{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T04:00:46Z","timestamp":1779940846348,"version":"3.53.1"},"reference-count":28,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,10,11]],"date-time":"2019-10-11T00:00:00Z","timestamp":1570752000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2019,10,11]],"date-time":"2019-10-11T00:00:00Z","timestamp":1570752000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>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\u2009\u00b1\u200914.868 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 \u2018tension-change\u2019 at the defect and donor sites was \u22124.73\u2009\u00b1\u20090.21\u2009N and \u22124.88\u2009\u00b1\u20090.25\u2009N, respectively (p\u2009&lt;\u20090.001). The mean \u2018rate of tension-change\u2019 at the defect and donor sites was \u221269.48\u2009\u00b1\u20091.7% and \u221271.16\u2009\u00b1\u20091.33%, respectively (p\u2009&lt;\u20090.001). 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\u2009\u00b1\u20095.069 and 15.6\u2009\u00b1\u20096.512, respectively. Overall, we suggest that KDPIF reconstruction is a good surgical modality for the management of complicated ECs on the back.<\/jats:p>","DOI":"10.1038\/s41598-019-51289-4","type":"journal-article","created":{"date-parts":[[2019,10,11]],"date-time":"2019-10-11T10:04:04Z","timestamp":1570788244000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Keystone-design perforator island flaps for the management of complicated epidermoid cysts on the back"],"prefix":"10.1038","volume":"9","author":[{"given":"Chi Sun","family":"Yoon","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyo Bong","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Young Keun","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1261-9743","authenticated-orcid":false,"given":"Hoon","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyu Nam","family":"Kim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2019,10,11]]},"reference":[{"key":"51289_CR1","doi-asserted-by":"publisher","first-page":"2042","DOI":"10.1097\/01.prs.0000192460.98612.d3","volume":"116","author":"MT Suliman","year":"2005","unstructured":"Suliman, M. T. Excision of epidermoid (sebaceous) cyst: description of the operative technique. Plast. Reconstr. Surg. 116, 2042\u20132043 (2005).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR2","doi-asserted-by":"publisher","first-page":"12188","DOI":"10.1097\/MD.0000000000012188","volume":"97","author":"HW Lee","year":"2018","unstructured":"Lee, H. W. et al. Management of epidermal cysts arising from scar tissues: a retrospective clinical study. Medicine (Baltimore) 97, 12188\u201312195 (2018).","journal-title":"Medicine (Baltimore)"},{"key":"51289_CR3","doi-asserted-by":"publisher","first-page":"173","DOI":"10.1097\/00006534-198907000-00048","volume":"84","author":"JC Avakoff","year":"1989","unstructured":"Avakoff, J. C. Microincision for removing sebaceous cysts. Plast. Reconstr. Surg. 84, 173\u2013174 (1989).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR4","doi-asserted-by":"publisher","first-page":"52","DOI":"10.1007\/s002660010095","volume":"25","author":"M Nakamura","year":"2001","unstructured":"Nakamura, M. Treating a sebaceous cyst: an incisional technique. Aesthetic Plast. Surg. 25, 52\u201356 (2001).","journal-title":"Aesthetic Plast. Surg."},{"key":"51289_CR5","doi-asserted-by":"publisher","first-page":"597","DOI":"10.1007\/s00266-009-9331-2","volume":"33","author":"H Wu","year":"2009","unstructured":"Wu, H., Wang, S., Wu, L. & Zeng, S. A new procedure for treating a sebaceous cyst: removal of the cyst content with a laser punch and the cyst wall with a minimal postponed excision. Aesthetic Plast. Surg. 33, 597\u2013599 (2009).","journal-title":"Aesthetic Plast. Surg."},{"key":"51289_CR6","doi-asserted-by":"publisher","first-page":"140","DOI":"10.5999\/aps.2014.41.2.140","volume":"41","author":"SW Kim","year":"2014","unstructured":"Kim, S. W., Yang, S. H., Kim, J. T. & Kim, Y. H. Perforator flaps after excision of large epidermal cysts in the buttocks. Arch. Plast. Surg. 41, 140\u2013147 (2014).","journal-title":"Arch. Plast. Surg."