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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_855_Библиотеки_им_академика_М_И_Перельмана
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2.1 Case Presentations
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Fig. 2.121 The inferior limit of the ap closes into the
preauricular defect and the cyanotic lines of tension are
subsequently overcome by the hyperaemic phase. Anydog
ear or redundant tissue can be excised at the epidermal
level andis not a contraindication for immediate surgical
excision because the cervical fascial base ensures
circulation
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Fig. 2.122 The reliability of the circulation allows one to
trim the dog ear in the acute phase and the surgical delineation of the island is closed directly down the nasolabial
line. Some clinical points from this image: 1. The L infraorbital wound closure is angled upwards to minimise any
ectropion. 2. The ap closure under tension allows tightness of the L cheek and is a form of static facial nerve
reconstruction. No microsurgical nerve grafting was done.
3. The ‘dog ear’ excision is completed at the time of the
initial closure because of the hyperaemia developed in the
tissues with the Keystone Island principle. 4. The tensional closure and the static facial nerve manoeuvre eliminates any need for an initial tarsorrhaphy
Fig. 2.123 The appearance at 2 years following radiation. There is no element of any ectropion evident at this
early stage. However, subsequently the weight of the tissue caused some element of droop and for comfort; a tarsorrhaphy was performed only after 3 years
Fig. 2.124 Operative sequence (
10.1007/000- b4y)
https://doi.org/
▶
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2 Major Head andNeck Regions Using theKeystone Technique
2.1.5.6 Case 16: Anterior Cervical
Submental Keystone foraLarge
Parotid Defect ina75 Year Old
Melanoma level III, IV over the parotid with R
neck clearance with sentinel node (negative). A
DRAPE procedure was performed, i.e. Delayed
Reconstruction Awaiting Pathology Evaluation
(see Figs.2.127, 2.128, 2.129, 2.130, 2.131, and
2.132).
In summary, the P.A.C.E.S. charactristics of
the Keystone were all exemplied.
Fig. 2.125 Operative sequence (
10.1007/000- b4z)
Fig. 2.126 Operative sequence (
10.1007/000- b50)
https://doi.org/
▶
https://doi.org/
▶
Fig. 2.127 The surgical specimen 5×5cm with the sentinel node staining
Fig. 2.128 The 7×5cm defect sitting over the angle of
the mandible. The cervico-submental Keystone (arrowed)
for closure of the defect. The excisional defect after tumour
removal was closed. The cervico-submental ap from the
neck to the point of the chin incorporating anterior cutaneous nerves C2, C3 from the dermatomal mark out
2.1 Case Presentations
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Fig. 2.129 Close-up of the excisional defect
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Fig. 2.130 The cervico-submental Keystone based on
cervical fascia and designed within the dermatomes C2,
C3 is undermined two thirds. The proximal one third
attachment over sternomastoid random perforators
ensures viability. The Keystone is then rotated into the
defect and then the single layer 3-phase suture technique
is employed using locking mattress sutures in a single
layer at the points of maximum tension, ordinary mattress
to close the wound and an epidermal continuous nylon to
produce cutaneous seal. The 30-min timeframe (timestamped) for the reconstruction and Keystone insertion
and closure of the secondary defect
Fig. 2.131 Appearance at 14 days from timestamped
image
Fig. 2.132 Operative sequence (
10.1007/000- b51)
https://doi.org/
▶
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2 Major Head andNeck Regions Using theKeystone Technique
2.1.5.7 Case 17: Posterior Cervical
Orientated Keystone
foraMitotic Lesion ina35 Year
Old
See Figs.2.133, 2.134, 2.135, 2.136, and 2.137
In summary, the P.A.C.E.S. charactristics of
the Keystone were all exemplied in this young
male smoker who was warned accordingly.
Fig. 2.135 Defect size 8×5cm and the closure with a
posterior orientated cervico Keystone based on sternomastoid perforators with the superior limits of the
Keystone to close the cheek defect leaving one third deep
attachment inferiorly over the random sternomastoid
perforators
Fig. 2.133 The recurrent mitotic lesions over the parotid
which was cleared including a parotidectomy and no neck
dissection
Fig. 2.134 The
dermatome mark out
2.1 Case Presentations
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Fig. 2.136 The Red Dot Sign conrming the hyperaemic
phase and therefore the increased vascularity eliminates
any necrosis with the closure under tension
Fig. 2.137 The appearance on completion using the single layer 3-phase suture technique of locking mattress
sutures, simple mattress sutures and continuous nylon for
epidermal seal. Note the hyperaemia throughout the ap
compared with the surrounding tissues. The wound is
healed normally
2.1.6 Nose
This Keystone technique in nasal reconstruction
for melanoma and other mitotic lesions has wide
application. Incidentally, the multifocal skin
lesions of the nasal bridge were excised and once
pathology clearance was achieved [16], a forehead island ap was used for closure. The standard vertical ap rotated to 180° often leaves a
secondary defect at the hairline needing grafting.
This supraorbital forehead island ap overcomes
that problem, in spite of closing under tension, a
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characteristic of the Keystone. It is noteworthy
this patient wanted the secondary procedure done
during the healing phase of the L forehead lesion,
showing again, the reliability of the Keystone
vascularity, based on anatomical norms using the
dermatomal mark outs. In this case, the supratrochlear and supraorbital neurovascular structures producing an acceptable aesthetic
outcome.
The principles of nasal reconstruction have a
long tradition referring to Burget and Menick’s
work (1994). In these Melanoma cases, usually
the skin cover only is required and the Keystone
provides vascular foundation in the nasal reconstruction reconstructing the cutaneous envelope.
Free tissue transfer has no applications in this
Keystone concept and has universal application
in covering all elements of this nasal envelope.
