Clinical application of a modified double keystone design perforator island flap for repair of defects after excision of Bowen disease in posterior midline lumbar region_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Qizun ¹ , LI Qianqian ² , WANG Jingdong ³ , WANG Xiao ⁴ , CHEN Bohua ¹ ,  LI Haiyan ¹ ,  WU Xiaolin ¹

1. Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao Shandong, 266003, P. R. China;
2. Department of Abdominal Ultrasound, Affiliated Hospital of Qingdao University, Qingdao Shandong, 266003, P. R. China;
3. Department of Orthopedics, Dezhou Municipal Hospital, Dezhou Shandong, 253000, P. R. China;
4. Department of Pathology, Affiliated Hospital of Qingdao University, Qingdao Shandong, 266003, P. R. China;

Corresponding?author：

LI Haiyan, Email: hyandhx@163.com; WU Xiaolin, Email: fyqs01@qdu.edu.cn

Keywords：

Keystone design perforator island flap; double-arch technique; Bowen disease; posterior midline lumbar region; wound repair

DOI：

10.7507/1002-1892.202602055

Video：

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Objective To investigate the effectiveness of a modified double keystone design perforator island flap in repairing large skin and soft tissue defects in the posterior midline lumbar region following extensive excision for Bowen disease. Methods A retrospective analysis was conducted on the clinical data of 9 patients with Bowen disease in the posterior midline lumbar region admitted between January 2020 and June 2024. There were 4 males and 5 females; ages ranged from 55 to 80 years, with a mean age of 68.9 years. Lesions were located at L_1-5 levels and concentrated near the midline posterior to the spinous processes. And the lesions were confined to the skin and subcutaneous tissue. The size of residual defects following extensive excision ranged from 6.0 cm×5.5 cm to 10.0 cm×8.5 cm. The modified double keystone design perforator island flaps were designed with the defect as the center. Subcutaneous and adipose tissues were dissected without incising the deep fascia, while preserving perforator vessels. The bilateral flaps were advanced toward the midline using V-Y advancement sutures; the size of unilateral flap ranged from 8.5 cm×3.5 cm to 15.0 cm×6.0 cm. The donor sites were directly sutured. Results Operations were successfully completed in all 9 cases. The operation time ranged from 80 to 100 minutes (mean, 90 minutes); intraoperative blood loss ranged from 20 to 80 mL (mean, 41.1 mL); and the length of hospital stay ranged from 9 to 15 days (mean, 10.4 days). All flaps survived, with only 1 case of mild fat liquefaction at the recipient site. All patients were followed up 9-18 months (mean, 12.4 months). All flaps were similar in texture, thickness, and color to the surrounding skin, with no obvious “cat’s ear” deformity observed. The lumbar mobility was normal, with no sensation of tightness or pain. At last follow-up, the subjective satisfaction, as assessed by the visual analogue scale (VAS) score, ranged from 7 to 10, with a mean of 8.7. No tumor recurrence was observed during follow-up. Conclusion For large defects resulting from extensive resection of Bowen disease in the posterior midline lumbar region, the use of a modified double keystone design perforator island flap offers the advantages of reliable blood supply, uniform tension distribution, no need for skin grafting, and minimal trauma at donor site.

Citation： WANG Qizun, LI Qianqian, WANG Jingdong, WANG Xiao, CHEN Bohua, LI Haiyan, WU Xiaolin. Clinical application of a modified double keystone design perforator island flap for repair of defects after excision of Bowen disease in posterior midline lumbar region. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(7): 1094-1098. doi: 10.7507/1002-1892.202602055 Copy

