TECHNICAL STRATEGY

The Keystone Perforator Island Flap in Nasal Reconstruction: An Alternative Reconstructive Option for Soft Tissue Defects up to 2 cm Epameinondas Kostopoulos, MD, PhD, Vincent Casoli, MD, PhD,y Christos Agiannidis, MD, Petros Konofaos, MD, PhD,z Georgios Drimouras, MD, Avraam Dounavis, MD, Grigorios Champsas, MD, MSc, Marios Frangoulis, MD, PhD, and Othon Papadopoulos, MD, PhD Abstract: 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. Key Words: Perforator flap, keystone, nasal reconstruction, nasal subunit, basal cell carcinoma (J Craniofac Surg 2015;26: 1374–1377)

PATIENTS AND METHODS From January 2013 to August 2014, thirty patients presenting with different nasal defects (diameter 2 cm) following tumor resection sustained reconstruction with the KPIF concept. Different types of the flap were used applying the nasal subunit principle in the flaps’ design. Approval from the institutional research ethics committee was granted, and informed consent was obtained from all of the patients participating in the study.

Flap Vascular Anatomy

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asal reconstruction has always been challenging for plastic surgeons. Midfacial position of the nose and the relation between convexities and concavities of nasal subunits makes impossible to hide any sort of deformity without a proper reconstruction.1 Much has been written in the literature regarding nasal reconstruction.1,2 The nasal subunit principle as evolved by Burget and Menick3 offered a valuable tool in the management of small- and medium-sized defects (diameter 2 cm). From the Department of Plastic Surgery, A. Syggros Hospital, National and Kapodestrian University of Athens Medical School, Athens, Greece, the yPlastic and Burn Surgery Department, Francois-Xavier Michelet Center, Centre Hospitalier Universitaire, Bordeaux 2 University, Bordeaux, France, and the zDepartment of Plastic Surgery, University of Tennessee Health Science Center, Memphis, TN. Received November 22, 2014. Accepted for publication January 29, 2015. Address correspondence and reprint requests to Epameinondas Kostopoulos, MD, PhD, Department of Plastic Surgery, A. Syggros Hospital, National and Kapodestrian University of Athens Medical School, 120 D. Gounari St, 15125 Maroussi-Athens, Greece; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001746

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The keystone perforator island flap (KPIF) was described by Behan4 in 2003. Based on arterial perforators, it combines both the robust vascularity of perforator flaps and the advantages of local tissue rearrangement. To the best of our knowledge, there have not been any reports for the use of the KPIF in nasal reconstruction. In this article, we present our experience with the use of KPIF in a case series of 30 patients with small- to medium-sized (diameter 2 cm) nasal defects hoping to assist plastic surgeons in planning an effective reconstructive strategy.

The vascular supply of the flap is based mainly on the muscular perforators from the musculoaponeurotic layer (nasal superficial muscular aponeurotic system [SMAS]). The nasal subcutaneous muscular aponeurotic system is a continuation of the SMAS of the lateral face. The nasal muscles (mainly anomalous nasi muscle, transverse nasalis, and procerus) and their aponeuroses of the SMAS are supplied and contain the major cutaneous branches from the 2 main angiosomes involved in the vascular supply of the nose: the ophthalmic and the facial artery angiosome with collaterals through the anterior ethmoidal arteries. Lead oxide vascular studies have shown nasal branches from the ophthalmic artery coursing longitudinally over the nasal dorsum and sidewall.5 These perforators are excellent feeders for the flap. Of course, whenever salvage of the subcutaneous vascular network was feasible, care was taken to sustain it to promote the venous drainage of the flap.

Surgical Technique The tumor defect was drawn in an elliptical manner (Fig. 1A), and depending on its location a type I or III KPIF was used as classically described by Behan.4 According to the keystone flaps’ classification system as it was developed in 2003, type I is the standard flap without division of the fascia, type II concerns a flap with division of the fascia for further mobilization, type III includes 2 identical standard flaps designed on either side of the defect in an attempt to close larger defects, and finally in type IV up to the two thirds of the flap are undermined to facilitate closure.

