Based on the anatomical principles and natural evolution of PRS, the clinical scenario must be evaluated thoroughly as a dynamic event to develop a management sequence that minimizes morbidity and mortality and accelerates patients' reinsertion to normal life.

Background: The physiology and geometry of the keystone flap (KF) are the main factors that support its development. This study reports our experience using the KF and proposes the concept of pedicular area. Methods: A prospective cohort study was conducted from October 2014 to December 2016, in which 112 KF procedures were performed with an average follow-up time of 10 months. The conclusions drawn from clinical observations were compared with the findings of a literature review. Results: One hundred twelve flaps were performed in 89 patients (45 men and 44 women) with an average age of 64 years (range, 3–89 years). The flap survival rate was 100%. The term pedicular area (PA) was coined to describe a flap segment that remains attached to its bed without vascular detriment and whose location can be randomly selected. In this study, the PA could be reduced up to a 10%, which means that over 90% of each flap was dissected without any harm. Conclusions: The KF is a safe, cost-effective technique with better results when compared with other reconstructive procedures. Although research is still needed to better understand the physiological adaptations of KF, the clinical evidence supports its use in many reconstructive scenarios.