Extensive Mine-Shrapnel and Gunshot Wound Closure Using Keystone Island Perforator Flaps

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During military operations, one aspect of a plastic surgeon’s work is to restore extensive and deep wound defects in a short period of time and provide a high degree of functional recovery to the damaged area. Because many injuries caused by military operations cannot be closed using a primary suture, the specialist has to select another surgical approach to close the wound defect. Surgeons must select methods that not only cover the extensive wound defect in 1 step but also allow skin coverage that is anatomically, functionally, and visually similar to the surrounding tissues to reduce the length of the hospital stay and ensure optimal functional recovery of the damaged organ.


From 2014 to 2015, 25 patients underwent 36 reconstructions at our center after receiving mine-shrapnel and gunshot wounds. All reconstructions occurred during the acute period and used keystone island perforator flaps. The authors’ wound management technique was characterized by an aggressive surgical and antibiotic therapy protocol.


In all cases, after surgical debridement, the mine-shrapnel and gunshot wound defects were completely closed in 1 stage during the acute period. The working time in the operating room to perform the transposition of the flap ranged from 45 to 90 minutes, with an average of 68 minutes. All displaced flaps were similar in structure and color to the surrounding tissues and did not change the contours of the body. The adequate restoration of skin allowed patients to begin early recovery of functional activity.


Local keystone island perforator flaps can be considered one of the primary methods of plastic closure of extensive defects caused by mine-shrapnel and gunshot wounds at different anatomical locations, providing that the tissue surrounding the defect is intact and usable as a donor resource.

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