Perforator Island Flap Research Articles

Keystone Perforator Island Flap as an Alternative Reconstructive Option for Partial Thickness Alar Defects Up to 1.5 Centimeters.

The ala is a unique landmark of the nose disposing aesthetic and functional properties. The head and neck area is the main site of appearance of nonmelanoma skin cancer. One third of them are located in the nose with an alar preponderance compared with other nasal subunits. Correction of alar defects is a challenging reconstructive task. The keystone perforator island flap (KPIF) was introduced as an alternative in nasal reconstruction by senior authors. In the present case series, KPIFs' application is introduced into the alar subunit as an alternative, versatile, and reproducible reconstructive option, even for the novice plastic surgeon. From April 2014 to September 2015, patients presenting with partial thickness alar defects (≤1.5 cm) secondary to tumor extirpation sustained reconstruction with different types of KPIF. A total of 31 patients (mean age of 72 years) were treated with various types of KPIF. The mean diameter of the defect was 1.14 cm. The vast majority of reconstructions concerned a type IV KPIF (18/31 or 58.1%). Sometimes an upward alar retraction was noted. A minimal rim wedge excision was performed (≤0.3 mm) using counterbalancing correcting sutures. All flaps survived without any sign of venous congestion, whereas the rim healed uneventfully. The mean follow-up period was 6.5 months. KPIF was introduced as a single-stage alternative reconstructive option for partial thickness alar defects, completing author's experience with this flap into such a challenging and aesthetically critical anatomic area.

Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications.

Keystone flaps have demonstrated growing clinical applications in reconstructive surgery in the past decade. This article highlights flap modifications and their versatility for clinical applications and management of complex defects. A retrospective chart review was conducted of consecutive patients undergoing keystone flap reconstruction at the authors' institution from January of 2012 to December of 2014. Patient demographics, indications, and operative and postoperative details were abstracted. Forty-two keystone flaps were performed in 36 patients. Indications included malignant melanoma (n = 14), soft-tissue sarcoma (n = 12), benign pathologic conditions (e.g., exposed hardware, enterocutaneous fistula, tissue necrosis) (n = 6), and nonmelanoma skin cancer (n = 4). Twenty-eight percent received neoadjuvant irradiation, and 70 percent of these were for sarcoma. Locoregional adjunct flaps were performed in eight patients. The deep fascia was nearly completely in a circumferential manner in 18 of 36 patients (50 percent), in 92 percent of the sarcoma reconstructions, and located mainly in the lower extremity. Average defect size was 215 cm (range, 4 to 1000 cm). Average defect size was 474 cm and 35.8 cm after sarcoma and malignant melanoma resection, respectively. Average flap size was 344 cm (range, 5 to 1350 cm). Ninety percent of cases had flap sizes exceeding the traditional 1:1 ratio. There was no flap loss or partial necrosis. Mean time to mobilization was 1.8 days, and mean hospital length of stay was 6.8 days. Keystone flaps offer an excellent versatile tool for reconstructive surgeons. Fundamental principles behind the vascular basis of the keystone flap and its modifications permit their greater utility in complex wounds in the settings of large oncologic resections, irradiation, and trauma. Therapeutic, IV.

The Use of Submental Artery Perforator Island Flap Without Including Digastric Muscle in the Reconstruction of Lower Face and Intraoral Defects.

For reconstruction of intraoral and lower face defects, it is important to use flaps that prevent reliable and pliable soft tissue and it is possible to use aesthetically most compatible with recipient site. In this study, the authors aimed to present their clinical experiences and results of lower face and intraoral defects reconstructions with submental artery island perforator flap without including the digastric muscle to have a thinner and useful flap. Six patients with lower face and intraoral defects that were reconstructed using the submental artery island flap between November 2013 and February 2015 were retrospectively analyzed. Patient demographics, age, sex, defect etiologies, and complications were assessed. Hand Doppler examination was performed and submental artery marked preoperatively. The superior border of the flap was designed at least 1 cm away from the mandibular border to avoid injury to the marginal mandibular nerve and prevent lip eversion. After the identification of the submental artery via the retrograde dissection, the anterior belly of the digastric muscle was not included the flap to prevent a thinner flap. After the dissection, the island flap was transferred to the defect site through a subcutaneous tunnel. The donor sites were closed primarily. A partially flap necrosis was occurred in 1 patient due to hematome in the tunnel around the pedicle. The wound healed uneventfully with conservative management. In the remaining patients there were no complications. The submental artery perforator island flap without including the digastric muscle is a reliable and suitable option for the medium-sized defects in the lower face and intraoral defects.

