Major Trunk Defects Using the Keystone Perforator Island Flap Technique

Abstract

The Keystone reconstructive technique provides a simple solution to major oncological defects, espeically on the trunk and back. These are challenging problems and we have all seen cases from experts where sometimes the surgical scar line has reached from the scapular down to the buttock to close large defects, as I recall one case sent for me to review from the late Neville Davis in Brisbane who established the Queensland Melanoma Project. It was he who said ‘Felix, I always take the deep fascia underneath the melanoma’ and this has been my oncological practice throughout my career, thanks to Neville.

Skin grafting procedures on the back are noted for their striking limitations. From poor graft uptake, extended duration of dressings, the tender exposed fibres in the deep plains in the deep surgical defect bordering on the bony structures, i.e. the scapular.

Each of the following cases will be accompanied by slides and the details of which will have my explanation with a video PowerPoint supplement, explaining their significance and the operative procedure and patient outcome.

The Keystone is an expeditious solution to major defects of the trunk. I have included initially a longitudenaly aligned Keystone cases 34 and 35 crossing dermatomal bridge lines as this was the orientation of the pathology specimen and these cases almost midline of the back healed without complication. The biggest problem in back lesions is premature removal of the tension locking sutures and sometimes when dressings are expedited through an outside clinic, sometimes premature removal is the course of wound rupture. These respond to resuturing.

Keystones overlying the scapula and the aggravation of shoulder girdle movement are another reinforcement for caution and to avoid the removal of sutures prematurely, with the additional support of shoulder splintage (refer case 41 in Upper Limb chapter).

The major defect 14 × 8 cm in case 37 the closure as designed and illustrated on video is closed by the Keystone between T4 and T8 dermatomes, based on intercostal perforators in the vicinity of its middle third attachment. The arms of the Omega close the defect, even allowing dog ear removal because of the reliability of the circulation in this hyperaemic phase of the Keystone principle.