RECONSTRUCTIVE

Keystone Island Flap Reconstruction of Parotid Defects

Felix C. Behan, F.R.A.C.S. Cheng H. Lo, M.B.B.S. Andrew Sizeland, Ph.D., F.R.A.C.S. Toan Pham, M.B.B.S. Michael Findlay, F.R.A.C.S., Ph.D.
Parkville, Footscray, and East Melbourne, Victoria, Australia

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. However, we have found keystone island flaps to be a simple and robust alternative, with low donor-site and patient morbidity. The aim of this article is to share our surgical technique, experience, and outcomes of reconstructing parotid defects with keystone island flaps. Methods: The authors retrospectively reviewed 62 patients who had 63 parotid defect reconstructions at a single institution from 2004 to 2009 (5-year period). Results: The diseases involved were squamous cell carcinoma (52 cases), melanoma (five cases), basal cell carcinoma (four cases), and others (two cases). Nine patients presented with a previous history of radiotherapy and 33 patients required adjuvant radiotherapy. Seven patients (11 percent) suffered postoperative complications necessitating a return to the operating room. Conclusions: Keystone island perforator-based flaps present an alternative to free tissue transfer. From the series presented, it can be seen that reliable and reproducible results are achievable. (Plast. Reconstr. Surg. 130: 36e, 2012.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

econstruction of parotid defects is common in the field of head and neck cancer surgery. Although fewer than one-third of parotid tumors are malignant (mucoepidermoid carcinoma being the commonest), 70 to 85 percent of all adult salivary gland tumors occur in the parotid gland.1 In addition, Australia has the highest incidence of melanoma and nonmelanoma skin cancers in the world (and the incidence is rising).2,3 Wide local excision remains the most common treatment modality for these skin cancers.2,3 Also, squamous cell carcinoma from the frontotemporal scalp region has a propensity to metastasize to the periparotid or intraparotid group of lymph nodes.1
From the Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital; the Department of Plastic and Reconstructive Surgery, Western General Hospital; and the Department of Surgical Oncology, Peter MacCallum Cancer Institute. Received for publication October 6, 2010; accepted March 10, 2011. Presented at the 79th Annual Scientific Congress of the Royal Australasian College of Surgeons, in Perth, Western Australia, Australia, May 4 through 7, 2010. Copyright 2012 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182547f55

Free tissue transfer has been the standard of care in the reconstruction of large head and neck defects. However, our senior author (F.C.B.) has used the keystone island flap with success for more than 20 years to reconstruct defects often otherwise appropriate for microsurgical reconstruction. The principles of the keystone island flap, a locoregional perforator-based island flap, were first detailed in 1992, and ensuing publications followed largely in the Australasian literature until recently.4 7 The aim of this article is to share our surgical technique, experience, and outcomes of reconstructing parotid defects with keystone island flaps. The advantages and disadvantages of this reconstructive technique and comparisons with alternate reconstructive options are discussed.

PATIENTS AND METHODS

Study Design A retrospective review of 62 patients who had parotid defect reconstructions at a single hospital

Disclosure: The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

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(Western General Hospital, Melbourne, Australia) over a 5-year period (2004 to 2009) was performed. Patient information gathered from hospital records included patient demographics, disease, treatment, and outcomes. These were supplemented by records and photographs from the senior author (F.C.B.). Surgical Technique The principles and technique of keystone island flap have been published previously, and a summary of the pertinent points are presented here.4,5,8 In 2003, a classification system was developed for keystone island flaps,5 as follows: Type I: standard flap design without division of deep fascia. Type II: deep fascia on the convex aspect of the flap is divided to enhance mobilization. Further subcategorization (type IIa) secondary defect is closed primarily and (type IIb) secondary defect is closed with a split skin graft. Type III: double keystone flaps are designed to facilitate closure, one on either side of the defect. Type IV: up to two-thirds of the flap is undermined. Flap mobilization is maximized. The keystone island flap is usually a curvilinear trapezoidal design but, for parotid defects, the exact shape of the keystone island flap is less important and may deviate from being keystone shaped. The flap is designed to exploit the surrounding donor tissue available, with planning in reverse often being necessary to ensure adequate tissue mobilization and defect closure. Type IV keystone island flaps involve flap undermining, mobilization by means of advancement, transposition or rotation, and closure of the secondary defect either primarily or with a skin graft. Effort should be made to place incisions along lines of election or natural junction lines to hide the scar among rhytides and render the scar less conspicuous (Fig. 1).9 The C2 and C3 dermatomes serve as a guide for flap placement.8 From a posterosuperior perspective (based on occipital and posterior auricular perforators), the keystone flap within the C2 and C3 dermatomal alignment along the neck can be rotated up to 180 degrees to fill parotid defects (omega or horseshoe variant) (Fig. 2). Based anteroinferiorly on the facial or submental artery perforators, the flap can be rotated superiorly into the defect. Keystone flaps raised posteriorly can be rotated to fill the auricular defect, but the secondary scalp defect requires skin grafting. Superiorly, rotation of the scalp flap of the keystone design has been used infrequently. Skin, fat, and fascia (or platysma) are incorporated into the flap, and associated subcutaneous venous or neural supports are preserved wher-

