Atlas of Keystone Reconstructive Technique in Melanoma Management

Book excerpt: Worldwide, it is quoted that 85% of Melanoma cases are treated surgically. The reliability of the Keystone Perforator Island Flap (KPIF) as a reconstructive technique has wide applications. Its low complication rate is the key to its surgical success. The technique is clearly explained in this Atlas by the author, a renowned plastic and reconstructive surgeon, who established this reconstructive principle over 20 years. The illustrations range from simple to complex cases in an easy-to-follow format. Audio files, as a supplementary tool, amplify the technique to enhance the reader’s experience and foster clear understanding. Chapters focussing on anatomical regions contain carefully selected cases accompanied by images to demonstrate a step-by-step surgical technique. The basic design format for all Keystones are highlighted, all sitting within the dermatomal precincts. The KPIF must contain a fascial base for lining and the island outline is an essential pre-requisite. It is hypothesized that this islanding creates a sympathectomy effect resulting in hyperaemic blood flow which optimises healing. Undermining up to 2/3 is permissible as long as there is a deep attachment of 1/3 at the base of the flap to contain the random perforator vascular support. This design allows the rotation, advancement and transposition (ART) of the flap to facilitate the reconstructive closures. Presumably, there are somatic and autonomic neural support lines accompanying the vascular pathways of these random perforator flaps. The vascular perforator tree must not be skeletonised (as in propellor flaps) to allow preservation of such anatomical elements - somatic, autonomic and lymphatic pathways, all of which are an essential component in any surgical repair. This KPIF provides an alternative to microvascular procedures where the biggest drawback is tissue match. The KPIF addresses this problem admirably with a low pain component, an excellent aesthetic match with a low vascular complication rate and a performed in an expeditious manner – these all characterise the KPIF. Simple solutions solve problems and this KPIF Atlas for Melanoma becomes a welcome companion to any surgical speciality including plastic and reconstructive surgeons, surgical oncologists, general surgeons and dermatologists.