Major Upper Limb Defects Using the Keystone Technique

Abstract

Excision of melanoma defects in the upper limb becomes remarkably simple in the upper bicipital segment area and inferiorly below elbow in the forearm compartment. The orientation of the Keystone flap along the dermatomal mark outs in the upper limb provides a very simple method of closure for melanotic defects. The laxity of the muscle bellies facilitates this from the bicipetal region above or those around the extensor complex in the forearm. The Keystone closure thus becomes remarkably simple if the basic rules of technique are followed – dermatomal alignment of the island flap is fascial based, division of the deep fascia on the convex side to allow the unit to bridge between two surgical sites and closure under tension is not a contraindication, without any undermining. However, if undue tension is a restriction, a grafted secondary defect is always a discrete option, particularly around the elbow region and depending on the experience of the operator.

The orientation of the biopsy is a taxing problem when done circumferentially because in the Keystone reconstructions have to be orientated in the same direction which includes a tight repair, and the ease of longitudenal alignment provides easy closure. For example, the illustrated cases (Cases 42 and 43) of the wrist and the elbow illustrate this contrainidcation. However, when cases are referred to a tertiary centre done by an external clinic, an educational response in the correspondence could warn the General Practioner of the value of biopsy alignments. The transverse wrist crease of the hand biopsy provides a difficult closure when the Keystone on the dorsum of the hand is orientated transversely. However, hyperextension allowed the wound alignment to settle and only with a staged removal of sutures was the outcome aesthetically refined in this dairy farmer – back at work in 3 weeks. A graft would be 3 months healing in such an environment.

Each of the cases below substantiates the findings, and accompanied by slides with a video PowerPoint supplement in the operative procedure and the outcome achieved.