1.	Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ (Bowen’s disease) 2014. Br J Dermatol, 2014, 170(2): 245-260.
2.	Sharma A, Birnie AJ, Bordea C, et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma in situ (Bowen disease) 2022. Br J Dermatol, 2023, 188(2): 186-194.
3.	Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. J Trauma, 2002, 53(1): 61-65.
4.	Behr B, Wagner JM, Wallner C, et al. Reconstructive options for oncologic posterior trunk defects: a review. Front Oncol, 2016, 6: 51. doi: 10.3389/fonc.2016.00051.
5.	Kern JN, Weidemann F, O’Loughlin PF, et al. Mid- to long-term outcomes after split-thickness skin graft vs. skin extension by multiple incisions. In Vivo, 2019, 33(2): 453-464.
6.	Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg, 2003, 73(3): 112-120.
7.	Pelissier P, Gardet H, Pinsolle V, et al. The keystone design perforator island flap. Part Ⅱ: clinical applications. J Plast Reconstr Aesthet Surg, 2007, 60(8): 888-891.
8.	Yoon CS, Kong YT, Lim SY, et al. A comparative study for tension-reducing effect of type Ⅰ and type Ⅱ keystone perforator island flap in the human back. Sci Rep, 2021, 11(1): 16699. doi: 10.1038/s41598-021-96272-0.
9.	Ahmed I, Berth-Jones J, Charles-Holmes S, et al. Comparison of cryotherapy with curettage in the treatment of Bowen’s disease: a prospective study. Br J Dermatol, 2000, 143(4): 759-766.
10.	Morton CA, Szeimies RM, Basset-Séguin N, et al. European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications-field cancerization, photorejuvenation and inflammatory/infective dermatoses. J Eur Acad Dermatol Venereol, 2020, 34(1): 17-29.
11.	Zhong S, Zhang R, Mei X, et al. Efficacy of photodynamic therapy for the treatment of Bowen’s disease: An updated systematic review and meta-analysis of randomized controlled trials. Photodiagnosis Photodyn Ther, 2020, 32: 102037. doi: 10.1016/j.pdpdt.2020.102037.
12.	Moermans MMG, Ahmady S, Nelemans PJ, et al. Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in the treatment of Bowen’s disease: Long-term results of a multicenter randomized controlled trial. J Am Acad Dermatol, 2025, 94(5): 1447-1453.
13.	Petzold A, Wessely A, Steeb T, et al. Efficacy of interventions for cutaneous squamous cell carcinoma in situ (Bowen’s disease): A systematic review and meta-analysis of proportions. J Eur Acad Dermatol Venereol, 2025, 39(3): 543-554.
14.	Riccio CA, Chang J, Henderson JT, et al. Keystone flaps: physiology, types, and clinical applications. Ann Plast Surg, 2019, 83(2): 226-231.
15.	Yan M, Rose PS, Houdek MT, et al. Outcomes of the keystone perforator island flap for oncologic reconstruction of the back. J Surg Oncol, 2021, 124(7): 1002-1007.
16.	Singh A, Singh R, Chaturvedi G, et al. Utility of keystone flap in armory of dermatosurgeons. Indian J Dermatol, 2024, 69(6): 432-441.
17.	Park TH, Lee JH, Kim JH. How to safely use the perforator-based keystone island flap in the scalp: basal cell carcinoma of the scalp with local invasion to calvarium. J Craniofac Surg, 2024, 35(4): e354-e357.
18.	Bonetti C, Arleo S, Valdatta L, et al. The keystone design perforator flap: a flap to simplify complex reconstructive issues. Indian J Plast Surg, 2024, 57(Suppl 1): S30-S35.
19.	Park TH. Outcomes of omega variant keystone flap in conjunction with single fraction radiotherapy for helical keloids: A comprehensive one-year follow-up study. J Plast Reconstr Aesthet Surg, 2024, 90: 359-366.
20.	Li D, Pang B, Zhu Y, et al. Repair of buccal mucosa and floor of mouth defects using keystone design perforator island flap. Oral Surg Oral Med Oral Pathol Oral Radiol, 2024, 138(2): e27-e32.
21.	Bordianu A, Petre I, Bejinariu C. The keystone flap: a game changer that promises new horizons in reconstructive surgery. Cureus, 2024, 16(9): e69297. doi: 10.7759/cureus.69297.
22.	Le Guern A, Wiart T, Modiano P, et al. The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases. Ann Dermatol Venereol, 2021, 148(4): 241-245.
23.	Aithal SS, Loganathan E, Shekar R. Keystone island flap for reconstructive surgery—A novel approach. J Cutan Aesthet Surg, 2022, 15(3): 315-318.
24.	Lo Torto F, Frattaroli JM, Kaciulyte J, et al. The keystone flap: A multi-centric experience in elderly patients treatment. J Plast Reconstr Aesthet Surg, 2022, 75(1): 226-239.
25.	Yushan M, Hamiti Y, Yalikun A, et al. Clinical application of keystone design perforator Island flap (KDPIF) in trunk defects: a retrospective study. ANZ J Surg, 2022, 92(9): 2280-2285.
26.	Sahu RK, Mahadik K, Giri SK, et al. Versatility of the keystone design perforator island flaps in resurfacing soft tissue defects. Indian J Plast Surg, 2024, 57(3): 208-215.
27.	Oh JM, Jwa SJ, Won JM, et al. A bipedicled keystone perforator island flap: Pedicle division technique with enhanced advancement potential for chronic wound coverage. J Plast Reconstr Aesthet Surg, 2023, 86: 239-245.
28.	Ren S, Liu H, Chang Z. Effectiveness of negative pressure wound therapy in treating deep surgical site infections after spine surgery: a meta-analysis of single-arm studies. J Orthop Surg Res, 2025, 20(1): 44. doi: 10.1186/s13018-025-05463-2.
29.	Sch?r RT, Suter MR, Stebler K, et al. Risk factors for surgical site infections after single-level anterior lumbar interbody fusion. Surg Infect (Larchmt), 2023, 24(6): 521-527.

1. Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ (Bowen’s disease) 2014. Br J Dermatol, 2014, 170(2): 245-260.
2. Sharma A, Birnie AJ, Bordea C, et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma in situ (Bowen disease) 2022. Br J Dermatol, 2023, 188(2): 186-194.
3. Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. J Trauma, 2002, 53(1): 61-65.
4. Behr B, Wagner JM, Wallner C, et al. Reconstructive options for oncologic posterior trunk defects: a review. Front Oncol, 2016, 6: 51. doi: 10.3389/fonc.2016.00051.
5. Kern JN, Weidemann F, O’Loughlin PF, et al. Mid- to long-term outcomes after split-thickness skin graft vs. skin extension by multiple incisions. In Vivo, 2019, 33(2): 453-464.
6. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg, 2003, 73(3): 112-120.
7. Pelissier P, Gardet H, Pinsolle V, et al. The keystone design perforator island flap. Part Ⅱ: clinical applications. J Plast Reconstr Aesthet Surg, 2007, 60(8): 888-891.
8. Yoon CS, Kong YT, Lim SY, et al. A comparative study for tension-reducing effect of type Ⅰ and type Ⅱ keystone perforator island flap in the human back. Sci Rep, 2021, 11(1): 16699. doi: 10.1038/s41598-021-96272-0.
9. Ahmed I, Berth-Jones J, Charles-Holmes S, et al. Comparison of cryotherapy with curettage in the treatment of Bowen’s disease: a prospective study. Br J Dermatol, 2000, 143(4): 759-766.
10. Morton CA, Szeimies RM, Basset-Séguin N, et al. European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications-field cancerization, photorejuvenation and inflammatory/infective dermatoses. J Eur Acad Dermatol Venereol, 2020, 34(1): 17-29.
11. Zhong S, Zhang R, Mei X, et al. Efficacy of photodynamic therapy for the treatment of Bowen’s disease: An updated systematic review and meta-analysis of randomized controlled trials. Photodiagnosis Photodyn Ther, 2020, 32: 102037. doi: 10.1016/j.pdpdt.2020.102037.
12. Moermans MMG, Ahmady S, Nelemans PJ, et al. Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in the treatment of Bowen’s disease: Long-term results of a multicenter randomized controlled trial. J Am Acad Dermatol, 2025, 94(5): 1447-1453.
13. Petzold A, Wessely A, Steeb T, et al. Efficacy of interventions for cutaneous squamous cell carcinoma in situ (Bowen’s disease): A systematic review and meta-analysis of proportions. J Eur Acad Dermatol Venereol, 2025, 39(3): 543-554.
14. Riccio CA, Chang J, Henderson JT, et al. Keystone flaps: physiology, types, and clinical applications. Ann Plast Surg, 2019, 83(2): 226-231.
15. Yan M, Rose PS, Houdek MT, et al. Outcomes of the keystone perforator island flap for oncologic reconstruction of the back. J Surg Oncol, 2021, 124(7): 1002-1007.
16. Singh A, Singh R, Chaturvedi G, et al. Utility of keystone flap in armory of dermatosurgeons. Indian J Dermatol, 2024, 69(6): 432-441.
