Local flaps or based on a single perforator have great utility in reconstructive surgery, however, its use is complicated posterior midline due to the characteristics of the tissues, the keystone flap described in 2003 has become one of the main options for reconstruction due to safety, easy reproducibility, shorter surgical time, and shorter learning curve, there are three cases of posterior midline defects where the characteristics of the patient required a shorter recovery time with adequate functional and esthetic results.