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Reconstructing Complex Open Back Wounds with a Modified Keystone Flap
Kyle M. Rako BS, Spencer R. Anderson MD, Sunishka M. Wimalawansa MD MBA.
Dept. of Orthopedic and Plastic Surgery, Wright State University
2018-01-30
Presenter: Kyle M. Rako
Affidavit:
Both the resident and medical student have equally contributed to the production of this project, with case provided by the associate professor.
Director Name: R. Michael Johnson, MD
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: General Reconstruction
Purpose: The paraspinal "Keystone" flap is a reconstructive technique based upon paraspinal perforators for closure of complex back/spinal wounds. The senior author employs a modified technique eliminating the lateral incision thereby decreasing donor site morbidity, allowing additional advancement if indicated, and producing greater aesthetic results.
Methods: Retrospective chart review was performed, with detailed description of technical modifications of the Keystone flap.
Results: A 61-year-old female patient was referred 12 days post-op with a complex infected and dehisced paraspinal wound post spinal fusion. Following debridement and revision of hardware, the deep dead space was eliminated using bilateral paraspinal muscle flaps. This left a large skin defect, reconstructed using the modified Keystone flap, providing well-matched soft tissue coverage, tension-free closure, and off-loaded incision lines (keeping key suture lines away from midline spinal processes). Here, we avoid making the lateral incision (unless absolutely necessary); perform subfascial elevation and lateral fascial release using lighted breast retractors, blunt elevators, and extended-tip electrocautery; and dissect out paraspinal perforators using a hand-held Doppler. This allows tension free flap mobilization while eliminating need for lateral back-cuts and double V-Y donor closures. Patient healed without complications and minimal additional external scarring.
Conclusion: The modified Keystone flap is a great option for reconstructing spinal/paraspinal wound defects, yielding adequate tissue coverage, an overall pleasing aesthetic result, and allows additional future flap advancement for coverage if necessary, given that we have not committed to a lateral skin incision.