17. Park TH, Lee JH, Kim JH. How to safely use the perforator-based keystone island flap in the scalp: basal cell carcinoma of the scalp with local invasion to calvarium. J Craniofac Surg, 2024, 35(4): e354-e357.
18. Bonetti C, Arleo S, Valdatta L, et al. The keystone design perforator flap: a flap to simplify complex reconstructive issues. Indian J Plast Surg, 2024, 57(Suppl 1): S30-S35.
19. Park TH. Outcomes of omega variant keystone flap in conjunction with single fraction radiotherapy for helical keloids: A comprehensive one-year follow-up study. J Plast Reconstr Aesthet Surg, 2024, 90: 359-366.
20. Li D, Pang B, Zhu Y, et al. Repair of buccal mucosa and floor of mouth defects using keystone design perforator island flap. Oral Surg Oral Med Oral Pathol Oral Radiol, 2024, 138(2): e27-e32.
21. Bordianu A, Petre I, Bejinariu C. The keystone flap: a game changer that promises new horizons in reconstructive surgery. Cureus, 2024, 16(9): e69297. doi: 10.7759/cureus.69297.
22. Le Guern A, Wiart T, Modiano P, et al. The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases. Ann Dermatol Venereol, 2021, 148(4): 241-245.
23. Aithal SS, Loganathan E, Shekar R. Keystone island flap for reconstructive surgery—A novel approach. J Cutan Aesthet Surg, 2022, 15(3): 315-318.
24. Lo Torto F, Frattaroli JM, Kaciulyte J, et al. The keystone flap: A multi-centric experience in elderly patients treatment. J Plast Reconstr Aesthet Surg, 2022, 75(1): 226-239.
25. Yushan M, Hamiti Y, Yalikun A, et al. Clinical application of keystone design perforator Island flap (KDPIF) in trunk defects: a retrospective study. ANZ J Surg, 2022, 92(9): 2280-2285.
26. Sahu RK, Mahadik K, Giri SK, et al. Versatility of the keystone design perforator island flaps in resurfacing soft tissue defects. Indian J Plast Surg, 2024, 57(3): 208-215.
27. Oh JM, Jwa SJ, Won JM, et al. A bipedicled keystone perforator island flap: Pedicle division technique with enhanced advancement potential for chronic wound coverage. J Plast Reconstr Aesthet Surg, 2023, 86: 239-245.
28. Ren S, Liu H, Chang Z. Effectiveness of negative pressure wound therapy in treating deep surgical site infections after spine surgery: a meta-analysis of single-arm studies. J Orthop Surg Res, 2025, 20(1): 44. doi: 10.1186/s13018-025-05463-2.
29. Sch?r RT, Suter MR, Stebler K, et al. Risk factors for surgical site infections after single-level anterior lumbar interbody fusion. Surg Infect (Larchmt), 2023, 24(6): 521-527.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical application of a modified double keystone design perforator island flap for repair of defects after excision of Bowen disease in posterior midline lumbar region

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