Background: The keystone perforator flap was introduced by Behan in 2003, and since then has gained popularity for its versatility and reliability in reconstruction. 

Conclusions: This article describes the flap physiology, technique, modifications, limitations & applications to various parts of the body, in an article that will be of interest to any reconstructive surgeon 

 Authors: C.Riccio et al

Journal: Annals of Plastic Surgery, 2019; 83: 226-231

Background: Lipomas are benign tumours of adipose tissue and can cause functional issues or, commonly in the case of lipomas of the forehead, can be cosmetically embarrassing. The aetiology is unknown, although blunt trauma has been postulated to be a factor. Differential diagnoses include cysts, frontal bone growths, vascular lesions, malignancies and extension of intracranial lesions. Such lipomas are often placed on lists for trainees, and the authors performed a literature search with an aim to provide a comprehensive overview.

Findings: 14 papers were included for analysis, comprising 43 patients. 100% of forehead lipomas presented as solitary swellings, were three times more common in males, and average age of presentation was 48 years. Treatment is usually by surgical excision through a transverse, forehead-crease incision, and the majority were found to be deep to the frontalis muscle. No reports of recurrence were found.

Conclusions: The authors explain that trainees should understand that, if the lipoma cannot be found in the subcutaneous plane, then further dissection into, and beneath, frontalis should be performed. The location of underlying structures, especially the supratrochlear and supraorbital neurovascular bundles should be borne in mind, as division can result in forehead numbness and bleeding.

 Authors: R.Murphy et al

Journal: The Surgeon, 2019; 17: 186-189

Background: Melanoma of the external ear is relatively uncommon, and it used to be thought that it carried a poor prognosis. More recent studies have shown that prognosis may not be as grave as once thought, but treatment principles can still differ between surgeons. Surgery of the ear has both functional and cosmetic impact; some surgeons advocate excision with the underlying cartilage while others allowing for preservation of the cartilage in a bid to maintain function & form.
In order to further investigate the prospect of cartilage sparing, the authors conducted a literature search as well as looking at 17 years of their own data.

Findings: A total of 5 papers met the inclusion criteria for review. A further 40 patients were identified from the author’s own institution that had had excision and sentinel node biopsy for melanoma of the ear; 11 had had ‘wedge excision’ of the ear, and 29 had cartilage-preserving surgery with 17 having full-thickness skin graft reconstruction and 8 local flaps. There were no statistically significant differences between patient or tumour characteristics, and no significant differences between the two groups in recurrences or 5 & 10 year melanoma-specific survival. One patient had local recurrence, being in the wedge-excision group.

Conclusions: The authors describe that the perichondrium serves as a barrier and in their experience cartilage-preserving surgery does not seem to increase the risk of local recurrence, which is supported by the literature evidence.

Authors: C.Harrison et al

Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery, 2019; 72: 92-96