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The modified bipedicled flap for reconstruction of oncological skin defects of the trunk and extremities
Abstract
Background/aims:
Oncological skin defects of the extremities and trunk can be challenging. Our modified bipedicled flap utilises the principle of the bipedicled advancement flap, but allows for direct closure of the donor site (as opposed to skin grafting). It does not rely on the preservation of perforators and it random pattern, making it extremely versatile. We aimed to assess the outcomes for patients reconstructed using the modified bipedicled flap technique including oncological safety and complications.
Methods:
Consecutive patients were retrospectively identified from July 2011 to January 2019 using operative records. Demographics, operative details, oncological data and complications were recorded from patient records and the institution's internal electronic patient records system. No cases, having a modified bipedicled flap, were excluded from this study.
Results:
One hundred flaps in 98 patients were included. Mean defect dimensions were 61.7 mm by 33.1 mm. Median length of stay was 1 day, time to discharge from dressing clinic was 15 days, and the length of follow-up was 6.0 years. Eight patients required oral antibiotics for suspected localised wound infection, and 6 patients had minor wound healing problems. There were no cases of flap failure, partial flap loss, returns to theatre for flap-related complications, or local disease recurrence.
Conclusions:
To our knowledge, this is the largest series of bipedicled flaps published to date. Our technique is easy to execute, versatile, and allows for direct closure of the secondary defect with excellent cosmetic results. It is oncologically safe, with a low incidence of complications. We commend it for use in the reconstruction of oncological skin defects of the trunk and extremities.
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There is always a constant search for a new solution to tackle defects in the limbs. The technique has to be simple, easily reproducible and performed within a short duration. The answer is keystone island flap keystone flap is a simple, less time consuming, durable and easily reproducible option to reconstruct most of the limb defects.
The aim of this article is to study the usefulness of keystone flap in reconstruction of various upper and lower limb defects.
This retrospective review involves study of 20 patients undergoing keystone flap reconstruction for various defects from 2012 to 2014. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications and follow-up were evaluated and are presented as uncontrolled case series.
Ages of the patients were ranging from 18 to 65 y with an average of 38.75y. Among the defects, 10 were following trauma (50%), 5 were due to tumour resection (25%), 3 followed debridement of abscess (15%) and another 2 defects were due to surgical wound dehiscence (10%). The largest defect covered by this flap in our study measured 45 x 18 cm and the smallest defect was 8 x4 cm. The average intra-operative time was 45.5 min (range 20-90 min). Fourteen flaps were done to cover lower limb defects (70%), 4 for upper limb defects and 2 were for defects in the axilla. Partial flap necrosis was observed in one case. The average duration of hospital stay of patients was 3.45 d. All patients were followed until they achieved stable, healed wound.The overall success rate was 95%.
Keystone flap can be safely used to cover various limb defects with minimal pain, a sensate cover and excellent cosmetic outcome, minimizing the need for microsurgical techniques or prolonged operative time.
The American Joint Committee on Cancer (AJCC) was founded in 1959. Over the last 60 years, the organization has been dedicated to expanding and promoting the TNM cancer staging system.
Background:
The perforator flap concept has revolutionized reconstructive surgery. Recently, the attention has moved toward flaps based on capillary perforators, which have been usually neglected in the past as reliable perforators. The aim of this article is to report a series of freestyle capillary perforator-based island flap (c-PBIF) for reconstruction of skin cancer defects of the face, body, and extremities.
Patients and methods:
Between September 2015 and July 2017, 20 consecutive patients underwent c-PBIF reconstruction of facial, body, and limb defects after melanoma and nonmelanoma skin cancer excision. Perforators were detected by means of unidirectional Doppler, and the flaps were designed taking into account the laxity of the surrounding skin in order to allow primary closure of the donor site. The mean defect dimension was 3.75 × 4.43 cm (ranging from 1 × 2 to 4.5 × 8 cm). All but 1 procedure was performed under local anesthesia.