A convenient flap for repairing the donor area of a distally based sural flap: Gastrocnemius perforator island flap

The reconstruction of complex lower leg and foot defects is difficult for plastic surgeons. The distally based sural flap (DBSF) is an option for non-free flap lower leg reconstruction. However, one of the major drawbacks of the DBSF is its aesthetically non-acceptable donor area scarring. Eight patients (six men and two women) who had lower leg or foot defects were evaluated in this study. We used an ipsilateral or cross-leg DBSF to repair the defect. A medial or lateral gastrocnemius perforator island flap (average size 8.1×6.1cm) was used to cover the donor area of the DBSF in a two-stage operative procedure. We did not observe any complications with the gastrocnemius perforator island flap. Two patients had local infections under the DBSF and were treated with bacteria-specific antibiotherapy. All patients were followed up for 1 year postoperatively. The donor areas of the distally based sural flaps were aesthetically acceptable. Patients gained ambulatory status during the follow-up period. Reconstruction of the donor area of a DBSF with a gastrocnemius perforator island flap allows for more acceptable aesthetics and functional results than do other reconstructive procedures.

TDAP: Island versus propeller

Thoracodorsal artery perforator (TDAP) island flap is a safe and reliable method for breast reconstruction. TDAP propeller flap has been described as a modification of the conventional island technique that saves time and does not require microsurgical skills. However, a substantial portion of the propeller flap remains under the axilla and is not used for breast augmentation. The aim of this study is to identify the differences in the reaching distances between the propeller and island TDAP flaps. In five cadaveric specimens and 10 breast reconstruction patients, an initial propeller flap was harvested and rotated to the anterior thorax; the distance from the tip of the flap to the anterior midline was recorded as the "midline-reaching deficit;" the flap was then converted into a conventional island flap, and the new midline-reaching deficit was recorded. Differences between groups were compared with paired two-tailed t-tests (α=0.05). In the cadaveric specimens, the mean midline-reaching deficit was 4.8 ±2.4cm with the propeller TDAP and -0.6±2.0cm with the conventional island TDAP (P<0.001). In the clinical cases, the mean midline-reaching deficit was 8.1±1.0cm with the propeller TDAP and -0.3±1.1cm with the island TDAP (P<0.000000001). We observed that the midline-reaching deficit could be reduced by 7-9cm with the conventional island TDAP in comparison to the propeller TDAP. This should be considered when reconstructing the medial inner part of the breast.

Lateral Thoracic Artery Perforator Island Flap in Rat

Lateral Thoracic Artery Perforator Island Flap in Rat

Avoiding Skin Grafts: The Keystone Flap in Cutaneous Defects.

Therapeutic, IV.

The Keystone Perforator Island Flap in Nasal Reconstruction: An Alternative Reconstructive Option for Soft Tissue Defects up to 2 cm.

The aim of this study was to present our experience with the use of the Keystone Perforator Island Flap (KPIF) in a case series of patients with small size (diameter ≤ 2 cm) nasal defects which will be useful prospectively to assist plastic surgeons in planning a reconstructive strategy that will work. The KPIF was utilized in 30 patients with nasal defects post tumor extirpation. More than one type of KPIF (type I or type III) was used following the nasal subunit principle or a modified version of it. The mean follow-up period was 10.5 months. Overall good outcomes were achieved, with no major complications encountered, except minor wound dehiscence in 3 cases. It is the first time that the utilization of this flap is reported in nasal reconstruction. The versatility of the KPIF makes it a safe technique even in the hands of inexperienced surgeons under guidance for nasal defects up to 2 cm in diameter.

Reconstruction of fingertip defects with digital artery perforator flap.

The aim of this study was to present our findings for the use of the digital artery perforator (DAP) flap in the covering of digital pulp defects. The study included 15 patients who underwent reconstruction of the fingertip using a DAP flap between July 2007 and February 2012. The blood supply of the perforator island flap was based on the distal and either radial or ulnar sides of the digit. Donor sites were closed using skin grafting in all cases. Static two-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWM) testing was performed at the final follow-up to determine extension loss and sensorial improvement. Mean follow-up was 22 (range: 7 to 62) months. Flaps size was between 2 x 1 cm and 2.5 x 1.5 cm. Temporary venous congestion was observed in 12 of the 15 patients and was without complication. All patients returned to their normal daily activities and work within an average of 39 (range: 30 to 45) days. Mean two-point discrimination was 5.3 mm and SWM test results were between 3.61 and 4.56 at the final follow-up. The DAP flap appears to be a reliable procedure with several advantages as a single-stage operating procedure, easy to harvest, good sensory recovery and preservation of digital arteries.

