Background: The management of myelomeningocele (MMC) defects poses significant reconstructive challenges. Numerous methods of reconstruction have been described. Nevertheless, the choice of the ideal reconstructive technique is still controversial. The keystone perforator island flap (KPIF), an emerging reconstructive option that is gaining popularity among reconstructive surgeons in many parts of the body. Herein, we aimed to evaluate the efficacy, safety, and surgical outcomes of using KPIF for the coverage of MMC defects. Methods: From April 2022 to April 2024, 16 consecutive newborns (10 male, 6 female) at a mean age of 4.4 days (1 - 15 days) with MMC defects were included in this prospective study. They underwent reconstruction using KPIF. The mean defect size was 5.6 × 5.1 cm (range, 4 × 4.5 cm to 8 × 6 cm). The defects were lumbar in 2 patients, thoracolumbar in 5 patients and lumbosacral in 9 patients. Operative time and early post-operative complications were recorded. Objective assessment regarding the durability of flaps and scar quality was done. Parents’ satisfaction with esthetic outcome was assessed. Results: Surgery time lasted between 60 and 110 minutes (mean: 83.8 minutes), excluding the neurosurgical repair. We used KPIF type III in 12 patients, and KPIF type IV -Omega variant in 4 patients. In all patients, tension-free closure was achieved, and healing was successful without any complications, except for 1 small wound dehiscence (<2 cm), which healed with conservative wound management. There was no case with a late breakdown of the wound or associated CSF fistula formation for a mean of 10.6 months (range, 6 - 18 months). 14 patients had thin, narrow scars, while 2 patients had wide, flat scars, and 87.5% subjective cosmetic satisfaction was noted. Conclusions: The keystone flap is an ideal reconstructive option for MMC defect closure as it is simple, reliable, versatile, and cost-effective treatment modality, offering advantages over traditional methods by improving patient outcomes and minimizing complications.
References
[1]
Kelly, T. and Leong, J. (2023) Long-term Follow-Up of Keystone Perforator Island Flap in Reconstructed Myelomeningocele Defects. JPRAS Open, 38, 261-268. https://doi.org/10.1016/j.jpra.2023.09.008
[2]
Hifny, M.A. and Hamdan, A.R. (2020) The Keystone Island Perforator Flap in Reconstruction of Large Myelomeningocele Defects. Annals of Plastic Surgery, 84, 575-579. https://doi.org/10.1097/sap.0000000000002058
[3]
Putri, N.M., Tunjung, N. and Sadikin, P.M. (2021) Closure of Meningomyelocele Defects Using Various Types of Keystone-Design Perforator Island Flaps. Archives of Plastic Surgery, 48, 261-268. https://doi.org/10.5999/aps.2020.01326
[4]
Park, H., Morrison, E., Lo, C. and Leong, J. (2016) An Application of Keystone Perforator Island Flap for Closure of Lumbosacral Myelomeningocele Defects. Annals of Plastic Surgery, 77, 332-336. https://doi.org/10.1097/sap.0000000000000600
[5]
Gómez, O. and Barrera, C. (2020) Keystone Flap: A Safe Coverage Option in the Handling of Salvage for Myelomeningocele. Child’s Nervous System, 36, 2765-2774. https://doi.org/10.1007/s00381-020-04662-y
[6]
Fairchild, B., Cepeda, A., Maiorino, E., Shah, M.N., Sandberg, D.I., Fletcher, S.A., et al. (2021) Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair. Annals of Plastic Surgery, 89, 82-88. https://doi.org/10.1097/sap.0000000000003043
[7]
Mrad, M.A., Alharbi, A., Mahabbat, N., Rafique, A. and Hashem, F. (2020) Surgical Application of the Keystone Island Flap for Closure of Thoracolumbar Myelomeningocele Defects—A Case Report. Annals of Medicine and Surgery, 57, 339-342. https://doi.org/10.1016/j.amsu.2020.08.012
[8]
Formentin, C., de Andrade, E.J., Matias, L.G., Joaquim, A.F., Tedeschi, H., Raposo-Amaral, C.E., et al. (2019) Using the Keystone Design Perforator Island Flap in Large Myelomeningocele Closure. Neurosurgical Focus, 47, E19. https://doi.org/10.3171/2019.7.focus19383
[9]
Lien, S.C., Maher, C.O., Garton, H.J.L., Kasten, S.J., Muraszko, K.M. and Buchman, S.R. (2010) Local and Regional Flap Closure in Myelomeningocele Repair: A 15-Year Review. Child’s Nervous System, 26, 1091-1095. https://doi.org/10.1007/s00381-010-1099-9
[10]
Yuste, V., Delgado, J., Silva, M., Rodrigo, J. and Albiñana, F. (2014) The Double Gluteal Myocutaneous Propeller Flap for the Coverage of Massive Myelomingoceles. Journal of Plastic, Reconstructive & Aesthetic Surgery, 67, 737-738. https://doi.org/10.1016/j.bjps.2013.12.011
