Principles of Keystone Reconstruction

Abstract

The principles of outlining the Keystone design must sit within the dermatomal precinct, it must not be undermined, it must be fascial lined and any neurovascular structures (i.e. venous tributaries and cutaneous nerves) are all defined and preserved without any surgical division. Even venous tributaries inadvertently damaged can be repaired to preserve the venous drainage system because as McGregor from Canniesburn quoted years ago, more flaps die from venoustasis than arterial insufficiency. The close of the defects under tension defy plastic surgical traditions but the hyperaemia, hypothetically a sympathectomy effect, allows one to close these island flaps under tension, employing the surrounding muscular bellies which seems to facilitate this manoeuvre.

In Fig. 1.2b, note the island flap outline in the V2 dermatome carry on these principles of closure under tension but no undermining of the flaps is employed. The surrounding island incision is just closed directly to ensure wound integrity, particularly on a lady’s face and hyperaemia is a contributing factor to this facial repair/healing which has important aesthetic implications. Yes, sensory recovery occurs in 6 weeks along the incision lines, with the resolution of oedema and swelling, again presumably a sympathectomy effect simply an observational finding as it occurs in all such Keystone designs.