},{"key":"51289_CR7","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1097\/GOX.0000000000000799","volume":"13","author":"NM Krishnan","year":"2016","unstructured":"Krishnan, N. M. et al. Reducing Wound Tension with Undermining or Imbrication-Do They Work? Plast. Reconstr. Surg. Glob. Open 13, 799\u2013805 (2016).","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"51289_CR8","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1080\/02844310902771657","volume":"43","author":"T Yamauchi","year":"2009","unstructured":"Yamauchi, T., Kiyokawa, K., Inoue, Y. & Rikimaru, H. V-Y fasciocutaneous flap of the medial thigh including the long saphenous vein for reconstruction of intrapelvic dead space. Scand. J. Plast. Reconstr. Surg. Hand Surg. 43, 142\u2013147 (2009).","journal-title":"Scand. J. Plast. Reconstr. Surg. Hand Surg."},{"key":"51289_CR9","doi-asserted-by":"publisher","first-page":"7008","DOI":"10.1097\/MD.0000000000007008","volume":"96","author":"H Kim","year":"2017","unstructured":"Kim, H., Ryu, W., Yoon, C. & Kim, K. Keystone-designed buried deepithelialized flap: a novel technique for obliterating small to moderately sized dead spaces. Medicine (Baltimore) 96, 7008\u20137015 (2017).","journal-title":"Medicine (Baltimore)"},{"key":"51289_CR10","doi-asserted-by":"publisher","first-page":"14167","DOI":"10.1097\/MD.0000000000014167","volume":"98","author":"CS Yoon","year":"2019","unstructured":"Yoon, C. S., Kim, H. B., Kim, Y. K., Kim, H. & Kim, K. N. 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. Medicine (Baltimore) 98, 14167\u201314177 (2019).","journal-title":"Medicine (Baltimore)"},{"key":"51289_CR11","doi-asserted-by":"publisher","first-page":"1960","DOI":"10.1097\/01.PRS.0000122207.28773.56","volume":"113","author":"LJ Draaijers","year":"2004","unstructured":"Draaijers, L. J. et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast. Reconstr. Surg. 113, 1960\u20131965 (2004).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR12","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1097\/01.prs.0000172982.43599.d6","volume":"116","author":"AL van de Kar","year":"2005","unstructured":"van de Kar, A. L. et al. Reliable and feasible evaluation of linear scars by the Patient and Observer Scar Assessment Scale. Plast. Reconstr. Surg. 116, 514\u2013522 (2005).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR13","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1186\/s12885-017-3645-2","volume":"18","author":"X Ma","year":"2017","unstructured":"Ma, X., Xia, Q. J., Li, G., Wang, T. & Li, Q. Aesthetic principles access thyroidectomy produces the best cosmetic outcomes as assessed using the patient and observer scar assessment scale. BMC Cancer 18, 654\u2013662 (2017).","journal-title":"BMC Cancer"},{"key":"51289_CR14","first-page":"135","volume":"9","author":"YH Lee","year":"1982","unstructured":"Lee, Y. H. A study on the skin thickness of Koreans. J. Korean Soc. Plast. Reconstr. Surg. 9, 135\u2013156 (1982).","journal-title":"J. Korean Soc. Plast. Reconstr. Surg."},{"key":"51289_CR15","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1111\/j.0909-725X.2006.00135.x","volume":"12","author":"LK Smalls","year":"2006","unstructured":"Smalls, L. K., Wickett, R. & Visscher, M. O. Effect of dermal thickness, tissue composition, and body site on skin biomechanical properties. Skin Res. Technol. 12, 43\u201349 (2006).","journal-title":"Skin Res. Technol."},{"key":"51289_CR16","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1046\/j.1445-2197.2003.02638.x","volume":"73","author":"FC Behan","year":"2003","unstructured":"Behan, F. C. The keystone design perforator island flap in reconstructive surgery. ANZ J. Surg. 73, 112\u2013120 (2003).","journal-title":"ANZ J. Surg."},{"key":"51289_CR17","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1097\/SAP.0000000000000995","volume":"79","author":"MA Lanni","year":"2017","unstructured":"Lanni, M. A., Van Kouwenberg, E., Yan, A., Rezak, K. M. & Patel, A. Applying the keystone design perforator island flap concept in a variety of anatomic locations: a review of 60 consecutive cases by a single surgeon. Ann. Plast. Surg. 79, 60\u201367 (2017).","journal-title":"Ann. Plast. Surg."},{"key":"51289_CR18","doi-asserted-by":"publisher","first-page":"302","DOI":"10.1177\/1534734617740971","volume":"16","author":"CS Yoon","year":"2017","unstructured":"Yoon, C. S., Kim, S. I., Kim, H. & Kim, K. N. Keystone-designed perforator island flaps for the coverage of traumatic pretibial defects in patients with comorbidities. Int. J. Low Extrem. Wounds 16, 302\u2013309 (2017).","journal-title":"Int. J. Low Extrem. Wounds"},{"key":"51289_CR19","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1097\/PRS.0b013e3182547f55","volume":"130","author":"FC Behan","year":"2012","unstructured":"Behan, F. C., Lo, C. H., Sizeland, A., Pham, T. & Findlay, M. Keystone island flap reconstruction of parotid defects. Plast. Reconstr. Surg. 130, 36\u201341 (2012).