Outcomes of the keystone perforator island flap for oncologic reconstruction of the back

Abstract

Background: Coverage of posterior trunk defects after tumor resection can be challenging due to the intricate anatomy. The keystone perforator island flap (KPIF) provides coverage of the defect without the need for distant flap coverage or microsurgery, matches the recipient's skin color and contour, and requires a short operative time.Methods: A retrospective review of all oncological back reconstructions with KPIF was performed at our institution. The patient comorbidities and surgical outcomes were collected.Results: A total of 17 patients underwent 20 KPIF (15 single and 2 double) for back reconstruction. Surgical indications were sarcoma (n = 12) and melanoma (n = 5). The mean age at surgery was 47.3 years (SD 23.3). The flaps were located in the upper back (n = 8), paraspinal (n = 4), middle back (n = 6), and lower back (n = 2). The average wound size after sarcoma and melanoma excision were 231.6 ± 297.4 and 156.7 ± 269.7 cm 2 , respectively. Four patients required an additional planned skin graft and one patient underwent a simultaneous myocutaneous latissimus dorsi flap.The mean operative time, including tumor resection, was 256 min (SD 118). The median length-of-hospital stay was 3 days (Q1-3: 1-6.5) and the median follow-up time was 35.3 months (Q1-3: 13.3-53.1). All flaps survived with minor surgical complications which included hematoma (n = 1), surgical site infection requiring debridement (n = 1), superficial wound dehiscence (n = 1), cellulitis (n = 1), and seroma (n = 1). The reconstructions were successful in 100% of patients. Conclusions:The KPIF is a reliable and safe option for reconstruction of oncological back defects with minimal perioperative complications. This flap option avoids the use of free flaps and myocutaneous flaps for moderate-sized back defects.

Vessel Loop Shoelace Technique followed by Keystone Flap to Treat a Large Mid-back Defect

“…Although high success rates were reported, there were still four patients requiring skin grafting owing to a large upper- to mid-back defect. 5 …”

“…In addition to free tissue transfers, the locoregional flaps have been recommended as the first choice for back reconstruction because of their shorter operative time, tissue similarity, and high reproducibility. 1 , 4 , 5 …”

“…In addition to free tissue transfers, the locoregional flaps have been recommended as the first choice for back reconstruction because of their shorter operative time, tissue similarity, and high reproducibility. 1,4,5 The keystone design perforator island flap, first described by Behan in 2003, has been gaining popularity as a local reconstructive option primarily used for the trunk and extremities. [5][6][7][8] However, according to the basis of the keystone flap, the width should be at least equal to the defect; otherwise, for larger defects, a single local advanced keystone flap may not be extensively mobilized for adequate coverage, and an additional flap or double-opposite keystone flaps may be considered.…”

“…1,4,5 The keystone design perforator island flap, first described by Behan in 2003, has been gaining popularity as a local reconstructive option primarily used for the trunk and extremities. [5][6][7][8] However, according to the basis of the keystone flap, the width should be at least equal to the defect; otherwise, for larger defects, a single local advanced keystone flap may not be extensively mobilized for adequate coverage, and an additional flap or double-opposite keystone flaps may be considered. 9,10 To obtain sufficient soft tissue coverage with a simply designed flap for a large mid-back defect, we present a strategy combining a wellestablished shoelace technique for decreasing tissue gap utilizing a periodically tightened elastic tension applied on the wound edges, followed by a keystone flap.…”

Multistage Reconstruction of Large Arm Defect Using Keystone Type I Flap and Temporary Synthetic Skin Substitute

“…It has a good skin color and contour match with a short operative time. 7 Among the principles guiding the keystone flap, the width should be at least equal to the defect; otherwise, the use of an additional flap or double opposite keystone flaps is suggested when the defect is so wide that a single local flap is not sufficient for coverage. 6 The use of these local perforator flaps could be confronted to challenges of tension following reconstruction with an increased risk of necrosis.…”