cell carcinomas accounted for 38&#46;8&#37; of the tumors excised&#44; squamous cell carcinomas 33&#46;3&#37;&#44; and malignant pigmented tumors 27&#46;7&#37;&#46; Cardiovascular risk factors were observed in 72&#46;2&#37; of patients&#46; Minor complications occurred in 38&#46;8&#37; of patients&#44; and there were no cases of partial or total flap necrosis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We consider the keystone flap to be a good alternative to other flaps and grafts for the surgical reconstruction of lower limb defects&#46; The success rate was high&#44; and the cosmetic and functional outcomes were good&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El colgajo de keystone es un colgajo fasciocut&#225;neo cuya vascularizaci&#243;n proviene de las arteriolas perforantes musculares&#46; Su aplicaci&#243;n en dermatolog&#237;a es para cubrir defectos en zonas de piel poco distensible &#40;miembros inferiores&#44; superiores y de la espalda&#41;&#46; Presentamos nuestra experiencia cl&#237;nica y los resultados quir&#250;rgicos del centro&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo de pacientes con tumores cut&#225;neos malignos en miembros inferiores en los que se realiz&#243; el colgajo de keystone&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se operaron 18 pacientes con una edad media de 77&#44;83 a&#241;os&#46; Se realizaron 17 mediante la t&#233;cnica propuesta por Behan y uno con la t&#233;cnica modificada de Moncrieff&#46; El 38&#44;8&#37; de los tumores extirpados fueron carcinomas basocelulares&#44; el 33&#44;3&#37; carcinomas epidermoides y el 27&#44;7&#37; tumores malignos pigmentados&#46; El 72&#44;22&#37; presentaba alg&#250;n factor de riesgo cardiovascular&#46; Se observ&#243; un 38&#44;8&#37; de complicaciones menores y ning&#250;n caso de necrosis parcial o total del colgajo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Consideramos que el colgajo de keystone es una buena alternativa terap&#233;utica a otros colgajos e injertos para la reconstrucci&#243;n de defectos en miembros inferiores&#46; Los resultados est&#233;ticos y funcionales son buenos&#44; con una tasa de &#233;xito elevada&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arag&#243;n-Miguel R&#44; Guti&#233;rrez-Pascual M&#44; S&#225;nchez-Gilo A&#44; Sanz-Bueno J&#44; Vicente-Martin FJ&#46; Aplicaci&#243;n del colgajo de keystone en dermatolog&#237;a&#46; Experiencia cl&#237;nica en 18 pacientes&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;515&#8211;520&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1213
            "Ancho" => 1517
            "Tamanyo" => 314193
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Design and technique of the keystone flap&#46; A&#44; The flap design is marked&#46; B&#44; Dissection is performed without reaching the deep fascia&#46; C&#44; The flap is advanced and brought to the defect&#46; D&#44; The defect is closed&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1167
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            "Tamanyo" => 249599
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Design and technique of the keystone flap&#46; A&#44; The flap design is marked&#46; B&#44; The lesion is excised&#46; C&#44; Dissection is performed without reaching the deep fascia&#46; D&#44; The defect is closed&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ACVA&#44; acute cerebrovascular accident&#59; AF&#44; atrial fibrillation&#59; BCE&#44; basal cell epithelioma&#59; CKD&#44; chronic kidney disease&#59; COPD&#44; chronic obstructive pulmonary disease&#59; DL&#44; dyslipidemia&#59; DM&#44; diabetes mellitus&#59; DVT&#44; deep vein thrombosis&#59; F&#44; female&#59; HF&#44; heart failure&#59; M&#44; male&#59; OSAS&#44; obstructive sleep apnoea syndrome&#59; PTE&#44; pulmonary thromboembolism&#59; RL&#44; right leg&#59; SCC&#44; spindle-cell carcinoma&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tumor Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Histological Defect Size&#44; cm &#40;cm<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Malignant ovarian neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lentigo maligna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;2 &#40;13&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DVT RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;7 &#40;10&#46;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&#44; DM&#44; stasis dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dehiscence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DL&#44; hypertension&#44; DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dehiscence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DL&#44; hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3 &#40;22&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&#44; DM&#44; ischemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;3 &#40;13&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;2 &#40;12&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&#44; DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;8 &#40;12&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bilateral PTE with Sintrom&#44; ACVD&#44; thrombophilia&#44; hyperhomocysteinemia&#44; thrombophlebitis RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postoperative bleeding&#44; dehisence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5 &#40;8&#46;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; HF&#44; AF with Sintrom&#44; venous insufficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postoperative bleeding&#44; infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lentigo maligna melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&#44; DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BCE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DL&#44; AF with Sintrom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postoperative bleeding&#44; dehisence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Legs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;3 &#40;16&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; DM&#44; DL&#44; popliteal vein insufficiency&#44; COPD&#44; OSAS&#44; CKD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dehiscence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5 &#40;14&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#44; AF with Sintrom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subtype&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Standard flap&#44; with no division of the deep fascia&#46; Generally lesions of smaller size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Type II&#46;</td><td class="td" title="table-entry  " align="left" valign="top">Deep fascia are divided to ensure mobility&#44; with subdivisions into&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIa Secondary defect with primary closure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIb Defect closed by skin graft&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Double flap Large defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial flap rotation Vascularization originates from the fixed part of the flap&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0095"
