Reconstruction of bilateral inferomedial gluteal defects after resection of hidradenitis suppurativa with symmetrical keystone flaps designed parallel to relaxed skin-tension lines: A case report.

RATIONALE: Surgical treatment of hidradenitis suppurativa (HS) is challenging. Wide excision of affected lesions followed by skin graft or flap coverage has been recommended to achieve remission and prevent recurrence. Herein, we present our experience of bilateral inferomedial gluteal defects coverage using symmetrical keystone flaps (KFs) designed parallel to relaxed skin-tension lines (RSTLs). PATIENT CONCERNS: An 18-year-old man was admitted for chronic inflammatory lesions in both inferomedial gluteal areas. DIAGNOSES: Physical examination revealed multiple sinuses with broad surrounding scars in both inferomedial gluteal areas, which led to a diagnosis of HS. INTERVENTIONS: We performed wide excision on all affected lesions. The size of the final defects was 6 × 10 cm on the right side, and 5 × 9 cm on the left side. We covered the defects with KFs 9 × 15 cm (right) and 8 × 12 cm (left), which were based on the hotspots of the interior gluteal artery and internal pudendal artery perforators, and parallel to RSTLs. OUTCOMES: The flaps were inset without tension on each side, and the donor sites were closed primarily. All flaps fully survived and there were no postoperative complications. The patient was satisfied with the final outcome after 6 months of follow-up. LESSONS: Successful reconstruction of bilateral inferomedial gluteal defects was achieved after resection of HS using symmetrical KFs designed parallel to RSTLs. The KF technique considering RSTLs could be a good reconstructive option for gluteal HS.

Keystone-design perforator island flaps for the management of complicated epidermoid cysts on the back.

Complicated epidermoid cysts (ECs) occur commonly on the back, but few reports have described their management. We present our experience in managing patients with ECs on the back using a keystone-design perforator island flap (KDPIF) reconstruction, thereby focusing on reduction and redistribution of wound tension. Altogether, 15 patients (average age, 48.067 ± 14.868 years) underwent KDPIF reconstructions after complete excision of complicated ECs on the back. We retrospectively reviewed the medical records and clinical photographs of all patients. Final scar appearance was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). All patients had ruptured ECs, while 6 patients also had cellulitis of the surrounding tissues. All defects, after complete excision of ECs and debridement of surrounding unhealthy tissues, were successfully covered with KDPIF. The mean 'tension-change' at the defect and donor sites was -4.73 ± 0.21 N and -4.88 ± 0.25 N, respectively (p < 0.001). The mean 'rate of tension-change' at the defect and donor sites was -69.48 ± 1.7% and -71.16 ± 1.33%, respectively (p < 0.001). All flaps survived with no postoperative complications. The mean observer scar assessment scale (OSAS) summary score and patient scar assessment scale (PSAS) total score were 14.467 ± 5.069 and 15.6 ± 6.512, respectively. Overall, we suggest that KDPIF reconstruction is a good surgical modality for the management of complicated ECs on the back.

Relaxed skin tension line-oriented keystone-designed perforator island flaps considering the facial aesthetic unit concept for the coverage of small to moderate facial defects.

A variety of reconstructive options including skin grafts, loco-regional flaps, and free flaps exist for the coverage of facial defects. Each technique has advantages and disadvantages. In this study, we present our experience with relaxed skin tension line (RSTL)-oriented, keystone-designed perforator island flap (KDPIF) reconstructions, in consideration of the facial aesthetic unit concept for coverage of small to moderate facial defects.Between May 2016 and February 2018, 17 patients (11 men and 6 women), with an average age of 63.53 years (range: 37-83 years) underwent KDPIF reconstructions to cover facial defects. We performed the KDPIF reconstructions in consideration of the RSTLs and facial aesthetic unit concept. We retrospectively reviewed the defect causes, locations, and sizes, and flap sizes, types, and survivals, as well as the complications. Cosmetic outcomes were evaluated using the Harris 4-stage scale from 3 independent plastic surgeons' point of view, and postoperative satisfactory surveys from all patients.All defects were successfully covered with KDPIF. The defect sizes varied from 1.5 × 1.5 cm to 3 × 3.5 cm. The flap sizes varied from 1.5 × 3 cm to 3 × 5.5 cm. All flaps fully survived and there were no postoperative complications. The average subjective patient satisfaction score was 8.29 (range: 7-10) and the objective cosmetic outcomes were favorable (fair, good, or excellent).Considering its simplicity and safety, the KDPIF is a good reconstruction option with few complications and high reproducibility. The RSTL-oriented KDPIF reconstruction is a good reconstructive option for covering small to moderate facial defects with superior aesthetic outcomes.