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      Closure of meningomyelocele defects using various types of keystone-design perforator island flaps

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          Various methods have been described to close large meningomyelocele defects, but no technique has been proven superior to others. This study presents cases of meningomyelocele defect closure with a keystone-design perforator island flap.


          A retrospective study was performed on 14 patients with meningomyelocele defects closed using various types of keystone flaps.


          The median age of the patients at surgery was 10.5 days (range, 1–369 days) and the average defect size was 22.5 cm 2 (range, 7.1–55.0 cm 2). The average operative time for defect closure was 89.6 minutes (range, 45–120 minutes). Type IV bilateral keystone flaps were used for four defects, type IV unilateral flaps for six defects, type IIA flaps for two defects, and type III flaps for two defects.


          All the defects healed completely with no major complications. The keystone-design perforator island flap is a reliable, easy, and fast technique to close large meningomyelocele defects.

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          Most cited references 27

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          The Keystone Design Perforator Island Flap in reconstructive surgery.

           Shawn Behan (2003)
          A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot. We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid-line area is the line of maximum tension and by V-Y advancement of each end of the flap, the 'islanded' flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients. In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap. The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.
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            Long-term outcome in open spina bifida.

            Doctors need reliable data on outcome in order to help parents faced with difficult decisions about termination of an affected pregnancy or treatment after birth. To determine survival, health and lifestyle at the mean age of 30 years in a complete cohort of adults born with open spina bifida. Prospective cohort study. Well-documented cohort of 117 consecutive cases of open spina bifida whose backs were closed non-selectively at birth between 1963 and 1971. Survivors (age range = 26 to 33 years) were surveyed by postal questionnaire and telephone interview. The main outcome measures were the health, independence and lifestyle of the survivors in terms of living in the community, driving a car and working in open employment. Ascertainment was 100%. Sixty (51%) had died, mainly the most disabled. Of the 57 survivors, 84% had a cerebrospinal fluid (CSF) shunt, 70% had an IQ of 80 or more, 37% lived independently in the community, 39% drove a car, 30% could walk more than 50 metres and 26% were in open employment. However one-third (19) still needed daily care, three were on respiratory support, two were blind, two had diabetes mellitus, and one was on dialysis. Mortality, disability and achievement reflected the neurological deficit that had been recorded in infancy in terms of sensory level. Attainment and independence were reduced in those who had needed revision of CSF shunt. The survivors in this unselected cohort showed a wide range of outcome from apparent normality to very severe disability. This reflected both the extent of their original neurological deficit and events in the history of their CSF shunt.
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              Keystone design perforator island flap for closure of myelomeningocele


                Author and article information

                Arch Plast Surg
                Arch Plast Surg
                Archives of Plastic Surgery
                Korean Society of Plastic and Reconstructive Surgeons
                May 2021
                15 May 2021
                : 48
                : 3
                : 261-268
                Division of Plastic, Reconstructive, and Aesthetic Surgery, Department of Surgery, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
                Author notes
                Correspondence: Nandita Melati Putri Division of Plastic, Reconstructive, and Aesthetic Surgery, Department of Surgery, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, RS Cipto Mangunkusumo, Gedung A Lantai 4, Jalan Diponegoro No. 71, Jakarta Pusat, Jakarta 10430, Indonesia Tel: +62-21-390-5556 Fax: +62-21-314-6938 E-mail: nandita.putri@ 123456ui.ac.id
                Copyright © 2021 The Korean Society of Plastic and Reconstructive Surgeons

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Original Article


                surgery, plastic, meningomyelocele, perforator flaps, island flaps, surgical flaps


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