              "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"
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                    ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "ANZ J Surg&#46;"
                        "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"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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            1 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Keystone flap reconstruction of primary melanoma excision defects of the leg &#8212;the end of the skin graft&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;D&#46; Moncrieff"
                            1 => "F&#46; Bowen"
                            2 => "J&#46;F&#46; Thompson"
                            3 => "R&#46;P&#46; Saw"
                            4 => "K&#46;F&#46; Shannon"
                            5 => "A&#46;J&#46; Spillane"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1245/s10434-008-0018-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg Oncol&#46;"
                        "fecha" => "2008"
                        "volumen" => "15"
                        "paginaInicial" => "2867"
                        "paginaFinal" => "2873"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18629589"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The keystone island and pedicle flap&#58; A handy local flap for soft tissue reconstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;D&#46; Shipkow"
                            1 => "A&#46; Mojallal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1245/s10434-008-0126-5"
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Surg Oncol&#46;"
                        "fecha" => "2008"
                        "volumen" => "15"
                        "paginaInicial" => "3625"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18726652"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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              ]
            ]
            3 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The keystone flap for lower extremity defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Hu"
                            1 => "J&#46;S&#46; Bordeaux"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1524-4725.2011.02236.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Surg&#46;"
                        "fecha" => "2012"
                        "volumen" => "38"
                        "paginaInicial" => "490"
                        "paginaFinal" => "493"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22141740"
                            "web" => "Medline"
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                      ]
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              ]
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              "identificador" => "bib0115"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The keystone fasciocutaneous flap in the reconstruction of lower extremity wounds"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;C&#46; Martinez"
                            1 => "J&#46;L&#46; Cook"
                            2 => "C&#46; Otley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1524-4725.2011.02239.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Surg&#46;"
                        "fecha" => "2012"
                        "volumen" => "38"
                        "paginaInicial" => "484"
                        "paginaFinal" => "489"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22211312"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
            ]
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                    0 => array:2 [
                      "titulo" => "Yin-Yang flaps&#58; The mathematics of two keystone island flaps for reconstructing increasingly large defects"
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                          "etal" => false
                          "autores" => array:3 [
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                            2 => "S&#46; Tan"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "ANZ J Surg&#46;"
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                        "paginaInicial" => "574"
                        "paginaFinal" => "575"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22295411"
                            "web" => "Medline"
                          ]
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                  ]
                ]
              ]
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              "identificador" => "bib0125"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The omega -&#937;- variant designs &#40;types A and B&#41; of the keystone perforator island flap"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            2 => "C&#46;H&#46; Lo"
                            3 => "M&#46; Findlay"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
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                        "tituloSerie" => "ANZ J Surg&#46;"
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                        "paginaInicial" => "650"
                        "paginaFinal" => "652"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22295410"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0130"
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              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The keystone perforator island flap concept"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Behan"
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                            2 => "C&#46;H&#46; Lo"
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                    ]
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                    0 => array:1 [
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                        "editorialLocalizacion" => "Australia"
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                  ]
                ]
              ]
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              "identificador" => "bib0135"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Eyelid reconstruction&#58; Expanding the applications of the keystone perforator island flap concept"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46;W&#46; Loh"
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                            3 => "J&#46; Crock"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1445-2197.2012.06222.x"
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                        "tituloSerie" => "ANZ J Surg&#46;"
                        "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"
                          ]
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                    ]
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                ]
              ]