[11]
Kankaya, Y., Sungur, N., Aslan, Ö.Ç., Ozer, K., Ulusoy, M.G., Karatay, M., et al. (2015) Alternative Method for the Reconstruction of Meningomyelocele Defects: V-Y Rotation and Advancement Flap. Journal of Neurosurgery: Pediatrics, 15, 467-474. https://doi.org/10.3171/2014.12.peds14133
[12]
Gutman, M.J., Goldschlager, T., Fahardieh, R.D., Ying, D., Xenos, C. and Danks, R.A. (2011) Keystone Design Perforator Island Flap for Closure of Myelomeningocele. Child’s Nervous System, 27, 1459-1463. https://doi.org/10.1007/s00381-011-1448-3
[13]
Behan, F.C. (2003) The Keystone Design Perforator Island Flap in Reconstructive Surgery. ANZ Journal of Surgery, 73, 112-120. https://doi.org/10.1046/j.1445-2197.2003.02638.x
[14]
Jamjoom, H., Alnoman, H. and Almadani, Y. (2016) Closure of a Large Thoracolumbar Myelomeningocele Using a Modified Bilateral Keystone Flap. Plastic and Reconstructive Surgery-Global Open, 4, e1114. https://doi.org/10.1097/gox.0000000000001114
[15]
Penington, T. (2013) Science and the Keystone Flap. ANZ Journal of Surgery, 83, 496-497. https://doi.org/10.1111/ans.12288
[16]
Findlay, M.W. and Kleid, S. (2014) The Keystone Concept: A Time for Good Science. ANZ Journal of Surgery, 84, 194-195. https://doi.org/10.1111/ans.12499
[17]
Abraham, J.T. and Saint-Cyr, M. (2017) Keystone and Pedicle Perforator Flaps in Reconstructive Surgery: New Modifications and Applications. Clinics in Plastic Surgery, 44, 385-402. https://doi.org/10.1016/j.cps.2016.12.005
[18]
Gómez, O.J., Barón, O.I. and Peñarredonda, M.L. (2019) Keystone Flap: Overcoming Paradigms. Plastic and Reconstructive Surgery-Global Open, 7, e2126. https://doi.org/10.1097/gox.0000000000002126
[19]
Luce, E.A., Stigers, S.W., Vandenbrink, K.D. and Walsh, J.W. (1991) Split-Thickness Skin Grafting of the Myelomeningocele Defect: A Subset at Risk for Late Ulceration. Plastic and Reconstructive Surgery, 87, 116-121. https://doi.org/10.1097/00006534-199101000-00018
[20]
Campobasso, P., Pesce, C., Costa, L. and Cimaglia, M.L. (2004) The Use of the Limberg Skin Flap for Closure of Large Lumbosacral Myelomeningoceles. Pediatric Surgery International, 20, 144-147. https://doi.org/10.1007/s00383-003-1056-8
[21]
Sarifakioglu, N., Bingül, F., Terzioǧlu, A., Ates, L. and Aslan, G. (2003) Bilateral Split Latissimus Dorsi V-Y Flaps for Closure of Large Thoracolumbar Meningomyelocele Defects. British Journal of Plastic Surgery, 56, 303-306. https://doi.org/10.1016/s0007-1226(03)00115-2
[22]
Zakaria, Y. and Hasan, E.A. (2010) Reversed Turnover Latissimus Dorsi Muscle Flap for Closure of Large Myelomeningocele Defects. Journal of Plastic, Reconstructive & Aesthetic Surgery, 63, 1513-1518. https://doi.org/10.1016/j.bjps.2009.08.001
[23]
Isik, D., Tekes, L., Eseoglu, M., Isik, Y., Bilici, S. and Atik, B. (2011) Closure of Large Myelomeningocele Defects Using Dorsal Intercostal Artery Perforator Flap. Annals of Plastic Surgery, 67, 159-163. https://doi.org/10.1097/sap.0b013e3181f3e0cf
[24]
Hifny, M.A., Hamdan, A.R., Tayel, A.M., El Khateeb, E.E., Yagi, S. and Park, T.H. (2022) Rotation Advancement Keystone Flap for Closure of Large Myelomeningocele Defects. Annals of Plastic Surgery, 89, 77-81. https://doi.org/10.1097/sap.0000000000003150
[25]
Kushida-Contreras, B.H. and Gaxiola-García, M.A. (2021) Myelomeningocele Defect Reconstruction with Keystone Flaps: Vascular Rationale for the Design and Operative Technique. Archives of Plastic Surgery, 48, 254-260. https://doi.org/10.5999/aps.2020.01746
[26]
Pelissier, P., Santoul, M., Pinsolle, V., Casoli, V. and Behan, F. (2007) The Keystone Design Perforator Island Flap. Part I: Anatomic Study. Journal of Plastic, Reconstructive & Aesthetic Surgery, 60, 883-887. https://doi.org/10.1016/j.bjps.2007.01.072
[27]
Donaldson, C., Murday, H.K.M., Gutman, M.J., Maher, R., Goldschlager, T., Xenos, C., et al. (2017) Long-Term Follow-Up for Keystone Design Perforator Island Flap for Closure of Myelomeningocele. Child’s Nervous System, 34, 733-736. https://doi.org/10.1007/s00381-017-3697-2
[28]
Bas, S. and Goker, B. (2024) Lateral Sacral Artery Perforator Flap as a New Option in Myelomeningocele Reconstruction. Annals of Plastic Surgery, 93, e58-e65. https://doi.org/10.1097/sap.0000000000004100
[29]
Leach, G.A., Pflibsen, L.R., Roberts, A., O’Connor, M.J., Bristol, R.E., Mabee, M.K., et al. (2023) Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review. Journal of Craniofacial Surgery, 34, 2040-2045. https://doi.org/10.1097/scs.0000000000009675