Reconstrucción de defectos amplios en tronco mediante colgajo de perforante en piedra clave

The Keystone Perforator Island Flap (KPIF) is a local fasciocutaneous islanded flap, first published in 2003 by Behan, that does not require identification o...

The keystone-design perforator-based flap for leg defects: a synthesis of philosophies

Aim: The classical keystone-design flap, although elegantly employed for various trunk defects, has limited movement on the leg. This study aims to modify the keystone-design flaps for leg defects. Methods: A keystone-design flap, in which perforators are identified and dissected, is described specifically for elliptical defects overlying the tibia. Results: It retains the unique advantages of both the perforator island flap concept as well as the keystone-design philosophy. Conclusion: The technique as well as the possibilities of raising such flaps over various areas of the leg is outlined.

Local perforator island flaps in post-traumatic reconstruction of middle third of the leg

Perforator flaps have been introduced for coverage of local and distant defects. Various designs of this flap are possible, but their role in the setting of trauma is debated. We report that it is possible to raise these flaps in cases of post-traumatic lower limb reconstruction with good results. Consideration must be given to the type of movement that is planned vis-a-vis the number of perforators identified.

The keystone design perforator island flap in reconstructive surgery

To introduce the experience in skin defects reconstruction using keystone design perforator island flap. Since June 2012 to June 2013, the flaps have been used in 14 patients. The size of defects ranged from 1 cm x 1 cm to 5 cm x 9 cm at the extremities, trunk and facial region. The trapezoidal shaped flap has the same width as the defect. The flap is designed along the edge of the defect with 90 degree angle at the ends of the island flap. This curvilinear- and trapezoidal-shaped flap essentially consists of two conjoined V-Y advancement flaps at the proximal and distal end. The vascular supply is supported by the subcutaneous vascular network and fascial/muscular perforators. Perforators should be detected by Doppler techniques when large size flaps are used. Primary wound healing and satisfactory result was achieved in 13 patients except for one with partial flap necrosis. The technique offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting.

Pharyngotracheal fistula closure using the internal mammary artery perforator island flap

Salvage laryngectomy following organ preservation therapy is a frequent condition that exposes patients to pharyngocutaneous and pharyngotracheal fistulas. Definitive treatment frequently requires well vascularized tissue harvested from the chest. To limit tracheostoma obstruction, a thin and pliable flap is preferable. The internal mammary artery perforator (IMAP) island flap fulfills these criteria, but it is not well known and is not commonly used by head and neck surgeons. In this article, based on our experience, we describe our surgical technique and the strengths and weaknesses of this flap. Retrospective cohort study and systematic review of the literature. An IMAP flap was performed on 12 patients to repair postoperative fistulas, located in the lower neck close to the tracheal stoma or involving the posterior tracheal wall, from March 2009 to December 2012. The medical records of each of patient were retrospectively analyzed. A breach of the pleura occurred in one patient. It was diagnosed and treated perioperatively. One patient had a total flap necrosis and required a reoperation. The postoperative course was uneventful in 11 patients (92%). All donor sites were closed primarily without any wound-healing problems. The IMAP flap is reliable. Its advantages make it a convenient flap to repair peritracheostomal defects and fistulas. The harvesting technique is not very demanding but requires training.