Fig. 1. (Left) A 7 6-cm left infraauricular defect with exposure of major vessels and accessory nerve. (Center) Six-day postoperative view. (Right) Excellent aesthetic results at 4 months postoperatively. (Reprinted with permission from Behar F, Findlay M, Lo C. The Keystone Perforator Island Flap Concept. Sydney, Australia; Elsevier; 2012.)

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dermining is carried out only as much as necessary, and the extent of undermining is now approaching two-thirds of the flap surface area.10,11 Preoperative investigations such as computed tomographic angiograms and perforator localization by means of handheld Doppler devices are not necessary for reconstructive purposes. Intraoperatively, we do not routinely isolate and skeletonize perforators.

RESULTS
At our center, tumor resection is routinely performed by a separate team of head and neck surgeons. Oncologic clearance remains the priority and is not compromised for reconstructive purposes. In total, 62 patients underwent reconstruction of 63 defects in the parotid region. The average patient age was 76 years (range, 31 to 97 years) and the average American Society of Anesthesiologists category was 2.7 (range, 1 to 4). The diseases involved were squamous cell carcinoma (52 cases), melanoma (five cases), basal cell carcinoma (four cases), and two others (one case of osteoradionecrosis and one small cell carcinoma). In the tumor extirpation process, 43 parotidectomies were necessary. Nine patients suffered some form of complication related directly to their surgery (14.5 percent). In decreasing order of frequency, the complications were partial flap necrosis (four cases), ectropion (four cases), wound infection (one case), wound breakdown (one case), bleeding (one case), and acute myocardial infarction (one case). Seven patients required return trips to the operating room for further management of their complications (two cases of ectropion, four cases of partial flap necrosis, one case of wound breakdown, and one wound infection; one flap was complicated by partial flap necrosis and infection simultaneously). Five wound de bridements were performed with three local flap closures, and two tarsorrhaphies were performed for ectropion. Only three patients required intensive care unit monitoring postoperatively. Average duration of inpatient stay was 11 days (range, 4 to 38 days). Duration of follow-up ranged from 6 days to 45 months. Forty-three patients required a parotidectomy. In this patient population subgroup, two patients developed ectropion (requiring tarsorrhaphy), three patients developed partial flap necrosis, and one patient suffered wound dehiscence (these four cases required de bridement and two local flaps). Parotidectomy did not seem to impact the complication rate; six of 43 (14 percent) were returned to the operating room. Nine of these patients had radiotherapy preoperatively and 34 patients underwent adjuvant

Fig. 2. (Above) Elderly patient with an 8 8-cm defect of the right parotidandtempleregionafterbasalcellcarcinomaresection.(Center) The keystone island flap is based on the posterior auricular and occipital artery perforators. (Below) Tension-free closure of the primary defect with direct closure of the donor site is performed. (Reprinted with permission from Behar F, Findlay M, Lo C. The Keystone Perforator Island Flap Concept. Sydney, Australia; Elsevier; 2012.)

ever possible.8 For larger parotid defects, it is often necessary to undermine and raise the flap in the subfascial (or subplatysmal) plane to facilitate flap mobilization and defect closure (type IV). Flap un-

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radiotherapy after keystone island flap reconstruction. The nine patients who had preoperative radiotherapy did not have a higher complication rate. Only one of nine patients (11 percent) had a complication (ectropion) requiring surgery. There were no partial or total flap losses in this patient group. Because of the retrospective nature of this article, the dimensions of defects were not recorded in every patient. However, these nine patients who had preoperative radiotherapy had an average defect size of 36 cm2, which appeared similar in size to the nonirradiated defects.

