Chia-Chun Lee

  • External expansion by the vessel loop shoelace technique followed by the keystone flap to treat large upper to mid-back defect

    Background:
    Keystone design perforator island flap (KDPIF) has been gaining popularity for reconstructing large skin and soft tissue defects. However, for defects with insufficient local tissue and tense laxity, a single keystone flap may not be so suitable for advancement and mobilization. Instead of an additional flap or double-opposite-designed keystone flaps, we attempted to apply the vessel loop shoelace technique for external expansion followed by only one keystone flap reconstruction for skin and soft tissue defect on upper and mid-back.

    Materials and Methods:
    Skin and soft tissue defect over upper to mid-back reconstructed with shoelace technique external tissue expansion followed by a type IIa KDPIF (SK-IIa) by a single surgeon was enrolled. External expansion contained two vessel loops inserted through skin staples crossing over each other in an interlacing fashion, and tightened the knots on both angles every 2-3 days for 7-10 days before proceeding with only one keystone flap reconstruction. Surgical outcomes were collected and analyzed.

    Results:
    A total of three patients underwent shoelace vessel loop external expansion followed by a single KDPIF for upper to mid-back reconstruction in stage surgery. Two of the defects were caused by wide excision after soft tissue malignancy (liposarcoma and dermatofibroma protuberans) and one was caused after en bloc excision of radiation ulcer. Patients’ mean age at surgery was 44.6 years old. The average wound size was 106.2cm2. Final flap-to-defect width ratio was 1:2. No simultaneous local flap or skin graft required. All the flaps were successful without necrosis, ischemic edge, wound dehiscence, nor infection.

    Conclusion: Shoelace technique for external tissue expansion followed by a single KDPIF may be effective in the reconstruction of large defects with insufficient soft tissue and tense laxity. Owing to the advantages of both techniques, this combined method shows its applicability, feasibility, and reliability, with an optimal aesthetic outcome on upper to mid-back reconstruction.

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