The Journal of Craniofacial Surgery



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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Keystone Flap for Nasal Reconstruction

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B

F

FIGURE 1. A, A 49-year-old immunocompromised male patient presented with a lesion on the nasal tip. B, Surgical markings of the excision area and the flap design. The ratio between the width of the excision and the flaps’ widths were 1:1. In this case, a type-III KPIF was deployed. C, The tumor excision was performed in an elliptical way. To accomplish that outline, adjacent residual skin was discarded (in this example, a small triangular skin area included above the excision bed). The depth of the excision reached the perichondrial plane for safe oncological margins. D, Incision of the cutaneous markings of the flap and dissection to the musculoaponeurotic layer releases the surrounding skin and facilitates closure. E, The flap is advanced to the defect site. Vascular supply of the flap depends on the muscular perforators of the nasal muscles. The flap has no dermal attachments with the surrounding skin. F, 10 month postoperatively without distortion of normal landmarks. KPIF, keystone perforator island flap.

Following tumor resection (Fig. 1B), the cutaneous markings of the flaps were incised along their entire length (Fig. 1C). Next, dissection proceeded through the superficial fatty panniculus to the level of the fibromuscular layer, releasing the surrounding skin (Fig. 1D). Care was taken not to undermine the area beneath the flap. Closure was performed in 2 steps as described by Behan,4 (Fig. 1E): the stay-sutures (using 3/0, 4/0, and 5/0 nylon) and the hemming (horizontal everting mattress method of suturing) sutures to close the limits of the flap. In selective cases, interrupted

C

D

FIGURE 3. A, A 77-year-old male patient presented with a BCC on the right sidewall. A type-I KPIF was drawn on the dorsum of the nose. B, Incision and dissection of the flap. C and D, 12 month postoperatively. BCC, basal cell carcinoma; KPIF, keystone perforator island flap.

sutures were used instead of hemming. Sutures were removed on the 10th postoperative day.

Defect Located on the Tip or the Dorsum Two identical opposing KPIFs (type III) were designed on each lateral wall (Fig. 2). The maximal width of each flap was equal to that of the defect. The caudal part of each flap was drawn over the nasoalar sulcus to the tip of the nose, whereas the cephalad part was drawn over the lateral wall. Following tumor extirpation, incision, and dissection as described above, both flaps were advanced in the longitudinal axis to fill the defect area.

Defect Located on the Lateral Wall In the same way, a KPIF (type I) was designed around the defect on the dorsum (Fig. 3). Following incision, dissection was sustained to the plane of the musculoaponeurotic layer, and the flap was advanced to the defect site on the lateral wall without any undermining. All of the patients were treated with local anesthesia because it was a 1-day surgery procedure without the need for hospital admission or overnight stay.

RESULTS A

B

C

D

FIGURE 2. A, A 52-year-old female patient was referred for a LM on the tip of the nose. Using the subunit principle, a type-III KPIF was opted for reconstruction. B, C, and D, Scars remained almost inconspicuous, giving an aesthetically pleasing outcome a year after surgery. KPIF, keystone perforator island flap; LM, Lentigo maligna.

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The demographic data of our series are summarized on Table 1. The median defect diameter was 1.46 cm (range 0.7–2.5 cm). The majority of the defects (18/30, 60%) were reconstructed with a type-I KPIF, whereas in 40%, a type-III KPIF was used. Half of the lesions (15/30 or 50%) concerned the lateral nasal wall, followed by the nasal tip (9/30 or 30%), whereas the minority was located at the dorsum (6/30 or 20%). More than 1 aesthetic nasal subunit was involved in half of the patients (15/30 or 50%) as donor site to reconstruct the defect. Overall good outcomes were achieved with no major complications encountered, except minor wound dehiscence in 3 patients or 10% (including patient no. 4 with a defect of 2.5 cm in diameter), which were healed by secondary intention.

DISCUSSION Reconstruction of the nose continues to progress to a new level of finesse that allows a surgeon to restore near-normal form and function to the majority of nasal defects.

