Relaxed skin tension line-oriented keystone-designed perforator island flaps considering the facial aesthetic unit concept for the coverage of small to moderate facial defects

Abstract

A variety of reconstructive options including skin grafts, loco-regional flaps, and free flaps exist for the coverage of facial defects. Each technique has advantages and disadvantages. In this study, we present our experience with relaxed skin tension line (RSTL)-oriented, keystone-designed perforator island flap (KDPIF) reconstructions, in consideration of the facial aesthetic unit concept for coverage of small to moderate facial defects.Between May 2016 and February 2018, 17 patients (11 men and 6 women), with an average age of 63.53 years (range: 37-83 years) underwent KDPIF reconstructions to cover facial defects. We performed the KDPIF reconstructions in consideration of the RSTLs and facial aesthetic unit concept. We retrospectively reviewed the defect causes, locations, and sizes, and flap sizes, types, and survivals, as well as the complications. Cosmetic outcomes were evaluated using the Harris 4-stage scale from 3 independent plastic surgeons' point of view, and postoperative satisfactory surveys from all patients.All defects were successfully covered with KDPIF. The defect sizes varied from 1.5 × 1.5 cm to 3 × 3.5 cm. The flap sizes varied from 1.5 × 3 cm to 3 × 5.5 cm. All flaps fully survived and there were no postoperative complications. The average subjective patient satisfaction score was 8.29 (range: 7-10) and the objective cosmetic outcomes were favorable (fair, good, or excellent).Considering its simplicity and safety, the KDPIF is a good reconstruction option with few complications and high reproducibility. The RSTL-oriented KDPIF reconstruction is a good reconstructive option for covering small to moderate facial defects with superior aesthetic outcomes.

Figure 1

(A) An 80-year-old man was diagnosed with squamous cell carcinoma in the left cheek area (lateral subunit of the cheek unit). (B) He underwent a wide excision with a 4-mm safety margin and the final defect was measured to be 2.5 × 3 cm². (C) We covered the defect with a Ω-variant Type IIA keystone-designed perforator island flap (flap size: 3 × 5.5 cm²) from the anterior side of the defect. (D) Postoperative clinical photograph after 6 months of follow-up.

Figure 2

An 82-year-old woman was diagnosed with basal cell carcinoma in the left nasolabial fold area (medial subunit of the cheek unit) by punch biopsy. (A) She underwent a wide excision with a 4-mm safety margin and the final defect was measured to be 2 × 3 cm². (B, C) We covered the defect with a Type IIA keystone-designed perforator island flap (flap size: 2.5 × 5.5 cm²) from the upper-lateral side of the defect. (D) Postoperative clinical photograph after 6 months of follow-up.

Figure 3

An 81-year-old woman was diagnosed with squamous cell carcinoma in the left temporal area (lateral subunit of the forehead unit) after a punch biopsy. (A, B) She underwent a wide excision with a 5-mm safety margin, and the final defect was measured to be 3 × 3.5 cm². (C) We covered the defect with bilateral Ω-variant keystone-designed perforator island flaps (flap sizes: 2 × 6 cm² and 1.5 × 5 cm²). (D) Postoperative clinical photograph after 10 months of follow-up.

Figure 4

A 62-year-old man was diagnosed with basal cell carcinoma on the nose (dorsal subunit of the nasal unit) after a punch biopsy. (A) He underwent wide excision with a 4-mm safety margin, and the final defect was measured to be 3 × 2.5 cm². (B) We covered the defect with bilateral Ω-variant keystone-designed perforator island flaps (each flap size was 1.5 × 3.5 cm²) from both dorsal side wall subunits. (C) Postoperative clinical photograph after 1 month of follow-up. (D) Postoperative clinical photograph after 12 months of follow-up.

Figure 5

Schematic diagram showing the relaxed skin tension line-oriented KDPIF considering the facial aesthetic unit concept. Red-colored ellipses represent defects and yellow-colored figures represent the design of KDPIF. (A) Frontal and (B) profile views of the aesthetic units and subunits of the face. 1, Forehead unit (1A, central subunit; 1B, lateral subunit; 1C, eyebrow subunit); 2, nasal unit; 3, eyelid units (3A, lower-lid unit; 3B, upper-lid unit; 3C, lateral canthal subunit; 3D, medial canthal subunit); 4, cheek unit (4A, medial subunit; 4B, zygomatic subunit; 4C, lateral subunit; 4D, buccal subunit); 5, upper-lip unit (5A, philtrum subunit; 5B, lateral subunit; 5C, mucosal subunit); 6, lower-lip unit (6A, central subunit; 6B, mucosal subunit); 7, mental unit; 8, auricular unit; 9, neck unit. (Reprinted from Fattahi^[16], with permission from Elsevier.). KDPIF = keystone-designed perforator island flaps.

Figure 6

Schematic diagram showing the relaxed skin tension line-oriented KDPIF considering the nasal unit. Red-colored ellipses represent defects and yellow-colored figures represent the design of KDPIF. 1, Tip subunit; 2, columellar subunit; 3, 6, right and left alar base subunits; 4, 5, right and left alar side wall subunits; 7, dorsal subunit; 8, 9, right and left dorsal side wall subunits. (Reprinted from Fattahi^[16], with permission from Elsevier.). KDPIF = keystone-designed perforator island flaps.