Keystone Perforator Island Flaps in Major Head and Neck Surgery – The P.A.C.E. Perspectives

Felix C Behan1* and Andrew Sizeland2

1Department of Plastic Surgery, Peter MacCallum Cancer Centre, Hospital, Australia
2Department of Surgical Oncology in Head and Neck, Peter MacCallum Cancer Centre, Hospital, Australia

^*Correspondance to: Felix C Behan 

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Abstract:

The four main characteristics of the Keystone Perforator Island Flap (KPIF) technique are repeated
and visually evident in any reconstruction and we use the acronym P.A.C.E. to synopsize these
characteristics:
Painless: The patient does not experience pain in any aspect of the reconstruction but it just feels
initially tight.
Aesthetic: Using like for like creates the best match of tissue in any location compared with the nonmatching
of tissue texture in free flap reconstruction.
Complications: Are remote and the only problems related to tensional closure and wound
breakdowns and not any relating to vascular insufficiency.
Economic: The timeframe of the procedure in one-to-two-hour units compares favorably with any
microsurgical saga that might have a 10% return to theatre because of microscopic failure.
This article demonstrates the value of the Keystone Perforator Island Flap (KPIF) when applied for
loco-regional reconstruction on various aspects of the head and neck. The cases all originated from
the Peter MacCallum Cancer Institute where Professor Andrew Sizeland and Steve Kleid sourced
the cases and appreciated the value of the KPIF.
Historically the keystone flap, a conjoined double V-Y flap which originally dates back to Dieffenbach
1845 and his V-Y flap in facial reconstruction. In 1995 the original KPIF was used which was a blend
of two V-Y islands and the random circulation of the base was the principle of their success.
The local flap is based on the principles of applied anatomy of the dermatomal markouts and the
physiology of a sympathectomy effect which results in hypervascularization once the island design
is completed around the dermatomal outline. This principle is used in flap salvage to increase
vascularization by incising the site of origin on the flap through the skin and epidermis only while
leaving 1/3rd of deep attachment. It is similar in context to the ‘pink foot’ outcome following a
lumbar sympathectomy in the day’s past in any vascular unit. Thus this principle is used when the
flap is not a standard KPIF design Types I and II but when loco-regional flaps are islanded adopting
the principle of hypervascularity, this avoids flap necrosis whatever the location as long as they are
dermatomally aligned. The KPIF technique compares favorably with any microsurgical closure of
the defect.

Keywords:

Dermatomal alignment; Keystone Perforator Island Flap; Head and neck oncological defects; Clinical observation; P.A.C.E. acronym

Cite the Article:

Behan FC, Sizeland A. Keystone Perforator Island Flaps in Major Head and Neck Surgery – The P.A.C.E. Perspectives. World J Surg Surgical Res. 2021; 4: 1293..