DISCUSSION
In 1973, the senior author (F.C.B.) introduced the term angiotome to refer to any area of integument supplied by an axial vessel.12 It was proposed that each angiotome may be safely raised as a flap, or extended by random communications or linkage vessels with an adjacent angiotome.12 The senior author (F.C.B.) went on to publish his experience with the keystone island flap concept (keystone design perforator island flap) in 1992 and 2003,4,5 a reconstructive technique developed and based on the angiotome concept. Keystone island flaps (perforator based) and dermal pedicled platysma flaps both incorporate skin, subcutaneous tissue, and the underlying platysma. Since platysma flaps were first introduced approximately 30 years ago,13 several variations have been described to provide coverage of neck, chin, cheek, lips, and the oral cavity. These include the standard or superiorly based platysma flap (submental artery, a branch of the facial artery),14 the distally or inferiorly based flap (transverse cervical or superficial cervical arteries)14,15 (Fig. 3), and the transverse platysma flap (occipital and posterior auricular arteries).16,17 Szudek and Taylor performed a systematic review of 16 case series and 190 patients with platysma flaps, revealing a total complication rate of 37 percent.18 According to their review, complication rates between 10 and 40 percent have been reported.18 Whereas platysma flaps were regarded as unreliable,18 our current series of keystone island flaps compared rather favorably, with a total complication rate of 14.5 percent despite 63 percent (43 of 62) of the patients having had radiotherapy in their multimodality tumor management. Preoperative radiotherapy is not a contraindication for keystone island flaps. In fact, the robust nature of keystone island flaps, even in irradiated fields affected by obliterative endarteritis and chronic ischemia, has been previously demonstrated and published.6 In our experience, complication rates

Fig. 3. (Above) A patient with a 13 7-cm right infraauricular defect after parotidectomy and neck dissection for squamous cell carcinoma. (Center) A double keystone flap (type III) is mobilized to close the defect. (Below) Direct closure of the donor site with a drain in situ is shown. (Reprinted with permission from Behar F, Findlay M, Lo C. The Keystone Perforator Island Flap Concept. Sydney, Australia; Elsevier; 2012.)

were acceptably low and compared favorably with those of other reconstructive techniques.6 A direct comparison may be made between the keystone island flap and the transverse platysma flap because they may be similarly oriented in the

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Fig. 4. (Above, left) The patient had a 10 6-cm left parotid defect after resection of squamous cell carcinoma, facial nerve sacrifice, and ipsilateral neck dissection. (Above, right) Design of the perforator-based keystone island flap is shown. (Below) The defect was closed after 83minutes.(ReprintedwithpermissionfromBeharF,FindlayM,LoC. TheKeystonePerforatorIslandFlapConcept. Sydney,Australia;Elsevier;2012.)

Fig. 5. Same patient as seen in Figure 4 is shown at 18-month follow-up. (Reprinted with permission from Behar F, Findlay M, Lo C. The Keystone Perforator Island Flap Concept. Sydney, Australia; Elsevier; 2012.)

