Modified Keystone Perforator Island Flap for Tension-Reducing Coverage of Axillary Defects Secondary to Radical Excision of Chronic Inflammatory Skin Lesions: A Retrospective Case Series

Abstract

Axillary defect coverage is often challenging after radical excision of chronic inflammatory skin lesions, such as complicated epidermoid cysts and hidradenitis suppurativa. This retrospective case series aims to demonstrate our experience with axillary reconstruction using the modified keystone perforator island flap (KPIF) technique, emphasizing its tension-reducing effects. All patients who presented for axillary reconstruction after radical excision of chronic inflammatory skin lesions between May 2019 and December 2020 were identified using the medical record database. Eleven patients ranging in age from 17 to 71 years underwent modified KPIF axillary reconstruction. Four types of modifications (modified type II KPIF, omega variation closure, Sydney melanoma unit modification, and hemi-KPIF) were used. All defects (size range, 2.5 × 3 c m 2 to 8 × 13 c m 2 ) were successfully covered using these modified KPIF techniques. All flaps (size range, 3.5 × 3.5 c m 2 to 11 × 30 c m 2 ) fully survived without complications. All patients exhibited favorable functional outcomes, and no cases of recurrence or limitations in joint range of motion were observed during the follow-up period (range, 4–5 months). Modified KPIF techniques may represent a reliable, effective alternative reconstructive modality for managing axillary defects.

Modified Keystone Perforator Island Flap Techniques for Small- to Moderate-Sized Scalp and Forehead Defect Coverage: A Retrospective Observational Study

“…In cases of defects, which result from non-oncologic causes, such as trauma, postoperative wound necrosis, and wound infection, patients received preoperative wound preparation management that included empirical antibiotic treatment, serial wound debridement, and wound dressing for approximately 1–2 weeks [ 7 , 11 ]. After sufficient wound preparation, final debridement followed by KPIF reconstruction was performed.…”

“…Four modifications of the KPIF were used in this study as follows: hemi-KPIF, which includes skin incision and division of the deep fascia at the unilateral apex with more than one-third of the ipsilateral-sided outer curvilinear line [ 14 ]; the Sydney melanoma unit modification (SMUM) KPIF, which involves the maintenance of a skin bridge along the outer curvilinear line [ 15 ]; the omega variation closure (OVC) KPIF, which includes fish-mouth-shaped defect closure through the addition of rotational flap movement [ 16 ]; and the modified Type II KPIF, comprising the deep fascia division along the whole circumference line of the flap [ 10 , 11 ]. Figure 1 illustrates these four KPIF modifications [ 11 ]. The choice of modification used was made intraoperatively [ 11 , 17 ].…”

“…Paradoxically, there is no unrivaled local flap for scalp and forehead reconstruction. Among the various types of local flap techniques, the keystone perforator island flap (KPIF), devised from Behan’s experience in over 300 cases with successful outcomes in 2003, has unique features, including intuitional defect-adaptable design and remarkable reproducibility with a minimal learning curve [ 6 , 7 , 9 , 10 , 11 ]. Based on these features, KPIF has become a popular reconstructive modality in most parts of the human body [ 9 , 10 , 11 ].…”

“…Among the various types of local flap techniques, the keystone perforator island flap (KPIF), devised from Behan’s experience in over 300 cases with successful outcomes in 2003, has unique features, including intuitional defect-adaptable design and remarkable reproducibility with a minimal learning curve [ 6 , 7 , 9 , 10 , 11 ]. Based on these features, KPIF has become a popular reconstructive modality in most parts of the human body [ 9 , 10 , 11 ]. Despite this popularity, studies applying KPIF to scalp and forehead reconstruction are limited compared with other areas, such as the face, trunk, and extremities [ 9 , 10 , 11 , 12 ].…”

“…Based on these features, KPIF has become a popular reconstructive modality in most parts of the human body [ 9 , 10 , 11 ]. Despite this popularity, studies applying KPIF to scalp and forehead reconstruction are limited compared with other areas, such as the face, trunk, and extremities [ 9 , 10 , 11 , 12 ]. Moreover, a previous study reported that the scalp is a relative contraindication to KPIF reconstruction [ 13 ].…”