The Keystone Perforator Island Flap in Head and Neck Reconstruction

The Keystone Perforator Island Flap in Head and Neck Reconstruction

The Island Perforator Flap Design Augments Vascularity

Sir: We read with great interest the article entitled “The Importance of a Skin Bridge in Peripheral Tissue Perfusion in Perforator Flaps,” and we congratulate the authors on their study.1 With dynamic laser-induced fluorescence videoangiography, Mešić et al.1 assessed perfusion of island and nonisland perforator flaps and concluded that conversion of a perforator flap with a skin bridge into an island perforator flap increases peripheral tissue perfusion. Cutting of the skin bridge and conversion of a nonisland flap into an island flap completely divide the dermal/subdermal plexus and are intuitively expected to further impair circulation of the flap. Based on a similar line of thought, perfusion in island flaps is intuitively expected to be lower than that of surrounding skin (or preoperative donor area) due to raising of the flap, division of smaller vessels, and skeletonization of perforators. However, there is now an emerging body of research to suggest otherwise. Rubino et al.2 performed echo color Doppler measurements of diameter and blood flow velocity in deep inferior epigastric, superior gluteal artery, and anterolateral thigh perforator flaps. Their data showed that in the donor area preoperatively, blood velocity in the perforator is lower than that in the corresponding pedicle, whereas after surgery, blood velocity in the perforator is higher than that in the corresponding pedicle. Figus et al.3 assessed hemodynamic changes in deep inferior epigastric perforator flaps with laser Doppler flowmetry. Their study demonstrated an increase of the blood velocity in the circulation of deep inferior epigastric perforator flaps both in the immediate postoperative period and after 3 months. Both groups suggested that the higher velocity within perforator flaps may be a favorable rheologic feature.2,3 We had a case of a 46-year-old man who underwent perineal defect reconstruction with an inferior gluteal artery perforator island flap following laparoscopic abdominoperineal resection of a low rectal malignancy. Seven days after the operation, laser Doppler flowmetry (Moor Laser Doppler Imager; Moor Instruments Ltd., Devon, United Kingdom) assessment of flap perfusion revealed an area of significant hyperperfusion where the inferior gluteal artery entered the flap (Figs. 1 and 2). In comparison to surrounding skin (yellow/green/pink), the perfusion where the pedicle entered the flap was significantly increased (red), while flap perfusion in the areas away from the pedicle was relatively decreased (blue/purple).Fig. 1: The inferior gluteal artery island perforator flap was used to reconstruct the perineal defectFig. 2: Laser Doppler flowmetry displayed in 16-color palette over the range 0 to 230 PU with five marked regions of interest. Flux is highest where the vascular pedicle enters the flap at region 3 (blue, lowest blood flow; red, highest blood flow).In 1975, Behan and Wilson4 introduced the angiotome concept, which culminated in the keystone design perforator island flap. For at least two decades, Behan5 has hypothesized that the island flap design augments vascular perfusion, based on his intraoperative and early postoperative, clinically observed “red dot sign” and hyperaemic flare. In the current era of evidence-based medicine, his observations and interpretations were met with some skepticism until recent years. There are now published clinical series of keystone island flaps reflecting favorable clinical outcomes over decades. It is now gratifying to see the emergence of experimental and basic sciences research that helps to explain our positive experiences with the keystone island flap. Many questions remain unanswered (i.e., in our case, why the perfusion was relatively decreased in the flap areas away from the pedicle), and we look forward to contributing to this body of work on perforator flaps in the near future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Cheng Hean Lo, F.R.A.C.S.(Plast.) Hana Menezes, C.C.R.N. Felix Behan, F.R.A.C.S.(Plast.) Monash Health Dandenong, Victoria, Australia

The Keystone Perforator Island Flap Concept

The Keystone Perforator Island Flap Concept

Medial sural perforator plus island flap: A modification of the medial sural perforator island flap for the reconstruction of postburn knee flexion contractures using burned calf skin

Medial sural perforator plus island flap: A modification of the medial sural perforator island flap for the reconstruction of postburn knee flexion contractures using burned calf skin

Eyelid reconstruction: expanding the applications of the keystone perforator island flap concept

Eyelid reconstruction: expanding the applications of the keystone perforator island flap concept

The cervico-submental keystone island flap for locoregional head and neck reconstruction

Locally advanced head and neck cancer often requires wide resections of the cheek and parotid gland, and in an ageing population preferred reconstructive options aim to avoid lengthy operating times or high risk surgery. While most large parotid defects traditionally require free flap reconstruction, we describe a new and versatile locoregional flap that has been shown to be reliable, simple and safe. We describe the cervico-submental (CSM) keystone-design perforator island flap for head and neck reconstruction, including an analysis of 33 consecutive patients with a range of head and neck defects. The flap was raised based on perforators of the external carotid artery and its branches, and designed to overlay the C2/C3 dermatomes (an aide memoire for flap design). The indications, and surgical technique are described. In 33 consecutive patients, no major complications were encountered. Five patients developed superficial infections, one developed post-operative bleeding and one patient developed partial tip necrosis. Theatre time was considerably shorter than our alternative reconstructive options. The CSM keystone-design perforator island flap is a novel and versatile flap, which can be used in a range of advanced cheek and parotidectomy defects, and may enable improved surgical management in an increasingly elderly and high-risk population.