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neck. In 1997, Ariyan reported seven cases of transverse platysma flap and stated that the skin paddle may be outlined across the midline of the neck.16 In 2003, two further cases were published, with the additional comment that the usable portion of the skin paddle does not extend beyond the midline.17 There appeared to be concerns about crossing the midline and, unfortunately, the illustrations published did not include frontal views showing the distal tip of donor site. It is not uncommon for keystone island flaps to cross the sagittal midline, incorporating at least two and possibly more than four vascular territories. With no cases of total flap loss and a partial flap necrosis rate of 6 percent (four of 63), we hypothesize that the perforator-based island flap design augments vascular hemodynamics and flap survival.4,6 The use of keystone island flaps for parotid reconstruction is subject to defect characteristics (e.g., type of tissue loss, location, size) and the availability of adjacent donor tissue. As with any other locoregional reconstructive technique, locoregional skin availability is a prerequisite. Redundant skin in the elderly is certainly an advantage. The youngest patient in our series was aged 31 years, with melanoma and a defect size of 6 4 cm. Patient assessment and patient selection is key, and the reconstructive approach for every patient must be individualized. Neck dissections and previous radiotherapy necessitate careful flap design but are certainly not contraindications (Figs. 4 and 5). In contrast, the keystone island flap is a reproducible, single-stage reconstructive option that is relatively easy and quick (Figs. 4 and 5) to perform without microsurgical skills or equipment. Donor-site morbidity is minimal (often direct closure). Keystone island flaps provide thin and pliable locoregional tissue and a good color match to the skin of the parotid region, and are often preferred over microvascular transfers.
PATIENT CONSENT

Written consent was obtained for use of the patient images in Figure 2.

REFERENCES
1. Saadeh PB, Delacure MD. Head and neck cancer and salivary gland tumors. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP, Gurtner GS, Spear SL, eds. Grabb & Smiths Plastic Surgery. 6th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2007:333346. 2. Cancer Council Australia and Australian Cancer Network. Basal Cell Carcinoma, Squamous Cell Carcinoma (and Related Lesions): A Guide to Clinical Management in Australia. Sydney, New South Wales, Australia: Cancer Council Australia and Australian Cancer Network; 2008. 3. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Wellington, New Zealand: Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group; 2008. 4. Behan FC. The fasciocutaneous island flap: An extension of the angiotome concept. ANZ J Surg. 1992;62:874886. 5. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112120. 6. Behan FC, Sizeland A, Porcedu S, Somia N, Wilson J. Keystone island flap: An alternative reconstructive option to free flaps in irradiated tissue. ANZ J Surg. 2006;76:407413. 7. Behan FC, Sizeland A. Reiteration of core principles of the keystone island flap. ANZ J Surg. 2006;76:11271134. 8. Behan FC, Sizeland A, Gilmour F, Hui A, Seel M, Lo CH. Use of the keystone island flap for advanced head and neck cancer in the elderly: A principle of amelioration. J Plast Reconstr Aesthet Surg. 2010;63:739745. 9. McGregor AD, McGregor IA. Fundamental Techniques of Plastic Surgery and Their Surgical Applications. 10th ed. New York: Churchill Livingstone; 2000. 10. Behan FC, Lo CH. Principles and misconceptions regarding the keystone island flap. Ann Surg Oncol. 2009;16:17221723. 11. Behan FC, Lo CH, Shayan R. Perforator territory of the keystone flap: Use of the dermatomal roadmap. J Plast Reconstr Aesthet Surg. 2009;62:551553. 12. Behan FC, Wilson I. The vascular basis of laterally based forehead island flaps, and their clinical applications. Plast Reconstr J (European section, Madrid) 1973;24 13. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg. 1978;136:504507. 14. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy & Technique. New York: Churchill Livingstone; 1997. 15. Coleman JJ III, Jurkiewicz MJ, Nahai F, Mathes SJ. The platysma musculocutaneous flap: Experience with 24 cases. Plast Reconstr Surg. 1983;72:315321. 16. Ariyan S. The transverse platysma myocutaneous flap for head and neck reconstruction. Plast Reconstr Surg. 1997;99:340347. 17. Ariyan S. The transverse platysma myocutaneous flap for head and neck reconstruction: An update. Plast Reconstr Surg. 2003;111:378380. 18. Szudek J, Taylor SM. Systematic review of the platysma myocutaneous flap for head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2007;133:655661.

CONCLUSIONS
The reconstruction of parotid defects after resection of primary parotid tumors or secondary metastases can be challenging. Keystone island flaps present a single-stage reconstructive option that is relatively easy to perform without the need for microvascular tissue transfer. From the series presented, it can be seen that reliable and reproducible results are achievable.
Cheng H. Lo, M.B.B.S. Department of Plastic and Reconstructive Surgery Royal Melbourne Hospital Grattan Street Parkville, Victoria 3050, Australia c_lo2@yahoo.com.au

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