Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas

Abstract

BackgroundAfter wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas.MethodsBetween January 2011 and September 2016, demographic, operative, pathologic, and outcome data were prospectively collected on 60 patients who underwent wide local excision of melanoma followed by immediate flap reconstruction. Flaps were of either rhomboid or keystone type. Chi-square analysis was used to compare relationships between factors.ResultsAll procedures were done by the senior author and as outpatient surgery. No patient required a surgical drain unless they were undergoing concomitant radical regional node dissection. Flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line) occurred in 16/61 patients (26 %). No patient had flap loss. The risk of flap morbidity was significantly higher if the primary tumor was on the distal extremity—10 of 24 patients (42 %), all with keystone flaps—than if it was on the trunk or the proximal extremity (6/37 patients, 16 %), p = 0.04. There were no margins positive for either invasive or in situ melanoma in the entire cohort.ConclusionsSimple transposition flaps can successfully cover large defects after melanoma excision without the need for skin grafting. Keystone flaps in the distal extremity are more prone to separation, but this is minor and does not result in flap loss. There is minimal risk of a positive margin requiring flap takedown and a second re-excision.

Outcomes of the Keystone Island Perforator Flap: A Systematic Review

“…Other relatively common etiologies included benign lesions (7%) and trauma (5%). One paper reported on reconstructions performed at the time of resection, 25 another performed only delayed reconstruction, 20 a third performed both immediate and delayed reconstruction, 18 and the remainder did not specify timing.…”

“…4 ) Overall, only four cases of thromboembolic complications were reported, all in patients who underwent lower extremity reconstruction. 2 13 25…”

“…20 Rao & Janna's patients underwent 3–4 days of splinting 17 while Khouri implemented knee immobilization on at least one patient. 18 Taleb's patients were allowed limited weight-bearing 25 while Stone's high-risk patients were limited to 50% weight-bearing. 23 Darrach imposed no mobility restrictions on patients who underwent keystone reconstruction, except for “pelvic rest” on a patient with a pelvic defect.…”

“…Twenty-three articles met the inclusion criteria for quantitative analysis and are described in Table 1 . 2 4 13 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 One of these articles (Behan 2003) 14 was excluded from quantitative analysis due to lack of outcomes reporting. Two investigators then independently reviewed all articles and extracted the data using a standardized form.…”

Keystone Flap: Overcoming Paradigms

“…Due to its versatility, the KF has been used in defects of varied etiology and in all age groups. 4,6,8,37,28,57–59 They have allowed coverage that, given their extension, would require free flaps or classic perforator flaps. 36,37,40,42,51,28,60–64 (See video, Supplemental Digital Content 3 which displays the defect secondary to parotid oncological resection covered with a Keystone flap.…”