This text and accompanying video addresses a selection of major cases in the head and neck region with reconstructive tips to broaden the surgeon’s scope when closing major oncological defects—offering an alternative to some microsurgical procedures.
Major defects in the head and neck region become a testing proposition whatever the surgeon’s experience. Standard microvascular reconstructive procedures have a universal appeal, or necessity, in most major units around the world. There are certain issues in head and neck surgery, that is, the scalp, where microvascular reconstruction is the pre-eminent method for repair.
However, the experience of the head and neck service at Peter MacCallum Cancer Institute using the keystone perforator island flap (KPIF) demonstrates the major contribution this technique has made in simplifying an alternative repair for oncological defects.
The various regions of the head and neck have their own specific application of this technique where the dermatomal, aligned with neurovascular support and a fascial-lined base, is the method for closure. Hypervascularity—a presumed sympathectomy effect evident in all KPIF reconstructions. This allows for closure under tension which is routinely contraindicated in all reconstructive procedures. The KPIF illustrates how this rule can be broken because the subfascial plexus is perforator based and not reliant on the subdermal plexus.
This ‘How to do it’ lists a range of cases, supplemented by video discussion, that explain the refinements of the KPIF technique to specific sites of the head and neck with a focus on the elderly, for whom the more simple procedure used, the better.
The KPIF has been in service in the reconstructive field for over 25 years since its initial publication.1 It can be applied all over the body and when the basic rules of island flap elevation are observed, the successful outcome of these neuro-dermatomal flaps becomes evident.
Blood supply is based on random perforator design located within various sites of dermatomal mark-out over the body (bypassing the need for angiographic confirmation, with obvious cost saving implications). The mark-out of the neuro-dermatome delineates the nerve supply at the cutaneous level2 and follows the principle that, if nerve supply is intact, there must be a supportive blood supply. (In paraplegics, the blood supply is intact but the complications of wound healing are staggering when one part of the equation has been eliminated, that is, no nerve supply but intact blood supply.)
From this simple principle (and where the design of the neurovascular island flap within the dermatomal precincts is based on a random axial and perforator) we have classified the KPIF as an angiotome. Leaving one-third attachment of the undermine island flap is a basic pre-requisite for successful completion.
The characteristics of the KPIF technique can be represented by a simple acronym, PACE:
When the PACE acronym is applied, the KPIF technique is a respectable alternative to microvascular surgery, particularly in the elderly, with minimal returns to theatre for vascular impedance problems4 which are not infrequent in microvascular reconstructions. A timeframe in theatre of one to two hours for any major repair using the KPIF technique also augers well for a suitable outcome when theatre timeframes for microvascular surgery may be longer.
In the audio visual files linked to this article, I use 12 cases with a focus on the elderly (Table 1) to illustrate how the KPIF technique can be refined to help teach these principles. Case 10 illustrates the value of KPIF lip reconstruction compared with microsurgical pronator quadratus techniques.5 Case 13 lists a complication (Table 2).
Audiovisual presentation complements this paper. Produced for the author by Woodrow Wilson Clinical Imaging.
Patients/guardians have given informed consent to the publication of images and/or data.
The authors have no conflicts of interest to disclose.
The authors received no financial support for the research, authorship and/or publication of this article.
Supplementary online material
Updated: June 17, 2021 AEST (reclassified as a feature)