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              "identificador" => "bib0140"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Keystone island flap reconstruction of parotid defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46;C&#46; Behan"
                            1 => "C&#46;H&#46; Lo"
                            2 => "A&#46; Sizeland"
                            3 => "T&#46; Pham"
                            4 => "M&#46; Findlay"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PRS.0b013e3182547f55"
                      "Revista" => array:6 [
                        "tituloSerie" => "Plast Reconstr Surg&#46;"
                        "fecha" => "2012"
                        "volumen" => "130"
                        "paginaInicial" => "36e"
                        "paginaFinal" => "41e"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22743953"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "&#8216;Perineal keystone design perforator island flap&#8217; for perineal and vulval reconstruction"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            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"
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                        "tituloSerie" => "ANZ J Surg&#46;"
                        "fecha" => "2012"
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                        "paginaInicial" => "381"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23305061"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0150"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46; Jamjoom"
                            1 => "H&#46; Alnoman"
                            2 => "Y&#46; Almadani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/GOX.0000000000001114"
                      "Revista" => array:5 [
                        "tituloSerie" => "Plast Reconstr Surg Glob Open&#46;"
                        "fecha" => "2016"
                        "volumen" => "4"
                        "paginaInicial" => "e1114"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28293496"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0155"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;S&#46; Park"
                            1 => "E&#46; Morrison"
                            2 => "C&#46; Lo"
                            3 => "J&#46; Leong"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SAP.0000000000000600"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Plast Surg&#46;"
                        "fecha" => "2016"
                        "volumen" => "77"
                        "paginaInicial" => "332"
                        "paginaFinal" => "336"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26418773"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0160"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The keystone island flap&#58; Use in large defects of the trunk and extremities in soft-tissue reconstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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                            1 => "B&#46;M&#46; Egeland"
                            2 => "S&#46;D&#46; Daily"
                            3 => "M&#46;S&#46; Harake"
                            4 => "S&#46; Kwon"
                            5 => "P&#46;C&#46; Neligan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Plast Reconstr Surg&#46;"
                        "fecha" => "2011"
                        "volumen" => "127"
                        "paginaInicial" => "1212"
                        "paginaFinal" => "1221"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21364423"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "15"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Avoiding skin grafts&#58; The keystone flap in cutaneous defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Stone"
                            1 => "C&#46; Webb"
                            2 => "J&#46;G&#46; McKinnon"
                            3 => "J&#46;C&#46; Dawes"
                            4 => "C&#46;D&#46; McKenzie"
                            5 => "C&#46;F&#46; Temple-Oberle"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        "tituloSerie" => "Plast Reconstr Surg&#46;"
                        "fecha" => "2015"
                        "volumen" => "136"
                        "paginaInicial" => "404"
                        "paginaFinal" => "408"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26218384"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0170"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Keystone flap&#58; Versatile flap for reconstruction of limb defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;L&#46; Rao"
                            1 => "R&#46;K&#46; Janna"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7860/JCDR/2015/12720.5854"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Diagn Res&#46;"
                        "fecha" => "2015"
                        "volumen" => "9"
                        "paginaInicial" => "PC05"
                        "paginaFinal" => "PC7"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26046021"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Applying the keystone design perforator island flap concept in a variety for anatomic locations&#46; A review of 60 consecutive cases by a single surgeon"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46;A&#46; Lanni"
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                            2 => "A&#46; Yan"
                            3 => "K&#46;M&#46; Rezaj"
                            4 => "A&#46; Patel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SAP.0000000000000995"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Plast Surg&#46;"
                        "fecha" => "2017"
                        "volumen" => "79"
                        "paginaInicial" => "60"
                        "paginaFinal" => "67"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28252544"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0180"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            1 => "L&#46; Choi"
                            2 => "S&#46; Kim"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12957-016-1019-x"
                      "Revista" => array:5 [
                        "tituloSerie" => "World J Surg Oncol&#46;"
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                        "volumen" => "14"
                        "paginaInicial" => "269"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27756412"
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                          ]
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                      ]
                    ]
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                ]
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            ]
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Información del artículo

ISSN: 15782190
Idioma original: Inglés

DOI:10.1016/j.adengl.2018.05.011

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