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

Background: 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.

Methods: 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.

Oncologic clearance with preservation of reconstructive options: literature review and the 'delayed reconstruction after pathology evaluation (DRAPE)' technique.

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained.

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

Background: 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.

Methods: 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.

Keystone island flap reconstruction of parotid defects.

Background: Skin cancers of the face and scalp have a propensity to metastasize to the parotid group of lymph nodes. The resection of these secondary tumors and other primary tumors in the parotid region often results in defects requiring flap reconstruction. Pectoralis major flaps are reliable and free flaps are arguably the criterion standard.

Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects.

Background: Radical inguinal lymphadenectomy (RIL) for bulky metastatic melanoma and non-melanoma skin cancers of the inguinal region, while shown to improve morbidity and survival oncologically, can result in substantial morbidity from wound complications. Skin defects cannot be closed primarily and the substantial dead space predisposes to seroma, wound dehiscence and infection. Despite the clear need for reconstructive options, extended series describing reconstruction of large inguinal defects in this setting have not been reported.

The superior thyroid artery perforator flap: anatomical study and clinical series.

Unlabelled: The redundant tissues of the anterior neck are well suited as a donor site for fasciocutaneous flaps in head and neck reconstruction, with similar skin quality and numerous underlying perforators. However, historic cadaveric research has limited the use of this as a donor site for the design of long and/or large flaps for fear of vascular compromise. The authors undertook an anatomical study to identify the vascular basis for such flaps and have modified previous designs to offer the versatile and reliable superior thyroid artery perforator (STAP) flap.

Use of the keystone island flap for advanced head and neck cancer in the elderly--a principle of amelioration.

Traditional management strategies of advanced head and neck cancer in the elderly include palliation and radical resection with microsurgical reconstruction. The keystone flap approach is an alternate reconstructive technique with a range of benefits for the aging population. This publication presents a series of elderly patients with head and neck cancer who underwent resection and reconstruction using the keystone flap principles.