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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3181c2a66f
Letters

Anatomical Basis for the Keystone Island Flap in the Upper Thigh

Behan, Felix C. M.B.B.S.; Lo, Cheng Hean M.B.B.S.; Findlay, Michael M.B.B.S.

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Department of Surgical Oncology; Peter MacCallum Cancer Institute; East Melbourne, and Department of Plastic and Reconstructive Surgery; Western General Hospital; Footscray, Victoria, Australia (Behan)

Department of Plastic and Craniofacial Surgery; Royal Children's Hospital; Parkville, Victoria, Australia (Lo)

Department of Surgical Oncology; Peter MacCallum Cancer Institute; East Melbourne, and Department of Plastic and Reconstructive Surgery; Western General Hospital; Footscray, Victoria, Australia (Findlay)

Correspondence to Dr. Lo; Department of Plastic and Craniofacial Surgery; Royal Children's Hospital; Flemington Road; Parkville, Victoria 3052, Australia; c_lo2@yahoo.com.au

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Sir:

We wish to congratulate Saint-Cyr et al. on their recent publication “The Extended Anterolateral Thigh Flap: Anatomical Basis and Clinical Experience.”1 From their cadaveric studies, the importance of large-diameter suprafascial linking vessels between angiotomes2 was highlighted. In addition, they reported a series of 12 patients who successfully underwent free extended anterolateral thigh flap reconstructions (without flap necrosis—partial or total). We read the article with great interest, noting the striking resemblance between Figure 1 illustrating their investigative principles and the design of keystone island flaps we use to close groin defects (Fig. 1): a totally serendipitous event. The publication by Saint-Cyr et al. provides the anatomical basis for our keystone island flap design in upper thigh reconstructions. The aim of this letter is to present our clinical verification for their marvellous investigative work.

Fig. 1
Fig. 1
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Keystone island flaps are perforator-based, fasciocutaneous island flaps used for locoregional reconstruction. Derived from his earlier work on the angiotome principle,2 our senior author (F.C.B.) has been performing fasciocutaneous island flaps for more than three decades and first published an article describing the surgical technique of keystone island flaps in 2003.3 Although others may consider preoperative imaging a necessary investigative tool, it has not been our practice to date because of the reliability of perforator supply. Identifying and dissecting individual perforators are routine in raising perforator free flaps. For locoregional reconstruction, however, rotational type IV keystone island flaps are raised in the subfascial plane and undermined only as much as necessary. Suprafascial linking vessels undoubtedly play an important role between adjacent angiotomes, especially because our keystone flaps have been safely raised and undermined up to two-thirds of the total flap surface area. We do not routinely localize and skeletonize perforators. Although of investigative value, it adds operating time, unnecessary complexity, and postoperative scarring. The risk of perforator damage is increased, and the absence of soft-tissue support may contribute to vessel kinking or occlusion (how does a gas fitter bend a copper pipe?).

In the upper thigh region, lumbar dermatomes are used as guides for keystone island flap designs. Because of the extensive undermining during inguinal dissections (by oncologic surgeons), our keystone designs had to be sizable over the anterior quadriceps region to incorporate more perforators (Fig. 1). Flap islanding (through skin, fat, and fascia lata) remains an absolute prerequisite to allow superomedial movement of the anterior quadriceps keystone, facilitating defect closure (Figs. 2 and 3).

Fig. 2
Fig. 2
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Fig. 3
Fig. 3
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At the Peter MacCallum Cancer Institute, a tertiary referral oncologic center in Melbourne, Australia, the keystone island flap has been established as a major reconstructive tool for advanced melanoma and other oncologic conditions. With the duet of oncologic and reconstructive surgical teams, the keystone island flap has been the preeminent reconstructive tool for closing large groin defects. There are approximately 18 cases in our series currently being compiled. There have been no cases of total flap loss or partial flap necrosis (one wound dehiscence and one infection). Early cases were reported previously.4

To conclude, Saint-Cyr et al. have produced a useful article on the anatomical basis of the anterolateral thigh fasciocutaneous flap. It explains the success we have enjoyed in keystone island flap reconstruction of groin defects.

Felix C. Behan, M.B.B.S.

Department of Surgical Oncology

Peter MacCallum Cancer Institute

East Melbourne, and Department of Plastic and Reconstructive Surgery

Western General Hospital

Footscray, Victoria, Australia

Cheng Hean Lo, M.B.B.S.

Department of Plastic and Craniofacial Surgery

Royal Children's Hospital

Parkville, Victoria, Australia

Michael Findlay, M.B.B.S.

Department of Surgical Oncology

Peter MacCallum Cancer Institute

East Melbourne, and Department of Plastic and Reconstructive Surgery

Western General Hospital

Footscray, Victoria, Australia

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REFERENCES

1. Saint-Cyr M, Schaverien M, Wong C, et al. The extended anterolateral thigh flap: Anatomical basis and clinical experience. Plast Reconstr Surg. 2009;123:1245–1255.

2. Behan FC, Wilson I. The principle of the angiotome, a system of linked axial pattern flaps. In: Transactions of the 6th International Congress of Plastic and Reconstructive Surgery. Paris: Masson; 1975

3. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112–120.

4. Behan F, Sizeland A, Porcedu S, Somia N, Wilson J. Keystone island flap: An alternative reconstructive option to free flaps in irradiated tissue. ANZ J Surg. 2006;76:407–413.

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Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

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©2010American Society of Plastic Surgeons

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