Results:
Mean flap size was 5.37 × 9.97 cm (ranging from 1 × 3 to 6 × 8 cm). In all cases, flaps were based on visible capillary perforators with a caliber of approximately 0.5 mm. All flaps survived. One minor tip flap necrosis was experienced in the largest flap of the series, which was successfully managed with dressing changes. The final reconstructive outcomes were satisfactory both for the patients and surgeons.
Conclusions:
Freestyle c-PBIF might represent a further method for local reconstruction of skin cancer defects of the face, body, and extremities, allowing a high tissue efficiency, reduced scarring, and expeditious reconstruction with pleasant outcomes. Further research is needed in order to explore the maximal perforasome potential of capillary perforators.
Introduction:
The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions.
Methods:
This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used.
Results:
Defects varying in size from 6 to 63 cm(2) were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss.
Conclusion:
The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.
After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population.
To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure.
A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model.
The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01).
Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.
Soft tissue defects exposing the Achilles tendon are common in patients who have undergone trauma or in those with pressure ulcers associated with vascular diseases. The purpose of this article was to present our experience of 11 patients who underwent reconstruction of soft tissue defects of the Achilles tendon using bipedicled fasciocutaneous flaps. Between August 2008 and August 2012, 11 patients were admitted to our hospital, presenting with soft tissue defects overlying the Achilles tendon. After adequate debridement, the 11 patients underwent bipedicled fasciocutaneous flap placement to resurface the complex soft tissue defects and provide a gliding surface for the exposed Achilles tendon. The patients' age, comorbidity, etiology, defect size and location, wound culture, skin graft size, complications, surgery duration, and follow-up period were reviewed. The 11 fasciocutaneous bipedicled flaps survived completely, and the wounds healed satisfactorily at a mean follow-up period of 20.9 months (range, 6-48 months). Only 1 flap was complicated with wound dehiscence and superficial necrosis of its lateral edge, which healed conservatively. The donor sites were covered with split-thickness skin grafts and healed well without complications. The bipedicled fasciocutaneous flap is a reliable flap for coverage of defects overlying the Achilles tendon, especially in patients with vascular problems and/or elderly patients. The ease of handling, short operative time, and early recovery of mobilization function are of great benefit to patients. Thus, the bipedicled fasciocutaneous flap can be a valuable alternative for defect reconstructions overlying the Achilles tendon, with satisfactory results both functionally and cosmetically. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.
Complex, lower-extremity, soft-tissue defects pose a significant challenge to the reconstructive surgeon and often require the use of free flaps, which puts significant demands on the patient, the surgeon and the health-care system. Bipedicled flaps are random but receive a blood supply from two pedicles, allowing the surgeon to use local tissue with an augmented nutrient blood flow. They are simple to elevate and economical in operating time. This study describes our experience with lower-extremity wound reconstruction using the bipedicled flap as an alternative to pedicled flaps and free flaps.
Ten patients with lower-extremity defects underwent bipedicled flap reconstruction. Operative times, length of stay following flap procedure and postoperative complications were documented. Data were collected in a prospective fashion.
Two patients had minimal areas of flap necrosis, both of which resolved with conservative local wound care and one patient developed a postoperative wound infection remedied with a course of oral antibiotics. We experienced one major complication involving wound dehiscence requiring an additional flap.
Bipedicled flaps provide a safe, fast and relatively easy alternative for coverage of certain complex open wounds in the lower extremities. Their use does not preclude the use of more traditional options of pedicled muscle or free flap coverage at a later time should they be required. Clinical questions addressed/Level of evidence: What are alternative strategies for lower-extremity wound reconstruction. Level of Evidence V.
During the last 4 years, the keystone-design fasciocutaneous island flap has become the principal form of reconstruction in our unit for primary melanoma defects of the leg distal to the knee where primary closure is not possible.
Data describing the primary tumor, surgical management, and outcome were collected prospectively for consecutive keystone flap cases. The study's primary end points were complication rates and length of hospital stay.
