Application of Keystone Flaps in Extremity Reconstruction ―― Clinical Experiences and Literature Review

拱心石皮瓣在肢體重建的應用－臨床經驗及文獻回顧

李彥錞(Yen-Chun Lee) ； 謝雲寰(Yun-Huan Hsieh) ； 蔡宗芸(Tzong-Yun Tsai) ； 姚全豐(Chuan-Fong Yao) ； 林承弘(Cheng-Hung Lin)

《臺灣整形外科醫學會雜誌》 26卷3期 (2017/09) Pp. 309-320

摘要

Background: The Keystone flap is an islanded local flap based on random axial perforators. It may be utilized as an alternative option to microsurgical reconstruction. It shares common advantages with other local flaps including short operating time, favourable esthetic results, and less donor site morbidity. This paper aims to report the experience of using Keystone Flap based on its Type IIA design and our modifications for extremity defect reconstructions in CGMH, Linkou, Taiwan. Aim and Objectives: Determining the feasibility and safety of Keystone Flap for various extremity defect reconstructions as well as assessing its surgical indications and limitations. In addition, rationales and applications of our modified designs of keystone Flaps are described and illustrated. Materials and Methods: Consecutive patients who presented with extremity defects and received keystone flaps from 2013 to 2016 were included in this study, their case history and progress were retrospectively reviewed. Total of 8 patients were recruited from the service of 2 surgeons. Results: The mean age of the patients is 58 years old (rang from 33-73), 6 were male and 2 were female with 1 to 24 months of follow up. Seven defects were lower extremity (leg, foot and ankle) defects, and only one defect was located in upper extremity (shoulder). The flap width to defect width ratio ranges from 1:1 to 1:2. Primary closure of both donor site and the defect was achieved in 6 patients, where 2 patients had delayed primary closure due to initial concerns of flap circulation. There is no complete or partial flap loss, no complications observed needing secondary procedures for subsequent wound managements. Conclusion: The keystone flap is a reliable and less technically demanding reconstruction approach to extremity defects. Increasing flap/defect ratio can overcome the presence of inherent or acquired regional skin rigidity by decreasing its wound tension up on closure, thus achieving superior esthetic outcome. Dividing the deep fascia over superior or inferior border in addition to original Type IIA design of the keystone flap is safe; it enables a better inset and tension free closure, particularly, along the long axis of the flap.

關鍵字

keystone flap ； extremity reconstruction ； trauma ； soft tissue

並列摘要

背景：拱心石皮瓣是由隨機軸向的穿通支供應，可以用作顯微手術重建的替代選擇，與其他局部皮瓣具有共同的優點，包括短的手術時間，較好的美觀結果和較少的供體位發病率。本文旨在報告在林口長庚醫院修改使用IIA型拱心石皮瓣用於肢端缺損重建的經驗。目的及目標：確定拱心石皮瓣對各種肢體缺損重建的可行性和安全性，並評估其手術適應症和局限性。以及我們對拱心石皮瓣設計修改的描述和說明材料及方法：收集了於2013年至2016年間有肢體缺損並接受拱心石皮瓣重建的患者，進追溯性回顧。總共有8名患者，由兩位整形外科醫師進行手術。結果：本系列患者的平均年齡為58歲（33-73歲），6例為男性，2例為女性，術後追蹤時間1〜24個月。七個缺陷位於下肢（腿，腳和腳踝），只有一個缺陷位於上肢（肩）。拱心石皮瓣拱心石皮瓣缺陷寬度 與寬度比為1:1至2:1。6名患者的取皮瓣部位初級閉合，其中2名患者由於憂心閉合後皮瓣的循環，而延遲了初級閉合。沒有完全或部分瓣瓣丟失或其他需要二次手術的併發症。結論：拱心石皮瓣對於肢體缺損重建是一種可靠且技術要求較低的重建方法，增加皮瓣與缺損寬度比可以減少傷口的張力而有更好傷口癒後，有更好的術後外觀。在原本拱心石皮瓣Type IIa沿著皮瓣長軸的設計上將上下其中一側筋膜分割是安全的，能更好的擺放皮瓣和進行無張力閉合。