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TABLE 1. Summary of Characteristics of the 30 Patients Who Underwent Nasal Reconstruction With the Use of the KPIF Concept, Following Tumor Resection at a Single Hospital, Between January 2013 and August 2014 Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Sex

Age, y

Male Female Male Male Male Male Male Male Male Male Male Female Male Female Male Male Female Male Male Female Male Male Male Female Male Female Male Male Female Male

65 52 73 68 71 77 65 69 73 72 75 56 80 67 74 57 88 49 85 71 65 53 92 76 12 81 53 81 86 76

Primary Lesion Site Lateral wall Tip Tip Tip Tip Lateral wall Dorsum Dorsum Dorsum Lateral wall Tip Tip Dorsum Lateral wall Lateral wall Dorsum Lateral wall Tip Lateral wall Nasal ala Tip Nasal ala Nasal ala Dorsum Nasal ala Lateral wall Inner canthus Inner canthus Tip Nasal ala

Lesion Pathology

Lesion Diameter, cm

KPIF Type

Follow-Up, mo

BCC LM BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC BCC

1.0 1.5 1.2 2.5 1.7 1.1 1.5 1.8 2.0 1.0 1.6 1.5 1.3 1.2 1.2 1.7 1.5 1.3 2.8 1.0 1.5 1.0 1.0 1.3 0.7 1.5 1.7 1.5 2.0 1.0

I III I I III I III III III I III III I I I III I III I III III I I I I I I I III I

19 17 20 16 19 15 18 18 18 18 19 11 9 8 9 11 8 9 11 8 7 10 7 5 10 6 8 11 3 3

Complications None None None MWD None None None MWD MWD None None None None None None None None None None None None None None None None None None None None None

Median follow-up time was 10.5 months (range 3–20 months). BCC, basal cell carcinoma; KPIF, keystone perforator island flap; LM, Lentigo maligna; MWD, minor wound dehiscence.

These advances are based on the concepts of respecting the borders of aesthetic units of the nose and replacing missing tissue with like tissue.3 Application of KPIF for nasal reconstruction was inspired by the work by Behan4 in other anatomic sites.6 We strongly believe that the nasal subunit principle is a valuable tool in nasal reconstruction and strived to use it with the keystone flap. Wherever that was not fully feasible, we adjusted the reconstruction effort toward a modified aesthetic subunit version by placing the reconstruction scar between 2 lines of transition. That was solely done when we used a bilateral lateral wall keystone flap to reconstruct a dorsum defect. We believed that the modified subunit principle in these patients did not downgrade the final aesthetic result in these patients. Our initial experience with the KPIF has demonstrated its utility for the reconstruction of nasal defects up to 2 cm in diameter, with a high degree of success. The KPIF uses identical local tissue with an ideal color, texture, and thickness match resulting in superior aesthetic qualities as the scars well concealed in natural creases were becoming unnoticeable. The KPIF is a reproducible, single-stage reconstructive option that is relatively easy and quick to perform without microsurgical skills or equipment, avoiding the steep technical learning curve and the necessity of prolonged operative times.6 Regardless of its advantages, this flap also has limitations. Its size is probably not enough for reconstruction of very large nasal defects (diameter 2 cm). The

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advancement capability is limited, providing skin that can be used only for outer lining of the nose. Nevertheless, for defects up to 2 cm in diameter, different options have been proposed by numerous authors. The bilobed flap7 is often the first-choice solution for tip and dorsal defects up to 1.5 cm, providing good color match and skin coverage in a wide range of partial thickness nasal defects. It can leave visible scars running through the subunits, causing local nasal contour distortion. Rieger8 flap with its revision by Marchac and Toth,9 and its modification by Rohrich et al10 is a valuable tool for larger defects (up to 2 cm). Technically it is more demanding as dissection proceeds into the deep submuscular plane above the periosteum, degloving the entire dorsum in an effort to create sufficient laxity. Symmetrical upward tip rotation remains a possibility after such reconstructions. The superiorly based nasolabial flap2 is useful for small sidewall and alar defects. It provides skin of different quality and causes pin cushioning, however, at the receptor site. Banner flap11 is a classic adjunct in the management of small defects concerning the dorsum and the tip. Concavity at the donor site and pin cushioning at the receptor site are common tendencies of the method. Rintala12 described a random nasal advancement flap suitable for tip reconstruction in a single stage. It needs a large undermining above the perichondrium and the periosteum, ensuring a better #