The Keystone provides excellent colour match,
thickness and texture in the reconstruction.
The principal melanoma excision and closure
by elements of secondary intention is something
that is not practiced by plastic surgeons in spite of
a 1cm defect in spite of the aesthetic drawbacks.
Never forgetting, the grafting option is always a
possibility.
The Keystone principle seems to universalise
the collection of loco-regional aps in nasal
reconstruction – too many to list, including
advancement, rotation and transposition types
including Bi-lobed and the Hatchet variants [8].
Even Rohrich etal. 1999 nasal tip repair is based
on traditional techniques with skin from the
proximal two thirds, whereas the Keystone
design seems to incorporate this reference.
The staged midline forehead ap variety [18,
19] has its drawbacks with tightness, vascular
impedance and hairline secondary defects are
impediments to a good aesthetic outcome, let
alone subsequent repeat procedures looking for
surgical scar revision.
2.1.6.1 Case 18: Side oftheNose
The nasolabial line of reconstruction based on
random branches of the facial artery (see
Figs. 2.138, 2.139, 2.140, 2.141, 2.142, 2.143,
2.144, 2.145, and 2.146).
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2 Major Head andNeck Regions Using theKeystone Technique
Fig. 2.138 Recurrent mitotic lesion of the R side of the
nose 6 months following initial surgery
Fig. 2.139 The
dermatome mark out–
the basis for the
Keystone island ap
design
Fig. 2.140 Removal of the tumour. The underlying neurovascular axis (with the nasal branch of the facial artery)
is evident but not skeletonised or stripped. The DRAPE
procedure applied again. Following pathology clearance,
the Keystonerepair was completed
In summary, an aesthetically acceptable outcome using the V-Y Dieffenbach ap based on
random neurovascular perforators from the nasal
branch of the facial artery. The tissues are teased
with blunt dissection to facilitate advancement of
the ap into the defect.
2.1 Case Presentations
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Fig. 2.141 The Red Dot Sign at the suture point, indicating the reex hyperaemia evident in this V-Y island ap as
happens in the Keystone. The ap is supported by random
perforators from the nasal branch of the facial artery to
explain the hyperaemia. All vessels are not skeletonised as
this unnecessary manoeuvre may strip autonomic bres
along the vessel
Fig. 2.142 Drainage technique using a 10-ml syringe
with perforated plastic tubing attached. It is held out to
suction length and secured using the plastic sleeve of the
hypodermic needle
Fig. 2.143 Reinstating suction after release. The volume
contained in the syringe is a measure of blood loss in mls.
Reinstating the suction and reattaching the tubing allows
ongoing drainage to be monitored and measureduntil it
ceases
Fig. 2.144 Appearance at 24 h. The wound is closed with
the standard single layered 3-phase suture technique and
the nylon suture on the epidermis creates eversion to produce an excellent scar line as in the Keystone the
P.A.C.E.S. factors also apply (because this is comparable
to a hemi-Keystone in design)
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2 Major Head andNeck Regions Using theKeystone Technique
Fig. 2.145 Postoperative appearance at 2 years and the
P.A.C.E.S acronym have all been exemplied. This anxious patient appreciated the outcome of the modied
Keystone which is really a conjoined/double V-Y ap
2.1.6.2 Case 19: Total Nasal Cover
Reconstruction Using
aTransverse Keystone Design
Variant fromtheForehead
Multifocal mitotic skin lesions of the nasal bridge
are the background pathology. The lesion over
the L frontal eminence has successfully healed
(Case 7) (see Figs. 2.147, 2.148, 2.149, 2.150,
2.151, 2.152, 2.153, and 2.154).
In summary, each reconstruction exemplied
the P.A.C.E.S. characteristics of the Keystone as
applied to this variation of a forehead island ap.
It is simpler to execute with upward closure over
the R frontal eminence and no doubt sitting along
the supraorbital and supratrochlear angiotome
supply– V 1.
Fig. 2.146 Postoperative 6 years – patient perspective
(▶ https://doi.org/10.1007/000- b52)
2.1.6.3 Case 20: Nasal Tip
Reconstruction
A 63-year-old female nasal tip melanoma in
association with an adjacent BCC component
creating a defect 3×2cm with 7mm clearance
achieved (see Figs. 2.155, 2.156, 2.157, 2.158,
2.159, 2.160, and 2.161).
In summary, the P.A.C.E.S. charactristics of
the Keystone were all exemplied in this island
ap repair.
2.1 Case Presentations
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Fig. 2.147 The multifocal lesions of the nasal bridge.
Defect is 4×3cm awaiting pathology clearance (DRAPE).
The forehead island ap mark out, based on the R supratrochlear and supraorbital neurovascular dermatome
Fig. 2.149 The
dermatome mark out for
the trigeminal nerve– V
1
Fig. 2.148 Lateral view of the same defect in the V1
dermatome
Fig. 2.150 Staged insertion of the forehead island ap to
close the bridge
Fig. 2.151 Closing of the secondary defect under tension. Note the viability of the nasal Keystone and the
upper forehead Keystone has not been compromised and
the defect on the lateral side of the nose was full-thickness
grafted
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Fig. 2.152 The L forehead lesion with staged removal of
sutures. The fenestrated full thickness graft on the L side
of the nose (arrowed) and the forehead island ap completes the closure
2 Major Head andNeck Regions Using theKeystone Technique
Fig. 2.154 Operative sequence (
10.1007/000- b53)
https://doi.org/
▶
Fig. 2.153 Appearance at 6 months postoperative
Fig. 2.155 The arrow indicates the planned tumour
clearance incision
Fig. 2.156 The oncological defect 3×2cm
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