Patient-Centric Advances in Chest Wall Reconstruction: The “Double-Handled Saucepan” Keystone Flap Technique for Mastectomy Defects
Key Points Highlighted:
- Technique Name: “Double-handled saucepan” modified keystone flap.
- Indication: Closure of extensive mastectomy chest wall defects.
- Advantages:
- Avoids need for free flaps and secondary donor sites.
- Preserves skin bridge to maintain vascularity.
- No major complications reported in 16 patients.
- Suitable for hospitals lacking microsurgical infrastructure.
- Average Defect Size: ~23 x 17 cm.
- Average Flap Size: ~36 x 21 cm.
- Average Operative Time: ~124 minutes.
- Zero Flap Loss: No cases of dehiscence, infection, or flap necrosis.
- Flap Design: Inspired by saucepan structure – arc as base, V-Y limbs as handles.
Mastectomy procedures, particularly in advanced breast cancer, often leave extensive chest wall defects that present unique reconstructive challenges. In the December 2024 issue of the Indian Journal of Plastic Surgery, Harsono et al. presented a surgical innovation—the “double-handled saucepan” modified keystone flap—for covering large post-mastectomy defects without the complexity of microsurgery. This technique not only reflects technical ingenuity but also offers a scalable, patient-friendly alternative for resource-limited settings.
The keystone flap is already known for its versatility, ease of design, and dependable vascular supply based on local fasciocutaneous perforators. However, its application in large mastectomy defects has been limited by risks of necrosis under tension and perfusion deficits. In response to these limitations, Harsono and colleagues developed a novel modification that preserves the flap’s vascularity and enhances coverage capacity—by retaining a subdermal plexus via a skin bridge and optimizing flap arc geometry.
Dubbed the “double-handled saucepan” for its circular arc body and lateral V-Y advancement “handles,” this modified keystone design allows for dynamic expansion of native tissue without jeopardizing perfusion. It mimics traditional type IV keystone principles while modifying the axis to accommodate wider chest defects.
Between 2021 and 2024, 16 female patients with post-modified radical mastectomy (MRM) defects underwent reconstruction using this technique. The average defect measured approximately 23.1 x 16.9 cm, and the harvested flaps were significantly larger—36.3 x 21.2 cm—ensuring tension-free closure. Impressively, none of the patients experienced complications such as seroma, dehiscence, infection, or flap loss.
This flap was particularly beneficial for patients with contraindications to free flap reconstruction, such as diabetes or vascular disease, and in centers without microvascular surgical tools. Moreover, by avoiding secondary donor sites, the procedure reduced operative trauma and hospital stay (average: 4.5 days), thereby enhancing patient recovery.
The surgical steps are meticulously described: Doppler was used to locate perforators, and flap incisions respected vascular landmarks. A significant innovation was the preservation of 30–50% of the skin bridge on each side of the tangent line—retaining the subdermal plexus and ensuring centrifugal angiosomal perfusion. Undermining was limited to 50% to enable flap advancement without compromising blood supply.
Postoperatively, all patients healed without incident. In four detailed case reports, patients presented with large chest wall defects (ranging from 24–28 cm in length), which were successfully closed using flaps harvested from the adjacent axillary and abdominal areas. Even at 30-day follow-up, results showed full integration of the flap with surrounding tissue and minimal scarring.
This technique proves especially beneficial for patients likely to undergo radiotherapy, where a skin graft may fail due to fragility and a thick myocutaneous flap may obscure recurrence. The modified keystone flap provides an optimal thickness that balances protection and oncological surveillance.
From a surgical efficiency standpoint, the method is time-saving and avoids the steep learning curve of free flap microvascular anastomosis. Its simplicity allows for broader application, even by less experienced surgeons, without sacrificing outcome quality.
However, the authors acknowledge that the study is limited by its small sample size and retrospective nature. Future research should assess long-term oncological safety, recurrence rates, and functional outcomes. Moreover, the technique’s applicability beyond mastectomy—such as in pressure sore or trauma defect closure—is currently under evaluation.
In a field where reconstructive options often favor highly specialized techniques, this innovation re-centers the conversation around practicality, patient access, and functional reliability. The “double-handled saucepan” flap symbolizes the kind of intelligent, context-aware surgery that can elevate global reconstructive care.
As resource disparities continue to challenge healthcare systems, especially in low- and middle-income countries, such modifications could revolutionize reconstructive paradigms. By enabling robust, low-risk chest wall reconstruction after mastectomy without the need for costly infrastructure, the modified keystone flap technique exemplifies how innovation can arise not from complexity, but from clarity of purpose and clinical empathy.
Reference:
Harsono AD, Tjokrovonco DM, Bas BMR, Putra PM. Modified Keystone a Versatile Flap Reconstruction for Mastectomy Defects: Our Clinical Experience. Indian J Plast Surg. 2025;58(2):97-104. https://doi.org/10.1055/s-0044-1800780
FAQs:
- What is the double-handled saucepan keystone flap used for in breast cancer surgery?
It is a reconstructive flap used to cover large chest wall defects after mastectomy, especially when other flap options are limited. - Is this chest wall reconstruction suitable for diabetic breast cancer patients?
Yes, the flap avoids microvascular anastomosis, making it ideal for diabetics with compromised vessels. - Will I have scars on my abdomen after the double-handled keystone flap?
Yes, since part of the flap is harvested from the abdominal region, but scarring is minimal and well-managed. - Is the modified keystone flap safe for post-mastectomy radiotherapy patients?
Absolutely. Its thickness is ideal—it withstands radiation yet allows for detection of recurrence. - How long is the hospital stay after mastectomy chest wall reconstruction with this flap?
On average, patients stayed around 4.5 days, showing rapid recovery. - Can the keystone flap reconstruction be done in hospitals without microsurgery?
Yes, this technique was designed for centers without microsurgical tools or expertise. - What is the average surgery time for this modified keystone flap reconstruction?
The average operation time is around 2 hours (124 minutes), making it efficient and practical. - Are there any risks or complications with the keystone flap?
In this study, no complications like infection or flap loss occurred among the 16 patients. - Is this reconstructive option good for patients with large breast tumors?
Yes, especially when tumor excision leaves a large defect not amenable to primary closure. - Can I get breast reconstruction later if I have this flap?
This flap may limit future use of abdominal tissue for breast mound creation, so it’s not recommended for patients planning delayed reconstruction.
Keywords:
- mastectomy chest wall defect reconstruction
- double-handled saucepan keystone flap
- keystone flap mastectomy closure
- postmastectomy flap reconstruction
- modified keystone flap breast cancer
- non-microsurgical breast reconstruction
- keystone flap for large defects
- fasciocutaneous flap after mastectomy
- flap reconstruction radiotherapy
- chest wall flap surgery without grafts
Mastectomy procedures, chest wall defects, reconstructive challenges, surgical innovation, keystone flap,
mastectomy flap reconstruction, non-microsurgical breast reconstruction, keystone flap chest defect, double-handled keystone flap
Discover the “double-handled saucepan” keystone flap: a reliable, non-microsurgical option for mastectomy chest wall defect closure with excellent patient outcomes and no complications.