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR20","doi-asserted-by":"publisher","first-page":"1212","DOI":"10.1097\/PRS.0b013e318205f36f","volume":"127","author":"JS Khouri","year":"2011","unstructured":"Khouri, J. S. et al. The keystone island flap: use in large defects of the trunk and extremities in soft tissue reconstruction. Plast. Reconstr. Surg. 127, 1212\u20131221 (2011).","journal-title":"Plast. Reconstr. Surg."},{"key":"51289_CR21","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1111\/ans.12291","volume":"83","author":"CD Douglas","year":"2013","unstructured":"Douglas, C. D. & Morris, O. The \u2018keystone concept\u2019: time for some science. ANZ J. Surg. 83, 498\u2013499 (2013).","journal-title":"ANZ J. Surg."},{"key":"51289_CR22","doi-asserted-by":"publisher","first-page":"486","DOI":"10.1111\/ans.14163","volume":"88","author":"LC Donovan","year":"2018","unstructured":"Donovan, L. C., Douglas, C. D. & Van Helden, D. Wound tension and \u2018closability\u2019 with keystone flaps, V-Y flaps and primary closure: a study in fresh-frozen cadavers. ANZ J. Surg. 88, 486\u2013490 (2018).","journal-title":"ANZ J. Surg."},{"key":"51289_CR23","doi-asserted-by":"publisher","first-page":"499","DOI":"10.1111\/ans.12303","volume":"83","author":"R Shayan","year":"2013","unstructured":"Shayan, R. & Behan, F. C. Re: the \u2018keystone concept\u2018: time for some science. ANZ J. Surg. 83, 499\u2013500 (2013).","journal-title":"ANZ J. Surg."},{"key":"51289_CR24","doi-asserted-by":"publisher","first-page":"553","DOI":"10.1016\/j.cps.2010.06.006","volume":"37","author":"SF Morris","year":"2010","unstructured":"Morris, S. F., Tang, M., Almutari, K., Geddes, C. & Yang, D. The anatomic basis of perforator flaps. Clin. Plast. Surg. 37, 553\u2013570 (2010).","journal-title":"Clin. Plast. Surg."},{"key":"51289_CR25","doi-asserted-by":"publisher","first-page":"1256","DOI":"10.1097\/SCS.0000000000002742","volume":"27","author":"E Kostopoulos","year":"2016","unstructured":"Kostopoulos, E., Agiannidis, C., Konofaos, P., Somia, N. & Wilson, J. Keystone perforator island flap as an alternative reconstructive option for partial thickness alar defects up to 1.5 centimeters. J. Craniofac. Surg. 27, 1256\u20131260 (2016).","journal-title":"J. Craniofac. Surg."},{"key":"51289_CR26","doi-asserted-by":"publisher","first-page":"387","DOI":"10.1016\/j.fsc.2007.05.001","volume":"15","author":"JA McCurdy Jr.","year":"2007","unstructured":"McCurdy, J. A. Jr. Considerations in Asian cosmetic surgery. Facial Plast. Surg. Clin. North Am. 15, 387\u2013397 (2007).","journal-title":"Facial Plast. Surg. Clin. North Am."},{"key":"51289_CR27","doi-asserted-by":"publisher","first-page":"397","DOI":"10.1007\/s00266-003-2099-x","volume":"27","author":"Y Shirakabe","year":"2003","unstructured":"Shirakabe, Y., Suzuki, Y. & Lam, S. M. A new paradigm for the aging Asian face. Aesthetic Plast. Surg. 27, 397\u2013402 (2003).","journal-title":"Aesthetic Plast. Surg."},{"key":"51289_CR28","doi-asserted-by":"publisher","first-page":"1580","DOI":"10.1097\/PRS.0b013e3182a8070c","volume":"132","author":"S Kim","year":"2013","unstructured":"Kim, S. et al. Update on Scar Management: Guidelines for Treating Asian Patients. Plast. Reconstr. Surg. 132, 1580\u20131589 (2013).","journal-title":"Plast. Reconstr. Surg."}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-019-51289-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-019-51289-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-019-51289-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,17]],"date-time":"2022-12-17T14:31:04Z","timestamp":1671287464000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-019-51289-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,10,11]]},"references-count":28,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2019,12]]}},"alternative-id":["51289"],"URL":"https:\/\/doi.org\/10.1038\/s41598-019-51289-4","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,10,11]]},"assertion":[{"value":"10 April 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 September 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"11 October 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing Interests"}}],"article-number":"14699"}}