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Volume 26, Number 4, June 2015

vascular support. Vascular related problems of the edge of the flap associated with tip elevation are the commonest complications. Ebrahimi et al13 in a series of 25 patients presented a modified version of this flap, however, overcoming its disadvantages. Nasolabial flap initially was described by Warren in 1840 for reconstruction of nasal defects. Recent authors14–17 described refinements of the technique, enabling reconstruction of nasal defects in different locations. Specifically, the superiorly based nasolabial flap2 is useful for small sidewall and alar defects. It, however, provides skin of different quality and causes pin cushioning at the receptor site. For larger defects (>2 cm), the forehead flap18–20 remains the gold standard including subtotal and total reconstructions. Some of the aforementioned techniques7 –11 necessitate large dissection of the entire nose, whereas others12,14 provide skin of different quality outside the nose. Our experience demonstrated that KPIF needs a minimum of dissection filling the defect area with tissue of the same quality (adhering to the principle of ‘‘replacing like with like’’), giving a good functional and a pleasant aesthetic outcome. In addition, its robust blood supply makes it an extremely safe reconstructive option. Subsequently, it could be considered as an alternative for small- and medium-sized nasal defects (diameter 2 cm).

CONCLUSIONS The versatility of the KPIF makes it a safe and elegant technique even in the hands of inexperienced surgeons for nasal defects up to 2 cm in diameter. Although early results are promising, additional data will be required before we can make definitive conclusions regarding its role in nasal reconstruction.

REFERENCES 1. Yoon T, Benito-Ruiz J, Garcia-Diez E, et al. Our algorithm for nasal reconstruction. J Plast Reconstr Aesthet Surg 2006;59:239–247 2. Rohrich RJ, Griffin JR, Ansari M, et al. Nasal reconstruction—beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;114:1405–1416 3. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239–247

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4. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003;73:112–120 5. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg 2000;105:2287–2313 6. Khouri JS, Egeland BM, Daily SD, et al. The keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruction. Plast Reconstr Surg 2011;127:1212–1221 7. Rohrich RJ, Barton FE Jr, Hollier L. Nasal reconstruction. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia, PA: Lippincott-Raven; 1997 8. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967;40:147–149 9. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg 1985;76:686–694 10. Rohrich RJ, Muzaffar AR, Adams WP Jr et al. The aesthetic unit dorsal nasal flap: rationale for avoiding a glabellar incision. Plast Reconstr Surg 1999;104:1289–1294 11. Masson JK, Mendelson BC. The banner flap. Am J Surg 1977;134:419– 423 12. Rintala A, Asko-Seljavaara S. Reconstruction of midline skin defects of the nose. Scand J Plast Reconstr Surg 1969;3:105–108 13. Ebrahimi A, Nejadsarvari N, Koushki ES. Application of modified Rintala flap in nasal tip reconstruction. Am J Otolaryngol 2012;33:685– 688 14. Wesser DR, Burt GB Jr. Nasolabial flap for losses of the nasal ala and columella. Plast Reconstr Surg 1969;44:300–302 15. Rohrich RJ, Conrad MH. The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction. Plast Reconstr Surg 2001;108:1727–1730 16. Sasaki K, Nozaki M, Katahira J, et al. A nasolabial composite free flap with buccal mucosa: reconstruction of full-thickness lower eyelid defects. Plast Reconstr Surg 1998;102:464–472 17. Mayer MH. Nasolabial flap. In: Evans GRD, ed. Operative Plastic Surgery. New York, NY: McGraw-Hill; 2000 18. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty and blood supply. Plast Reconstr Surg 1989;84:189–202 19. Menick FJ. Nasal reconstruction: forehead flap. Plast Reconstr Surg 2004;113:100E–111E 20. Menick FJ. A 10-year experience in nasal reconstruction with the threestage forehead flap. Plast Reconstr Surg 2002;109:1839–1855

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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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...
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