Arch Hand Microsurg.  2022 Sep;27(3):217-221. 10.12790/ahm.22.0004.

Keystone flap for reconstruction of ulnar side defect of the hand: a case report

• Koh IC
• Kim JH
• Kim H
• Lim SY

• KMID: 2532737
• DOI: http://doi.org/10.12790/ahm.22.0004

Abstract

Soft tissue defects of the hand may present in various forms and are often challenging to treat. The goal of surgical hand reconstruction includes both functional and aesthetic aspects. The keystone-design perforator island flap is a multi-perforator advancement flap with a safe flap harvesting technique, reliable blood supply, minimal donor site morbidity, and a simple dissection process that obviates the need for microsurgical techniques. Our patient was an 85-year-old man with squamous cell carcinoma on the left-hand ulnar side. The patient had difficulty in ambulation and used the affected area of the hand to stand up. Thus, we planned reconstruction using an omega-variant type B keystone flap to further reduce tension during flap insetting and to provide sufficient padding that would protect against excessive pressure postoperatively. The flap and donor site were closed primarily, without any postoperative complications. The patient was satisfied with the outcome after 19-month follow-up.

Keyword

Carcinoma; Squamous cell; Hand defect; Reconstructive surgical procedures

Figure

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  Fig. 1. Clinical photographs. (A) A 85-year-old male patient had a skin lesion in the lateral hypothenar area of the left hand. We supposed his lesions to be cancerous and planned an excisional biopsy. (B) After performing excision of the skin lesions, defect size was 1.5 × 2.5 cm2. A 4.0 × 5.5 cm2–sized keystone flap (KF) was designed on the lateral side of the defect. (C) We used the Ω-variant type IIB KF for coverage. (D) The postoperative photograph showed flap insetting with coverage of the dependent portion.

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  Fig. 2. (A) Previous flap site was identified to be a malignant lesion in the pathology examination. We planned further surgical management with a safety margin of 4 mm. (B) After performing further wide excision of the skin lesions, the defect was observed in the previous area of keystone flap (Ω-variant double-arm portion). (C) We used skin graft for coverage of defects to prevent contracture. (D) A postoperative photograph shows the donor site (wrist) in the ipsilateral area.

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  Fig. 3. (A) Postoperative photograph after a 19-month follow-up shows satisfactory results and functional outcomes with no contracture of the dependent portion. (B) It was confirmed that motion was not restricted and normal functioning was not hindered. (C) The getting-up position that the patient often assumed showed no discomfort after surgery. (D) The donor site of the graft successfully healed.

Reference

References

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