Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas
© The Author(s). 2016
Received: 2 August 2016
Accepted: 4 October 2016
Published: 19 October 2016
After wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas.
Between January 2011 and September 2016, demographic, operative, pathologic, and outcome data were prospectively collected on 60 patients who underwent wide local excision of melanoma followed by immediate flap reconstruction. Flaps were of either rhomboid or keystone type. Chi-square analysis was used to compare relationships between factors.
All procedures were done by the senior author and as outpatient surgery. No patient required a surgical drain unless they were undergoing concomitant radical regional node dissection. Flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line) occurred in 16/61 patients (26 %). No patient had flap loss. The risk of flap morbidity was significantly higher if the primary tumor was on the distal extremity—10 of 24 patients (42 %), all with keystone flaps—than if it was on the trunk or the proximal extremity (6/37 patients, 16 %), p = 0.04. There were no margins positive for either invasive or in situ melanoma in the entire cohort.
Simple transposition flaps can successfully cover large defects after melanoma excision without the need for skin grafting. Keystone flaps in the distal extremity are more prone to separation, but this is minor and does not result in flap loss. There is minimal risk of a positive margin requiring flap takedown and a second re-excision.
After wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. Although expedient and highly functional, grafting does result in two surgical sites (donor and recipient) and a potentially less satisfactory cosmetic outcome. An alternative is the use of transposition flaps to close large wounds. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas. We reviewed our experience for the rate of complications as well as the incidence of positive margins requiring flap takedown and re-excision.
We examined a prospectively collected database of all patients undergoing cutaneous melanoma excision by the senior author between January 2011 and September 2016 at the Karmanos Cancer Center (Detroit, MI). During this time period, 61 patients underwent excision and immediate reconstruction with a skin flap. Reconstruction was performed with either keystone or rhomboid flaps using previously described techniques [1, 2]. All cases were performed as outpatient surgery. No special postoperative dressings, wound appliances, or extremity immobilization devices were utilized. Patients were told to limit weight-bearing only to necessary activities of daily living until the first postoperative visit. Demographics, operative, pathologic, and outcome data formed the database. The main outcome measures were flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line), margin status, and local tumor recurrence. All chart reviews, data recordings, and analyses were carried out after IRB approval and abiding by federal and institutional HIPAA guidelines. Photographic consent was obtained as part of the consent for surgery. Statistical analysis of the data was performed using the SPSS software. Chi-square analysis of the data was used for comparison of the various factors.
Summary of patient, tumor, and operative data (see also Fig. 1)
Number of patients
26 (43 %)
35 (57 %)
Breslow depth (mm)
16 (26 %)
45 (74 %)
Total excised area (cm2)
Sentinel lymph node biopsy
Total number of SLNB
15 (28 %)
As a final point, some authors have advocated that reconstruction of skin defects after cancer excision should be done only after final pathologic diagnosis has been rendered, especially in esthetically sensitive areas and/or with complex reconstructions since this minimizes the amount of tissue initially excised . This obviates the need for flap takedown should further excision be required due to a positive margin. Unfortunately, routine hematoxylin and eosin frozen section assessment of margins for melanocytic lesions has been found to be notoriously inaccurate [7, 8]. In our cohort, however, no margins were positive for invasive melanoma or melanoma in situ on permanent section. Only one re-excision was necessary due to an incidental, discontinuous, high-grade dysplastic nevus in a patient with dysplastic nevus syndrome. Suture line recurrence occurred in only one patient, and she had initial advanced disease (T3N1) and subsequent rapid and widespread in-transit and skin metastases. Hence, we conclude that it is safe and justified to perform immediate reconstruction of defects after wide local excision, since there is a very low risk of a positive margin requiring re-excision and flap takedown. This is concordant with other reports that have demonstrated an infrequent need (2 %) for melanoma re-excision due to positive margins and/or early local tumor recurrence .
Our study has certain limitations. It is of relatively small size (N = 61) and involved the experience of only a single surgeon (although alternatively, there might also be an advantage to this since surgical technique was consistent in all cases). Despite these, it appears to validate the results of other reports that show good long-term cosmetic outcomes and low margin positivity rate when immediate flap reconstruction is performed after wide local excision of melanoma [2, 3, 9].
The keystone and rhomboid flaps are useful techniques to close wounds that are not amenable to primary repair. The former is associated with increased but mild morbidity when used in the distal extremity. Positive margins after wide local excision of non-head and neck melanomas are a rare event, justifying immediate flap reconstruction of the skin defect when necessary.
Availability of data and materials
Data is available and can be furnished on request.
MT contributed to the data analysis and manuscript writing. LC contributed to the data gathering, data analysis, and manuscript writing. SK contributed to the data gathering, data analysis, manuscript writing, and project conception. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
All chart reviews, data recordings, and analyses were carried out after IRB approval and abiding by federal and institutional HIPAA guidelines. Photographic consent was obtained as part of the consent for surgery.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Limberg AA. Mathematical principles of local plastic procedures on the surface of the human body. Leningrad: Medgis; 1946.Google Scholar
- Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112–20.View ArticlePubMedGoogle Scholar
- Moncrieff MD, Thompson JF, Stretch JR. Extended experience and modifications in the design and concepts of the keystone design island flap. J Plast Reconstr Aesthet Surg. 2010;63:1359–63.View ArticlePubMedGoogle Scholar
- Penington T. Science and the keystone flap. ANZ J Surg. 2013;83:E1–2.View ArticlePubMedGoogle Scholar
- Douglas C, Morris O. The ‘keystone concept’: time for some science. ANZ J Surg. 2013;83:498–9.View ArticlePubMedGoogle Scholar
- Behan FC, Rozen WM, Kwee MM, Kapila S, Fairbank S, Findlay MW. Oncologic clearance with preservation of reconstructive options: literature review and the ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique. ANZ J Surg. 2012;82:780–5.View ArticlePubMedGoogle Scholar
- Smith-Zagone MJ, Schwartz MR. Frozen section of skin specimens. Arch Pathol Lab Med. 2005;129:1536–43.PubMedGoogle Scholar
- Manstein ME, Manstein CH, Smith R. How accurate is frozen section for skin cancers? Ann Plast Surg. 2003;50:607–9.View ArticlePubMedGoogle Scholar
- Moncrieff MD, Bowen F, Thompson JF, et al. Keystone flap reconstruction of primary melanoma excision defects of the leg-the end of the skin graft? Ann Surg Oncol. 2008;15:2867–73.View ArticlePubMedGoogle Scholar