A total of 176 patients with new primary melanomas of the lower limb were treated over 4 years. The average Breslow thickness was 1.33 mm (range, in situ to 9.0 mm), and the average width of the defect was 3 cm. The reconstructions comprised 106 standard, 65 modified, and 5 double-opposing keystone type flaps performed from the knee to the dorsum of the foot. Complications that required further therapeutic intervention were seen in eight patients (4.6%), with only one partial flap necrosis (.6%) and one total flap loss (.6%). In this series, modification of the flap design significantly decreased the complication rate (Fisher's exact test, P = .033). There was no increase in complications in the distal third of the leg. The procedure was performed in day-only surgery setting in almost a quarter of patients.
We present the largest series of flap reconstructions for melanoma of the leg. The keystone flap is extremely reliable, affords excellent cosmesis, and is technically straightforward to perform. At the Sydney Melanoma Unit, reconstruction after primary melanoma excision on the leg has been transformed so that skin grafts are now rarely performed.
This paper describes modifications to the design of the keystone design island flap for the reconstruction of oncological defects. In particular, the paper outlines a spectrum of modifications to the design that permit the design to be tailored to a broad range of reconstructive needs, factoring in the anatomical location of the soft tissue defect and the quality of the integument in that locality. The biomechanics of the flap are also discussed in detail. (C) 2009 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
To evaluate the feasibility of using the bipedicled flap in the reconstruction of an exposed tibia.
Twenty-three patients underwent reconstruction of the exposed tibia using the fasciocutaneous bipedicled flap from the medial of the leg (in 12 patients), from the lateral aspect (in 9 patients) and from both the medial and the lateral (in 2 patients). In all cases, the donor site of the flap was covered by split-thickness skin graft.
In 23 patients, 25 fasciocutaneous bipedicled flaps were used, a single flap in 21 patients, and double flaps in two patients. Twenty-three flaps were completely viable and healed totally. One of the remaining flaps (which were used to cover an exposed tibia after excision of a chronic leg ulcer) was complicated by partial necrosis due to superficial necrosis of its lateral edge which healed conservatively. The last flap was severely infected resulting in necrosis which required debridement and reconstruction using a free forearm flap.
The bipedicled flap has advantages of dual blood supply, achievement of sensitivity in the damaged area and acceptable aesthetic appearance.
It is well known that a bipedicled skin flap permits survival of longer flaps due to the secondary recruitment of vascularity. Inclusion of the deep fascia with such a flap, obeying the principles of the single-pedicled fasciocutaneous flap, provides even greater security for the immediate transposition of yet larger or riskier flaps without the need for delay maneuvers. This variation is especially valuable for the management of difficult wounds encountered in the lower extremity when no other local options may be available. Thirteen local bipedicled fasciocutaneous flaps including both vertical and horizontal orientations, without isolation of any discrete fascial perforators, have been successfully used for soft tissue coverage in the distal leg and ankle with only three (23%) minor complications as untoward sequelae. Another major advantage of this bipedicled version of the fasciocutaneous flap was that the inclusion of a distal pedicle simultaneously may be designed to prevent bone or tendon exposure at the donor site that otherwise frequently is a concern with a unipedicled flap.
Covering defects of the lower leg is still an exceptional problem when tendons or bone are exposed within small defects, particularly in the malleolar region. We present 12 cases of successful wound closure on the lower leg with the versatile bipedicled flap. We had a low incidence of minor complications, whether it was used as a cutaneous, fasciocutaneous, or myo-fasciocutaneous flap, in some cases also based on underlying perforators to guarantee perfusion of the flap. If it is limited to selected indications and patients, the bipedicled flap may be a reliable alternative to other, more sophisticated methods of tissue transfer.
Bipedicle flaps have been used to provide good quality soft tissue cover for defects in many anatomical sites. The indications for the use of this flap have not been well defined and with the advent of more complex modes of tissue transfer this simple technique is often overlooked. We have found it to be a safe and expedient method of providing cover for difficult defects on the extremities. We present a series of 9 flaps raised on 7 patients over a 12-month period and discuss the indications and refinements in flap design.
A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot. We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid-line area is the line of maximum tension and by V-Y advancement of each end of the flap, the 'islanded' flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients.
In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap.
The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
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