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AUTHOR'S PROOF!
Metadata of the article that will be visualized in OnlineFirst
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Article Title
Improv ing the reliability of the Keystone flap
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Article Sub- Title
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Article Copyright Year
Springer-Verlag Berlin Heidelberg 2015 (This w ill be the copyright line in the final PDF)
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Journal Name
European Journal of Plastic Surgery
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Family Name
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Particle
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Given Name
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Corresponding Author
Nikkhah Dariush
Suffix Organization
Queen Victoria Hospital
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Division
Plastic Surgery Registrar
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Address
East Grinstead, UK
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e-mail
[email protected]
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Family Name
Vij ayan
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Particle
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Given Name
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Author
Roshan
Suffix Organization
Queen Victoria Hospital
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Division
Plastic Surgery Registrar
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Address
East Grinstead, UK
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e-mail
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Family Name
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Particle
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Given Name
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Author
King Ian
Suffix Organization
Queen Victoria Hospital
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Division
Plastic Surgery Registrar
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Address
East Grinstead, UK
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e-mail
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Family Name
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Author
Bayne
Particle Given Name
Duncan
AUTHOR'S PROOF! 32
Suffix
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Organization
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Division
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Address
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e-mail
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Received
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Schedule
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Keywords separated by ' - '
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Foot note information
East Grinstead, UK 8 February 2015
Revised Accepted
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Queen Victoria Hospital
14 April 2015
AUTHOR'S PROOF!
JrnlID 238_ArtID 1097_Proof# 1 - 17/04/2015
Eur J Plast Surg DOI 10.1007/s00238-015-1097-y
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LETTER TO THE EDITOR
Improving the reliability of the Keystone flap
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Dariush Nikkhah 1 & Roshan Vijayan 1 & Ian King 1 & Duncan Bayne 2
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Received: 8 February 2015 / Accepted: 14 April 2015 # Springer-Verlag Berlin Heidelberg 2015
* Dariush Nikkhah
[email protected]
Q1
We have found that at least doubling the flap to defect ratio has eliminated any need for back grafting and allowed direct closure on limbs with friable inelastic skin (Fig. 1). This is quicker than converting a type I or type IIa flap to the type III variant and allows for a much more robust flap. Behan’s suture protocol using a few interrupted nonresorbable mattress tensioning sutures and a continuous running non-resorbable horizontal mattress suture to hem the wound works well but requires staged removal of these stitches. We recommend using Vicryl rapide 3/0 or 4/0 for the tensioning and continuous hemming sutures to close these larger flaps. The suture line is then dressed with a perforated adhesive fabric tape in strips such as Mefix and then protected with gauze wool and a crêpe bandage. The gauze wool and crêpe bandage can be removed by the patient at 48 h, and then the wound can be washed and the tape patted dry by the patient for the next five days before they remove it. The patient is seen in clinic for the histology results 3 to 4 weeks after the surgery. Many of our patients are treated as day cases and who can ambulate full weight bearing with this regime. We have had excellent aesthetic outcomes and patient
N C O R R EC TE D
Sir, The defects after lower limb skin cancer excision especially in the elderly patient cannot often close directly due to unfavourable tissue factors such as poor skin quality, inelastic skin, and peripheral oedema. Traditionally, skin grafting is performed with variable success; failure occurs for many reasons including graft shear, haematoma, wound oedema, and infection [1]. Post-operatively, a successful graft and donor site require regular follow-up and after-care whilst any complications increase this requirement. The Keystone Design Perforator Island Flap is a relatively recent surgical option for these sites [2]. Behan’s original description of the Keystone flap states that a one-to-one ratio of defect to flap is suitable [2]. However, closure using the oneto-one ratio of defect to flap width is normally tight and can sometimes be challenging to close, therefore necessitating “back grafting” of the donor defect or the addition of a further Keystone flap opposite the first flap to make a type III repair. These lengthen the operation and increase its’ morbidity. Authors have also outlined a modification of the Keystone flap with a V–Y apposition centrally to improve the ability to close the defect [3].
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Plastic Surgery Registrar, Queen Victoria Hospital, East Grinstead, UK
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Queen Victoria Hospital, East Grinstead, UK
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AUTHOR'S PROOF! JrnlID 238_ArtID 1097_Proof# 1 - 17/04/2015
Eur J Plast Surg
Ethical standards This study does not contain clinical studies but the patient gave their informed consent for inclusion in the manuscript. Ethical approval was gained from the local ethics committee at the Queen Victoria Hospital. Conflict of interest None
References
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N C O R R EC TE D
satisfaction with no readmissions, dehiscences, or infections using this protocol.
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Fig. 1 SCC over mid shin. Keystone flap designed with increased width and tensionless closure with Vicryl rapide
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Bodenham DC, Watson R (1971) The early ambulation of patients with lower limb grafts. Br J Plast Surg 24(1):20–2 Behan FC (2003) The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg 73(3):112–20 Haydon BN, Caminer D (2014) ‘The Crown flap’: a modification to the keystone flap types I and IIA. Eur J Plast Sur 37(6):347–8
AUTHOR'S PROOF! AUTHOR QUERIES AUTHOR PLEASE ANSWER ALL QUERIES.
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PR O O F
Q1. Please check if the affiliations are captured correctly. Q2. "Keystone Island perforator flap" was changed to "Keystone Design Perforator Island Flap". Kindly verify if correct. Q3. Please check if the edits made to the sentence starting with "Many of our patients are treated" are correct.
