Incidence and Predictors of Lower Limb Split-Skin Graft Failure and Primary Closure Dehiscence in Day-Case Surgical Patients

Stankiewicz, Monica; Coyer, Fiona; Webster, Joan; Osborne, Sonya

doi:10.1097/dss.0000000000000391

Cited by 22 publications

(19 citation statements)

References 35 publications

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“…Qualitative and quantitative assessments of these advantages are undocumented in the literature, aside from complication rates, with the largest study to date of 176 patients indicating only 4.6% of all keystone flaps sustained a complication requiring therapeutic intervention, 14 compared with a reported failure rate of SSGs in the lower limb as high as 66%. 15…”

Section: Introductionmentioning

confidence: 99%

Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps—A Pilot Retrospective Cohort Study

Dobbs

Jovic

Jessop

et al. 2018

Plastic and Reconstructive Surgery - Global Open

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Background:The keystone perforator island flap provides a versatile form of reconstruction. Perceived benefits include better donor-recipient color match, less contour defect, and fewer complications. To date, there has been no high-quality evidence comparing keystone flaps to split-thickness skin grafts (SSG) from both a qualitative and quantitative point of view.Methods:The Objective and Patient Reported Assessments of Skin grafts versus Keystone flap cohort study compares keystone flaps with SSGs for the reconstruction of skin cancer defects. Patient-reported outcome measures were collected using the EuroQol 5 dimension scale and Patient and Observer Scar Assessment Scale (POSAS) questionnaires. Objective assessments of skin quality were assessed with the Courage and Khazaka system. Cost analysis was also performed.Results:Thirty-eight patients were studied: 20 keystone flaps and 18 SSGs. The keystone group had higher EuroQol 5 dimension scale scores (keystone median = 1.0; SSG median = 0.832; P = 0.641) indicating better general quality of life and lower POSAS scores indicating better disease/condition specific quality of life (keystone mean = 27.7; SSG mean = 35.7; P = 0.323). Observer POSAS scores were significantly lower in the keystone group compared with the SSG group (keystone mean = 10.889; SSG mean = 17.313; P < 0.001). Preservation of sensation was significantly better in keystone flaps (P = 0.006). There was an average £158/$207 (15%) saving when performing a keystone flap.Conclusion:This pilot study demonstrates a number of possible benefits of keystone flaps over SSGs. The results demonstrate the need for further research comparing these reconstructive options. We propose a prospective, controlled study using the methods developed in this pilot study.

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Section: Introductionmentioning

confidence: 99%

Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps—A Pilot Retrospective Cohort Study

Dobbs

Jovic

Jessop

et al. 2018

Plastic and Reconstructive Surgery - Global Open

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“… 19 , 20 However, there are no studies focused on identifying those factors that may delay this optimal timing. Preoperative risk factors or predictors of complications have already been investigated for skin grafts, free flap surgery or lower extremity surgery 21 – 24 ; nevertheless, there is no available literature on predictors of matrix failure or delayed skin grafting after reconstruction using dermal substitutes.…”

Section: Discussionmentioning

confidence: 99%

Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm

Scalise

Torresetti

Benedetto

2020

Plastic and Reconstructive Surgery - Global Open

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Background: Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience. Methods: An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications. Results: No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified. Conclusions: Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.

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“…Although keystone flaps have been used previously for generic lower limb reconstruction ( 6 , 25 ) they have not been used widely in the popliteal fossa or periarticular areas to our knowledge. Alternatives to fasciocutaneous flaps such as the keystone include reconstruction with skin grafts, though these do not parallel the robust tissue coverage of local flaps and may exhibit high failure rates ( 16 ), particularly in mobile areas where graft adherence may be compromised. In addition, contour defects, pigmentation mismatch ( 26 ), and secondary contractures ( 19 ) may also restrict cosmetic and functional outcomes, particularly when extrapolated to periarticular defects.…”

Section: Discussionmentioning

confidence: 99%

“…Periarticular wound closure is a unique reconstructive challenge due to multi-vector tensional forces ( 16 ). Adjacent tissue is continually subjected to stretch, compression and torsion and the reconstructive solution should possess the ability to withstand changes in tensile forces.…”

Section: Introductionmentioning

confidence: 99%

“…Adjacent tissue is continually subjected to stretch, compression and torsion and the reconstructive solution should possess the ability to withstand changes in tensile forces. It is widely known that periarticular skin grafts are subjected to movement and shearing forces, disrupting the formation of early fibrin bonds and leading to increased failure rates ( 16 – 18 ) and contracture ( 19 , 20 ). In our experience, the use of locoregional flaps to reconstruct periarticular defects left from skin cancer excisions are superior to skin grafts, and we illustrate this through the use of the keystone flap in five patients.…”

Section: Introductionmentioning

confidence: 99%

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The Use of Keystone Flaps in Periarticular Wound Closure: A Case Series

et al. 2017

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The Keystone perforator island flap (Keystone flap), is a Type A fasciocutaneous advancement flap, consisting of two V to Y advancement flaps. Skin cancer excision around joints presents a number of reconstructive challenges. Owing to the mobile nature of joints, the optimal periarticular reconstructive option should possess the ability to provide adequate tissue coverage and withstand regional changes in tensile pressures. We report a single-surgeon series of five cases of periarticular keystone flap between 2014 and 2017. Data were collected from operation notes, clinical photography, histopathology, and outpatient clinic records. The indication for keystone flap was skin cancer in all cases (n = 5). The largest defect size post-excision in was 75 mm × 40 mm × 15 mm. All keystone flaps demonstrate a color and cosmetic appearance comparable to adjacent tissue. There were no major postoperative complications including flap failure or impaired range of joint movement in the follow up period. Superficial wound infection occurred postoperatively in one case. This is the first case series to discuss the use of keystone flaps in periarticular wound closure. Locoregional fasciocutaneous wound coverage offered by keystone flaps may alleviate the risks of graft failure, contour defects, and donor site morbidity associated with alternative reconstructive options, with good functional and cosmetic outcomes. We advocate their use as a robust reconstructive option in periarticular areas.

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Incidence and Predictors of Lower Limb Split-Skin Graft Failure and Primary Closure Dehiscence in Day-Case Surgical Patients

Cited by 22 publications

References 35 publications

Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps—A Pilot Retrospective Cohort Study

Objective and Patient-reported Assessments of Skin Grafts and Keystone Flaps—A Pilot Retrospective Cohort Study

Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm

The Use of Keystone Flaps in Periarticular Wound Closure: A Case Series

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