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Keystone Flap Reconstruction of Primary Melanoma Excision Defects of the Leg—The End of the Skin Graft?

Marc D. Moncrieff MD, FRCS(Plast), Felicity Bowen MBBS, John F. Thompson MD, FRACS, Robyn P. M. Saw MS FRACS, Kerwin F. Shannon MBBS, FRACS, Andrew J. Spillane MD, FRACS, Michael J. Quinn MBBS, FRACS, Jonathan R. Stretch DPhil, FRACS
Volume 15, Issue 10 / October , 2008



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.


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