Aesthetic Reconstruction of Extensive Pubic Keloids Using Bilateral Modified Keystone Flaps

Complete excision of huge pubic keloids inevitably causes significant soft tissue defect requiring extensive wound coverage. Skin grafting after complete excision can be one of the options, but it might delay adjuvant radiation therapy timing and causes wound disruption due to its high infection rates. Free flaps can overcome many of these obstacles but keloid formation on donor site can be another significant concern to the patients and physicians. In this study, we introduce our one-stage successful reconstruction of huge perineal keloids using bilateral modified keystone flaps without any distant donor morbidity.

A 21-year-old woman visited to our clinic due to her recurrent ulceration and purulent discharge from central small pit in huge keloids of pubis. This patient also has multiple keloids on chest, shoulder, buttock, face, scalp, arm and forearm, and axilla. We conservatively dressed the wound with 2 or 3 days intervals because she did not want to get any surgery at that time. But febrile conditions repeatedly happened with continued wound problems and finally she agreed to undergo complete excision and flap reconstruction. She underwent abdominal keloid resection followed by local flap reconstruction 2 weeks ago.

We completely resected huge keloid on perineal area and encountered extensive soft tissue defect sized 15 x 16 cm requiring reliable reconstruction. After complete excision of perineal keloid, approximately 16x15 cm sized defect occurred and we decided elevated modified keystone flaps using adjacent soft tissue in inguinal and medial thigh areas. By skeletonizing medial branch of superficial circumflex iliac perforators which have been well described by several authors, we can fully mobilize upper half area of the flap. In lower half area, we harvested tissue using original keystone flap concept based on internal pudendal artery perforators.

Finally, the harvested flaps on both sides were advanced medially over the defect and they successfully covered the defect without any distant donor morbidities. Postoperative single fraction external beam irradiation (10Gy) was performed at 48 hours postoperatively. At postoperative 6 months, no significant sign of keloid recurrence was seen and the patient was satisfied with improved quality of life and free of infection at the wound.

We can successfully resurface a huge perineal keloid using bilateral modified keystone flaps. It provides a robust blood supply without any distant donor morbidities.