J. W. Rostas1, N. Bhutiani1, K. M. McMasters1, R. C. Martin1, C. S. Scoggins1, P. Philips1 1University Of Louisville,Surgery, Surgical Oncology,Louisville, KY, USA
Introduction:
Reconstruction after wide local excision of extremity melanoma often requires split thickness skin grafts for the resultant large defects. Keystone fascio-cutaneous island perforator ?ap is a reliable, rapid, simple and versatile reconstructive alternative. There is however, lack of data comparing this technique to skin grafts. The aim of this study is to evaluate and compare the functional, Quality of Life (QoL) and aesthetic outcomes of keystone flaps and skin grafts for extremity melanoma.
Methods:
Thirty-eight consecutive extremity melanoma patients (Keystone flap, n=24, Skin grafts, n=14) with an expected excisional diameter of >4 cm were prospectively enrolled to surgical outcomes study from 2013-2016 at the University of Louisville. Standard surgical techniques were employed and choice of reconstruction left to surgeon's discretion. Surgical outcomes were recorded prospectively. At the 3 month post-surgery follow-up visit, aesthetic and functional outcomes were evaluated using previously validated Wound Evaluation Scale (WES), visual analog score (VAS, 0=worst possible scar, 10: best possible scar), and a 10 point overall patient satisfaction score (OPS, 0=poor, 10 excellent). Quality of life after surgery was scored using 5 point Functional Outcome Measure (FOM:1=severe disability/deformity, 2= restriction even with mild use, 3=restriction in severe exertion, 4=no functional restriction, social restriction, 5= no restriction). Appropriate statistical tests were used.
Results:
Keystone flap group was similar to skin graft group with respect to melanoma thickness (1.75 vs. 2 mm, p=0.227), excision diameters (5.5 mm vs. 5.5 mm, p=0.782), concurrent sentinel lymph node biopsy (96% vs. 100%, p=0.632), completion lymphadenectomy (4 vs. 3, p=0.517), age (54.5 vs 59 years, p=0.227), diabetes and smoking history. Median hospital stay (1 vs. 2 days, p<0.001), return to activities of daily living (1 vs. 4 days, p<0.001), return to work (7 vs. 12.5 days, p<0.001) and duration of limb immobilization (1 vs. 4 days, p<0.001) were significantly lower in the keystone flap group. Keystone flap group had significantly fewer wound infections (n=4 vs. 2, p=0.049) and incomplete wound healing (n=1 vs. 3, p=0.047). The aesthetic and functional outcome scores as measured by WES (median 5 vs.3, p<0.001), patient VAS (median 8 vs. 5, p<0.001), OPS (median 8 vs. 6, p=0.034) and FOM (4 vs. 3, p-0.041) for keystone flap were also significantly superior to skin grafts. No local recurrences were noted and 3 patients at a median follow up of 13 months had distant metastatic disease.
Conclusion:
Keystone flap is an excellent reconstructive technique with cosmetic and aesthetic outcomes that are superior to skin grafts.
